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U winter 2011 |
Volume 30 | number 3
Journal of the Ontario Occupational Health Nurses Association
How to run a successful
Flu campaign
Integrated Health
Services Program
Epidemiology 101
Publications Mail #40026127
Journal of the Ontario Occupational Health Nurses Association
winter 2011 | Volume 30 | number 3
Board of Directors
Table of Contents
Karen Watson RN, BHSc(N), COHN(C), CRSP
Angela Wrobel RN, COHN(C)
Marlene Demko RN, DOHN, COHN(C)
Patricia C. Kent RN, CRSP, COHN(C), COHN-S, DOHS
Susan Ann MacIntyre RN, COHN(C), CRSP, BHA
Drew Sousa RN, COHN(C)
Ken Storen RN, COHN(C)
Practice |
Editorial Committee
Grace Bruford RN, BScN, COHN(C), COHN-S/CM
How to run a successful Flu Campaign
Jane Dekeyser BA, RN, COHN(C)
by Teresa McCormack
Jane Lemke RN, BHSc(N), M.Ed., COHN(C)
Shelley Skerlan RN
Managing Editor
Frances J. MacCusworth MA
E-mail: [email protected]
Printed by
Harmony Printing Ltd.
Design & Layout
Chris Simeon RGD
Executive Director and technical editor
Brian Verrall
Practice |
Development of an Integrated Health Services Program
by Rebecca Kwiatkowski
11 Practice |
Informing your practice with evidence—Epidemiology 101
Ontario Occupational
Health Nurses Association
Suite 605, 302 The East Mall
Etobicoke, ON M9B 6C7
Tel: 416-239-6462 Fax: 416-239-5462
E-mail: [email protected]
for Occupational Health Nurses. Part 2.
mission statement:
To foster a climate of excellence, innovation and
partnership, enabling Ontario Occupational Health
nurses to achieve positive workplace health and
safety objectives.
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Canadian Publication Agreement #40026127
OOHNA Journal n winter 2011
by Victoria Pennick
14 Research |
Predicting RTW following acute low-back pain
by Cindy Moser
16 Research |
Predicting prolonged work absences among nurses
by Cindy Moser
17 Practice |
Ethical Dilemmas in the Workplace
by Dr. Tom Foreman
Brian Verrall,
Technical Editor
Winter is a good time to look back at the year and take stock.
Despite a downturn in the western economy, canada continues to
experience modest growth and this has been reflected throughout 2011
in the growing number companies advertising full, part-time and contract
positions via OOhNa’s advertising service. Even in the hardest-hit manufacturing areas of the Toronto-Windsor corridor, jobs have increased and
employers choose OOhNa members because they know they come
insured with the best coverage in canada.
In 2011, OOhNa surveyed members in order to learn more about
your workplace challenges and the education needed to meet those
challenges. at the top of the list was mental health and government
legislation that impact on Occupational health Nurses, your employers
and employees. Through annual conference, webinars, workshops, and
through this publication, we strive to keep members up-to-date on all
important topics.
I’d like to acknowledge the on-going support of our regular contributing authors who help keep readers current and I’d like to thank all authors
who helped make the OOhNa Journal a quality publication in 2011.
Looking back over past issues, I am pleased that the number of articles by
or about Occupational health Nurses and OOhNa members continues
to increase.
OOhNa continues to grow because of the commitment and vision of
its Board of Directors who ensure this association offers many benefits
and added value to its members. OOhNa’s insurance plan is secondto-none and is now available to every Registered Nurse in practising in
On behalf of the Board of Directors, the Editorial committee and
OOhNa staff, best wishes for a happy, healthy and safe holiday season
and here’s to a New Year full of readers’ comments, articles and letters
to the editor.
OOHNA JOurNAl n wiNter 2011
n practice
How to run a successful Flu Campaign
by Teresa McCormack
Influenza is a highly contagious acute
viral infection of the respiratory tract that
causes seasonal outbreaks. The most
effective way to reduce the impact of
influenza is annual immunization of persons at high risk, healthcare workers or
others who could carry the virus to those
vulnerable (MOH Toronto p. 1, CDC p.
1). Immunization “is a highly effective
tool…particularly in healthy adults during seasons in which there is a close
match between the vaccine and the
circulating strains…even in years with a
substantial mismatch, the vaccine still
may be partially effective” (Talbot et al p.
987-988) and can, in a health care setting,
reduce the need to use antiviral medications after exposure to the influenza
virus. Although the vaccine can change
year to year, the strategies and objectives
remain the same—to immunize hospital
staff so that should an outbreak occur,
both staff and the vulnerable patient
population are protected.
The Scarborough Hospital (TSH) has
made a conscious effort to increase the
vaccine compliancy rate and generate a
high level of awareness about influenza
for employees, volunteers and students.
In 2009 there was the challenge of two
vaccines—H1N1 and seasonal. Many
Scarborough Hospital staff (68%) took
the H1N1 while only 26% took the
seasonal flu vaccine. This left Employee
Health Services wondering what the
outcome would be for 2010.
Employee Health Services were
pleasantly surprised when for the 20102011 flu season we had a dramatic
turnaround in flu shot compliance over
previous years. We had the second
highest immunization rate among
Toronto’s acute care hospitals, increasing from a compliance rate of 24 % to
45% at the General campus and from
29% to 46% at the Birchmount campus.
Although we did not reach our lofty
OOHNA Journal n winter 2011
goal of a 75% compliance rate by June
2011, our rates were up considerably.
A well-planned and coordinated Flu
Immunization Campaign called “Stick
it to the Flu”, along with excellent communication and easier access for staff
was key to that success. Although the
flu vaccine is not mandatory for hospital staff, it was important to ensure staff
had the information they needed to
make an informed choice. Individuals
were able to discuss their concerns
one-on-one with a nurse so they could
make a decision based on facts rather
than refusing the vaccine outright.
Staff response to flu vaccine
To develop our immunization campaign, we looked at all levels of
hospital staff and identified four different groups based on their reaction
to the vaccine:
1. Those that are convinced immunization is beneficial for themselves,
their families and patients;
2. The fearful—usually of needles or
getting ill;
3. The non-committal—could take it
or leave it;
4. Those that are adamantly opposed
based on their beliefs.
At the start of a campaign, GroupВ 1
is always the first to be immunized.
They don’t require an incentive,
although they do appreciate a small
reward such as chocolate or a coffee
coupon. Group 2 can be convinced
with good education; a reminder of
what it’s like to get the flu and reiteration of how harmful it can be to their
families and patients. Casual conversation, the offer of chocolate and
coffee also help. Group 3 are usually
fearful of needles and illness. They
require privacy, a nurse with compassion and understanding who can
quickly build trust. The Fourth—those
against immunization—have beliefs or
values that are a true barrier. They may
or may not even be willing to talk to a
nurse about immunization. However, if
given the chance, the nurse can help.
By understanding their fundamental
beliefs, she can help them to make an
informed decision. Whether this individual decides to have the vaccine or
not, the nurse needs to let the person
know that their decision is respected.
New approach to immunization
Employee Health Services treated the
campaign as a major project. One
person was the Project Lead for both
the General campus and Birchmount
campus sites. She received senior management support for the program,
including financial resources and staff to
provide immunization. The Employee
Health Team gave a lot of thought to
how we could change attitudes not only
of hospital staff but ourselves as well.
We also needed to constantly monitor
the program, be flexible and willing to
change our approach if certain parts
were no longer working.
In the past, staff was offered the
vaccine through Occupational Health,
at clinics in the hospital that were
available for a few days or they were
approached on the floor randomly.
The US National Foundation for
Infectious Diseases (NFID) literature says
that understanding barriers is the first
step to developing strategies (p.В 13).
Studies consistently show the reasons
for not receiving the vaccine are:
• Concern about side effects and
misinterpretation that the vaccine
can cause the flu
• Perception of low personal risk of
contracting the disease
• Inconvenience
• Lack of knowledge of standards
such as the PIDAC, OHA Guidelines,
or CDC recommendations
• Dislike of needles
practice n How to run a successful Flu Campaign
With the limited success of past
flu immunization campaigns, the
Employee Health Team took these
concerns seriously and addressed each
barrier to success in their planning.
Program Planning
The Employee Health Services Team
used a project management approach
with the goal of increased compliance.
A comprehensive plan was developed
to manage the process, including:
management of the scope of the
project, effective time and resources management, cost containment,
human resources, communication,
risks, and procurement of equipment.
As Project Leader, I developed
a project plan that aligned major
activities, resource requirements and
timelines. I devoted virtually all my
time to the campaign over a 4 week
period. When active clinics took place,
I was responsible for ensuring each
person understood the project plan
and assigned responsibilities. This
avoided misunderstanding and pro-
Strategies to increase vaccination rates in
Health Care workers:
•Select a leader to administer the influenza program
•Get commitment from senior management
•Create a policy statement affirming institutional
commitment to increasing health care worker
influenza vaccination rates
•Use every possible means to deliver messages
•Provide education and re-education
•Make influenza vaccine easily accessible
•Remove cost barriers to immunization
•Audit immunization programs and provide
feedback to key personnel
•Repeat the influenza program annually
NFID, p. 15
Circle your calendar
June 7 & 8, 2012
Keeping Workers Well 2012:
Focus on Mental Health
41st Annual OOHNA Conference
Niagara College,
Accommodation at
White Oaks Spa and The Hilton
Noted Canadian Author and
mental health advocate
OOHNA Journal n winter 2011
How to run a successful Flu Campaign n practice
Essentials of Project Management
• A project manager with strong soft skills
• A plan with major activities
• Resource requirements
• Active management of the process
moted accountability. I met regularly
with the team to track process, discuss
changes and resolve issues. Along
the way, I made adjustments to help
mitigate risks, communicated key deci sions, and set upcoming action dates.
A key area was to regularly keep man agement informed including project
changes, risks and timelines. I oversaw
the preparation and distribution of an
information package, including medi cal directives for use by Educators and
Occupational Health Nurses.
Also as Project Leader, I needed
to order equipment, arrange staffing,
prepare schedules, plan incentives,
and communicate the plan to the
whole team. When looking at supplies,
I ordered the best needles—sharp
and easy to use. The number of carts
increased from 2 to 4 to carry alcohol,
needles, vaccine, consents, directives,
policy, medical directives, epipen,
stickers and fact sheets.
Key members of the planning team
• The Project Manager
• Employee Health Services Manager
• Communications Manager
• Infection Control
• Senior Management to ensure staff
and carts for computers were avail able
• Housekeeping Manager to provide
space, tables, screens, etc.
• Information Services to assist with
set up of software system (Parklane
Simon Module)
• Pharmacy for vaccine availability
• Stores for equipment purchasing
(syringes, alcohol wipes)
• Cafeteria Manager for coffee cards
• Volunteers to assist at clinics
OOHNA Journal n winter 2011
Nursing Staff
Nursing staff for this program came
from the Educator group, as well as
part-time staff nurses, OHNs and modified workers. The Educators were very
supportive of the program and helped
out in all units. Over the first two weeks,
two to three part-time nurses worked
full shifts. Then, as the program targeted specific areas and shifts, the hours
varied. Nurses were selected for their
good clinical technique with injections,
amiability, availability and commitment
to the project.
Senior Management supported the
program by providing:
• The budget, including time and
• Private areas to set up clinics
• The support of Operations Managers
• Support for staff
i)Allowed staff time to go and get
“flu shot”
ii)Arranged to have Occupational
Health Department at staff
meetings to discuss the pros
and cons of vaccination
• Funds for incentives of free coffee
card and draws
Key Considerations
In previous years, immunization carts
were taken around to sites unannounced but it became obvious a
different strategy was needed. For this
campaign, immunization clinics were
set up throughout the hospital to cover
different rotations and schedules so it
was easy for staff to be immunized.
There was planning with the
Pharmacy to ensure there was adequate vaccine available throughout
the campaign.
Consents were colour coded for
volunteers, staff, physicians, students
to enable ease of counting and filing
Information Services ensured that
laptops and scanners ran the Parklane
Software System special module
SIMON so the nurse could scan the
employee card and pull them up on
the system as they were reading and
signing the consent. The system was
set up with vaccine information so the
nurse only had to enter RT or LT arm.
The campaign was branded “Stick it
to the Flu.” This logo was on everything
related to the campaign—posters,
emails, coffee cards, badge stickers.
Clinic set up and immunization
Each clinic had a nurse or Employee
Health secretary to swipe the employee card into SIMON. Once information
was read and the consent was signed,
staff received their shot from the nurse
and returned to the secretary to ensure
the correct documentation was completed in the system. The individual
was then given a small chocolate, a coffee card, sticker for their nametag and
a wallet card with proof of vaccination.
Equipment for each clinic included
chairs, tables, privacy screens, a fully
equipped cart and a computer with
a card swipe system. The carts used
were beauty salon carts on wheels
with mounted sharps containers. Each
cart had a cooler with thermometer to
carry vaccines with pre-loaded syringes. Outside of Employee Health hours
the carts were left for pick up and drop
off in a prearranged locked unit.
To maintain confidentiality, only
Occupational Health Department
staff used the computer. The Parklane
Software System allowed an ease of
administration that freed up staff to
spend more time with individuals hesitant about immunization.
Critical success factors
One of the keys to success was communications. The campaign had
practice n How to run a successful Flu Campaign
3 Senior Management Support
3 Be Prepared
3 Be Flexible
3 Never start until you are ready
the full and active support of the
Communications Manager. His understanding of and experience with
multiple communications channels
such as branding, posters/ signs, stickers for name tags, developing the
coffee cards, announcements using
the new intranet dedicated site which
complimented e-mails, helped get
the message to all staff. However,
none of this would have happened
without Senior Management support.
They were supportive right from the
beginning, providing the budget and
resources the campaign needed.
Maintaining confidentiality of medical
information which includes immunization status is critical. For this reason, it
was decided that Unit Nursing Managers
would not give flu shots as has been
done at other healthcare facilities. Unit
Managers would get immunization
status of staff from Employee Health
Services only when there was a confirmed flu outbreak on their site. This
helped maintain confidential medical
information within Employee Health.
With any immunization campaign,
it is important to be sensitive to staff
values and beliefs. Taking the time
to develop rapport and be sensitive to their concerns can influence
their decision to be immunized in the
future. It’s a fine line between making
your self available to give shots and
appearing to be harassing staff. Staff
need to be non-judgmental as immunization is not mandatory and people
have the right to refuse
change your strategy as you play the
game. You need to be flexible, know
when to move forward and when to
retreat. Most importantly you need to
acknowledge and honour staff decisions about flu vaccination.
Medical officer of Health. (2010). MayВ 17.
Influenza Immunization Rates in
Toronto Healthcare Facilities.
Public Health Protection and Prevention
Branch Ministry of Health and LongTerm Care. (2010). September.
Universal Influenza Immunization
Program Manual.
The Canadian Immunization Guide, 7th
Edition. (2006).
The College of Nurses of Ontario. (2008).
Medication Practice Standard
The College of Nurses of Ontario.
(2010). Fact Sheet: Practice Guideline
Influenza Vaccinations.
National Foundation for Infectious
Diseases. (2004). Improving Influenza
Vaccination Rates in Health Care
Workers: Strategies to Increase
Protection for Workers and Patients.
Canadian Healthcare Influenza immunization Network. (2010). Successful
Influenza immunization Campaigns
for Healthcare Personnel: A Guide for
Campaign Planners. (
Center for Disease Control and
Prevention. (2008). July 17, Vol. 57
Morbidity and Mortality Weekly
Report: Prevention and Control of
Influenza Recommendations of the
Advisory Committee on Immunization
T. Talbot, H. Babcock. A.L. Caplan,
D.Cotton, L.L.Maragakis, G. A. Polland,
E. J. Septimus, M.L. Tapper, D.J.
Weber. (2010). October, Vol. 31, No 10.
Revised SHEA Position Paper: influenza
Vaccination of Healthcare Personnel,
Infection Control and Hospital
OOHNA member, Teresa McCormack,В rn
works at The Scarborough Hospital,
Scarborough, Ontario.
Teresa thanks Marg Creen, rn, bscn, cohn(c),
and Anne K. Sowden
for their assistance in preparing this article.
cohn-s, cdmp, ma(dm)
A successful Flu campaign is like a
game of chess. In chess, you need to
OOHNA Journal n winter 2011
n practice
Development of an Integrated Health
Services Program by Rebecca Kwiatkowski
This article focuses on the development of an organization’s Integrated Health Services program.
Keeping workers well is what occupational health nurses are all about.
Workers who are well increase the
health of an organization which then
increases an organization’s profitability, lowers absenteeism and promotes
higher productivity.
The value of Integrated Health is
achieved by using best practices
including employee engagement (organizational initiative); programs (design,
delivery and systems technology); and
measurement (processes, risk reduction, financial and quality). According
to Watson Wyatt (2008) findings, companies with the most effective health
and productivity programs have superior financial returns and improvements.
Integrating programs and practices can
foster greater employee participation,
productivity and retention.
An integrated approach to tracking, measuring and addressing the
key determinants of any workforce and
organization’s health is necessary to
achieve and maintain a healthy organization. Four key areas of potential
risks: Clinical Operations; Wellness
and Leadership Operations; Employee
Assistance Programs; Claims Management Processes. Deficiencies plus the
potential risk exposures inherent in
those deficiencies assist in developing
an Integrated Health Services program. Figure 1 illustrates the risks of
non-integrative thinking.
Clinical Operations
Deficiencies in clinical operations may
result in increased potential risks for
the employer.
At ArcelorMittalDofasco we use
benchmarking to determine best
practices and resource mixes to deter-
OOHNA Journal n winter 2011
Clinical Operations Deficiencies
Potential Risk Exposure
• Inefficient/non existent consent
• Inadequate documentation
• Inefficient staff utilization
• Metrics captured not analyzed
• No accountability—no structure
• Inadequate clinic assessment
• Breaching current privacy laws
• Increased litigation potential
• Surplus of FTE’s—budget constraints (Financial)
• Inappropriate design/operational changes (Operational)
• Human rights case potential if
employee not properly assessed
and placed
mine best service tor employees. We
try to increase staff utilization to 100%
in order to decrease the need for
FTEs. We use the same return-towork approach for occupational and
non-occupational process, clarifying
accountability within each stage of the
return-to-work process.
Employee Assistance Programs
An EAP that does not follow the allinclusive model may result in increased
third party referrals that will affect
the company’s bottom line. Programs
that do not report utilization details
cannot be benchmarked and could
Wellness and Leadership
result in wellness initiatives that are
Deficiencies include non-integrated
wellness programs where metrics are
not used to make decisions regarding
the success or failure of the programs.
Potential risks from flawed and
unsuccessful programs have financial implications for an employer and
health implications for the workforce.
In our program we annually identify four initiatives to focus on based
on short-term (STD) and long-term
disability (LTD) statistics; WSIB diagnostics, the resources available and
EAP reporting metrics. We support
these initiatives by having the EAP
provide wellness seminars which have
been proven to assist in lowering
the incidence and frequency of STD
and financial terms. Programs limited
misaligned and costly in operational
only to employees (excluding their
families) are counter-productive, narrow in scope and could lead to lower
After extensive research, ArcelorВ­
MittalDofasco contracted with a new
EAP who offers an all-inclusive model
to support other program initiatives
and assist in evaluating performance.
By reporting metrics we are able to
align wellness initiatives with our EAP
to assist in integration.
The program actively encourages
the participation of employees and
we are seeing the results in improved
attendance productivity as the overall
health of employees improves.
Development of an Integrated Health Services Program
Claims Management Processes
With the recent changes to the
Occupational Health & Safety Act, the
Accessibilities Act, and the Human
Rights Act, proper management of
the claims process is very important
and the risk exposure very costly. For
example, a program designed with
two providers and an inefficient pay
structure does not allow for a seamless transition from STD to LTD.
Depending upon the policy’s elimination period (i.e. 52 vs 26 vs 17 weeks)
there may be no financial motivation for an employee to return to
work. Policies that are not transparent
and have barriers to information can
lead to increased risk in the “Duty
to Accommodate” (a Human Rights
issue) and missed opportunities for
early return-to-work which has negative financial, medical, operational
and HR implications.
The ArcelorMittalDofasco integrated health program has initiated the
following process to manage claims:
1. Undertake an Overall Needs
1.1 Measure total costs of claims
paid and associated metrics
2. Gap Analysis
Review provider contract
3.Claims Audits
3.1Provider audit to determine
standards and adherence to
best practices
4. Quarterly reviews with providers
5. Monthly reviews with internal stakeholders
Figure 1: Risk with Non-Integrative Thinking
Education via Wellness
Paramedical Services
(Control of Finances)
Drug Utilization
(+ Financial Risk)
Short Term Disability
(Control of Finance)
Return to Work Efforts
Systems Thinking Leads to Better Outcomes
Copyright В© ArcelorMittalDofasco
Figure 2: Integration—An Example
An Organization’s Current
Functional Abilities Evaluation
Process (FAE)
Proposed Functional Abilities
Evaluation Process
• HR identifies employee for redeployment/transfer;
• HR identifies employee for
• Employee screened at clinic and
sent offsite to external provider
for FAE;
• Employee clinically assessed by
physicians and physical/cognitive
abilities form completed;
• Report received in clinic and HR
sends available job profiles;
• Form sent to family physician for
sign off and to confirm no other
conditions exist;
• Nurses pull all Physical Demands
Analyses and job matches as per
report received from external
• Recommendation sent to HR.
• Form received by Claims Depart­
ment who request top three
available positions from HR;
• Job profiles sent to H&S to pull
• PDA’s sent to claims and forwarded to Business Unit Manager for
review and validation;
Integrated Health Program—
With many organizations, functions are
separated and are designed to address
problems without considering “the big
picture”. Problem solving using other
departments helps to mitigate issues
and to address other issues which
would otherwise go unnoticed. For
(Financial Investment)
• Once validated, H & S updates
spreadsheet and Claims DepartВ­
ment proceeds to job match;
• Report sent to HR and Business Unit
Manager with recommendations.
Copyright В© ArcelorMittalDofasco
OOHNA Journal n winter 2011
Development of an Integrated Health Services Program n practice
example: Your Medical Department
should consult the Employee Relations
Department when a complex case
involves performance issues. These
cannot be addressed as stand-alone
issues when one issue overlaps with
another. Unless both are addressed, it
becomes a never-ending cycle.
The Integration example in Figure
2 illustrates communication between
several departments allowing Health
& Safety to update Physical Demands
Analyses (PDA); shared accountability
with Business Unit Managers; filtering
of information from Human Resources
(HR); clinical assessment by clinic services and due diligent sign off by
employee’s attending physician.
Baseline Benchmarking is key to a
successful Integrated Health program.
It focuses on primary prevention in mitigating high risk claims. Benchmarking
at ArcelorMittalDofasco follows these
kReview drug utilization
• Identify the most utilized
drugs and paramedical services
kReview claims data
• STD/LTD—identify top five
diagnostics for each
• WSIB—identify top reasons
for Lost Time Injuries (LTI)
n DO
kAnalyze data to determine key
indicators (identify triggers)
OOHNA Journal n winter 2011
kCreate/organize wellness initiatives to mitigate those numbers
Schedule a quarterly meeting with a representative from
claims, Clinic Services Manager
of Integrated Health, Wellness
and EAP Coordinator to discuss
contentious claims.
kContinuously re-evaluate efforts
kMake benchmarking continuous
The goal of an Integrated Health
Services model should be to accommodate employee illness and
disability and support employees
dealing with chronic diseases while
striving to maintain a productive workforce and profitable organization (see
Figure 4). An integrated approach to
tracking, measuring and addressing
the key determinants of workforce and
organizational health is necessary in
achieving and maintaining a healthy
organization (Watson Wyatt 2008).
This Integrated Health Services
model has been employed for one
year and at the time of writing this
article, Claims has just been integrated. As such, cost-savings can
expect to be realized by the end
of 2012. Positive feedback, increased
participation in wellness initiatives and
happier employees are already being
realized. And there are plenty of stud-
ies that have proved a positive return
on investments.
The Integrated Health department
has seen many successes. A structured
and well-executed service brings with
it a positive variance in several ways,
• Increased participation in several
internal wellness initiatives
• Decrease in the frequency and
duration of disability claims
• Decrease in incidental absenteeism
• Decrease in the use of specific
drugs and paramedical services
• An increase in Workplace Assess­
ment Programs
• An overall increase in the health
and productivity of the overall
workforce, etc.
The biggest success which will
translate into all the above mentioned
positives is a strong, dedicated,
knowledgeable team with a strong
work ethic and a clear vision of where
they are headed. The buy in and
the team’s understanding is crucial to
develop and maintain an Integrated
Health model.
In summary, the pathway to a
Healthy and Productive Workforce is
to cultivate a workforce that is healthy,
productive and engaged in an effort
to thrive in a global and competitive
business environment. To accomplish
this, practice these seven steps:
1.Make Integrated Health part of
broader culture by connecting
to organizational goals, promoting healthy work environment and
practice n Development of an Integrated Health Services Program
Figure 4: Organizational Realignment
Most Effective at Reducing
Most Effective at Improving
Employee Health
• Clinical case management
• Written transitional return-to-work
• Physical health risk screening
• Operation Manager involvement
in absence management
• Performance standards for vendors
• Written transitional return-to-work
• Ergonomic work stations
• Job descriptions including cognitive demands analysis
• Non occupational injury prevention
• Clinical case management
• Physical health risk screening
• Return-to-work plans specific to
mental illness
• Educational programs for chronic
Most Effective at Improving
Employee Satisfaction
Most Effective at Increasing
• Work/life balance
• Fitness subsidy/ onsite
• Written transitional return-to-work
• Return-to-work plans specific to
mental illness
• Educational programs for chronic
• Mental health risk screening
• Ergonomic work stations
• Mental health risk screening
• Return-to-work plans specific to
mental illness
• Written transitional return-to-work
• Physical health risk screening
• Educational programs for chronic
• Ergonomic workstations
• Job descriptions including cognitive demands analysis
2.Identify and deal with stress by
working to reduce stigma and
create programs to manage and
balance work and life.
3.Integrate data across programs,
measure performance and achieve
higher levels of engagement.
4.Regularly analyze data to identify
opportunities, re-design programs
to meet user needs.
5. Simplify programs, integrate delivery
and consolidate program vendors to
improve program utilization.
6.Offer incentives to promote wellness strategy.
7. Engage support of senior leaders.
Watson Wyatt (2008) [email protected]
Rebecca Kwiatkowski, rn, bscn,В msc
is Manager of Integrated
Health, ArcelorMittalDofasco
([email protected]).
Rebecca thanks OOHNA Journal
managing editor, Frances MacCusworth
for her assistance in preparing this article.
Copyright В© ArcelorMittalDofasco
McCague Borlack
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OOHNA Journal n winter 2011
n practice
by Victoria Pennick
In the Spring 2011 issue of the OOHNA
Journal, I said that over the next couple
of issues, I would give you a brief overview of tools that will help you evaluate
and understand the literature, so that
you would more readily be able to use
it to inform your practices.
Let me start with some definitions,
to make sure everyone is on the same
page. Epidemiology is the “study of
the distribution and determinants
of health-related states or events in
specified populations”. The aim is
to identify the cause, scope, natural history, prognosis and treatment
of a disease. (Gordis, p. 3). Clinical
epidemiology is the application of
the science of epidemiology in a clinical setting, where the emphasis is
on a medically-defined population.
While there are some basic differences between the two disciplines,
they have converged on more levels
over time (Fletcher, p. 2) and for all
intents and purposes, the delineation
likely isn’t that important when you
are looking for scientific evidence to
inform your healthcare decisions.
There are many excellent text
books, articles and websites on
both Epidemiology and Clinical
Epidemiology, so I am only going to
give a brief overview of some of the
more important concepts you need to
understand in order to comprehend
information presented in a research
article on prevalence, etiology, natural
history and treatment.
Incidence, prevalence, and the
burden of the disease/disorder
Incidence is the number of new cases
of a disease (events) that occur during
a specified time period in a population that is at risk. (Gordis, p. 32). For
example: you have read that the annu-
OOHNA Journal n winter 2011
al incidence for occupational-related
neck pain can be as high as 47% (CГґtГ©
2008). Two years ago, there were 100
workers in your organization who used
a computer and/or telephone for up
to seven hours a day in the course of
their work; that year, the Occupational
Health Unit documented 47 complaints of neck pain, although not all
of them required time off. Last year,
due to the economic slow-down, 20
workers from this section were laid off;
47 complaints of neck pain were documented in the Occupational Health
Unit. What was the incidence?
Prevalence is the proportion of
affected persons in the population at
a specific time—either a point in time
(point prevalence) or during a period
of time (period prevalence). (Gordis,
p.В 33). This is calculated by dividing the
number of cases by the total population and multiplying by 100 (multiples
of 100 are used for larger populations,
so you will generally see prevalence
per 1000 or higher). Using the example above, the annual prevalence two
years ago of those who reported neck
pain was 47 per 100. What was the
annual prevalence per 100 last year?
When you look back at your records,
you see that during last July, there were
10 visits to the Occupational Health
Unit for complaints of neck pain. What
was the prevalence per 100 of reported
neck pain last July?
Burden of illness takes into account
the number of people affected, their
capacity to perform their usual activities and the costs incurred because
they are unable to perform their usual
activities. The burden of illness is generally considered on a societal basis;
the total number of days of sickness
absence, the cost of replacement
workers, cost of care, wage replacement, workstation re-engineering,
etc. Looking again at the neck pain
scenario, let us assume that of the
47 people who reported neck pain
last year, only 5 people (almost 10%)
missed work, for an average of five
days each; the cost of re-engineering
their workstations was an average of
$100 each (work station assessment by
the Occupational Health Nurse, new
mouse pads, head-sets, etc); none of
them had to be replaced during their
absence. The burden of illness to the
company wasn’t too great—even if
they decided to be pro-active and follow the same �treatment’ for the rest of
the workers in this section. Compare
this to a more systemic illness with a
poorer natural history and prognosis.
Over the past two years, there were
two workers (less than 5%) from this
same section diagnosed and treated
for cancer. They were off for three
months each and then started gradually assuming their previous duties,
returning to full duties after another six
weeks; a part-time temporary worker
was hired to cover their jobs while they
were away on a full-time basis. Which
health condition contributed to the
largest burden of illness?
Of course, burden of disease isn’t
quite that straight-forward. Those who
reported neck pain but didn’t take
time off may not have been working to
their full capacity. We don’t know how
successfully the workers with cancer
integrated back into the workforce when
they came back. In 1996, in an attempt
to measure the impact of different diseases on a regional basis, scientists
from Harvard and the WHO developed
a measure called the �disability-adjusted
life year’ (DALY), which measures the
loss (in years) of healthy life and covers
both years lost to premature death and
years lost to disability. (Gordis, p. 58,
Murray 1996, WHO website)
Informing your practice with evidence—Epidemiology 101
Data to calculate incidence and
prevalence may be collected from
population surveys, health records, and
other demographic records (i.e. birth
and death registers, etc). Accuracy of
reporting, collection and interpretation
of data is important for credible results.
Association, causation,
diagnostic tests, treatment
In order to understand an abnormality
(disorder/disease), it is important to first
understand what �normal’ looks like.
Epidemiology generally assumes that
there is a �normal distribution curve’
with which most of us are familiar. This
means that the majority of people will
exhibit the particular characteristic of
interest, with some on either end of the
curve who have much more or much
less than those in the middle. The
�norm’ is often regarded as the 90% to
95% of the population that lies in the
middle. (Weisstein).
An external factor that affects the
�normal distribution’ or natural history
is called a �confounder’, a �confounding
variable’ or a �risk factor’. �Association’ is
the relationship between one or more
factors (variables) and the development
of an abnormality, disorder or disease,
which may or may not prove to be the
cause of the disorder. �Causation’ may
be tested by measuring the same—or
similar—group of people over time to
observe their exposures to risk factors
and the result, thus building up a body
of evidence to support a hypothesis of
cause and effect. (At Work, #41, Gordis,
p. 184-195).
While this may be interesting background information, most people
really want to know what the problem
is and how it can be fixed. As healthcare practitioners, you are expected
to come up with a diagnosis and
suitable treatment to alleviate the
symptoms—and hopefully the cause
of them. Nurses and other clinicians
arrive at a diagnosis by gathering
information on the physical, psychological and/or sociological factors
(variables) to which the patient/client
may have been exposed and consid-
ering them in light of the presenting
factors (signs and symptoms). But how
do we narrow things down? This is
where an understanding of the normal
and relative probabilities of different
abnormalities comes in. What is the
likelihood that each of the possible
factors is at fault?
In many situations, a diagnostic
test will be undertaken to rule out
and/or confirm a diagnosis. How accurate are these tests? Well, it depends.
What is the agreed upon �reference
standard’ (threshold of abnormality)?
Will the results of the test identify
those with the disease without unduly
alarming those who don’t have it? This
is the sensitivity of the test. Will it also
rule out those who do not have the
disease without missing some who
do? This is the specificity of the test.
These values are commonly displayed
in a 2 x 2 table, showing the number of
cases that fall into each of the four categories (true positive, false positive,
true negative, false negative). The
relationship between the four values
is expressed as a likelihood ratio. It
is preferable to have simultaneously
high likelihood ratios for both positive
and negative test results. The degree
to which this is possible depends
on the availability of an agreed-upon
reference standard, the accuracy of
the test, and the validity and generalizability of the studies that evaluated
the test. (DiCenso, p.В 87-102). How
many of you realized that you were
using epidemiology and clinical epidemiological concepts when you
made a diagnosis?
Once a diagnosis is made, the goal
is to make treatment decisions that
will cure (and heal) the individual. I
touched on the importance of assessing the accuracy of a diagnostic test;
it is also important to assess the efficacy and effectiveness of a treatment.
Does it work in the best of all possible circumstances (i.e. is it efficacious
against a placebo, in the laboratory)?
How effective is it against other treatments for the same ailment? What are
its side effects? Does the patient think
it is worth trying? Is it available in your
practice setting? Are the results of the
studies that examined its effects valid
and generalizable to your population?
(DiCenso, p. 87-102).
Types of studies
Depending on the clinical question,
there are three broad classifications of
studies that can be used in an attempt
to find the answer. Broadly outlined,
they are: observational, experimental
and qualitative.
As the name suggests, in an observational study, researchers observe the
effect of a risk factor, diagnostic test
or treatment without trying to influence what happens. Such studies are
usually “retrospective” — the data
are based on events that have already
happened. Most workplace health
research falls into this category. There
are a number of specific study designs
that fall under this classification.
Cohort study: For research purposes, a cohort is any group of people
who are linked in some way and followed over time. Researchers observe
what happens to one group that’s been
exposed to a particular variable — for
example, the effect of company downsizing on the health of office workers.
This group is then compared to a similar group that hasn’t been exposed to
the variable. (At Work, #42).
Case control study: Here researchers use existing records to identify
people with a certain health problem
(“cases”) and a similar group without
the problem (“controls”). Example: To
learn whether a certain drug causes
birth defects, one might collect data
about children with defects (cases) and
about those without defects (controls).
The data are compared to see whether
cases are more likely than controls to
have mothers who took the drug during pregnancy. (At Work, #42).
Cross-sectional study: A crosssectional study compares different
population groups at a single point
in time—similar to taking a snapshot.
Findings are drawn from whatever fits
OOHNA Journal n winter 2011
Informing your practice with evidence—Epidemiology 101 n practice
into the frame of the clinical question.
(At Work, #55).
Longitudinal study: A study in
which researchers conduct several
observations of the same subjects
over a period of time, sometimes lasting many years. (At Work, #55).
In experimental studies, researchers introduce an intervention and
study the effects. Experimental studies are usually randomized, meaning
the subjects are grouped by chance.
While not all controlled studies are
randomized, all randomized trials are
Randomized Controlled Trial
(RCT): Eligible people are randomly assigned to two or more groups.
One group receives the intervention
(such as a new work-station) while
the control group receives nothing,
an inactive placebo, or another intervention (continues with the same
work-station). The researchers then
study what happens to people in each
group. It is important to be able to
isolate the difference in outcomes that
are specifically a result of the intervention. (At Work, #42).
Controlled Clinical Trial (CCT):
Subjects are assigned to two or more
groups and receive different interventions, but the allocation to the
group is not random. This increases
the chance that people may end up in
each of the groups in a way that could
influence the final results and decreases our confidence in the results. (At
Work, #42).
of the analyses, strengths and limitations of each of these study designs.
Please do not hesitate to contact me
if you have specific questions.
At Work, Issue 41, Summer 2005: Institute
for Work & Health, Toronto
how to understand it. Journal of the
Ontario Occupational Health Nurses’
Association; 30: 21-22.
Weisstein, Eric W. “Normal Distribution.”
From MathWorld—A Wolfram Web
(accessed October 31, 2011)
At Work, Issue 42, Fall 2005: Institute for
Work & Health, Toronto
WHO website; Global burden of disease.
At Work, Issue 55, Winter 2009: Institute
for Work & Health, Toronto
of_disease/en/ (accessed OctoberВ 31,
At Work, Issue 64, Spring 2011: Institute
for Work & Health, Toronto
CГґtГ© PD, van der Velde GD, Cassidy
JDD, Carroll LJP, Hogg-Johnson SP,
Holm LWD,et al. (2008) Burden and
Determinants of Neck Pain in Workers:
Results of the Bone and Joint Decade
2000-2010 Task Force on Neck Pain
and Its Associated Disorders. Spine
33:В S60-S74.
DiCenso A, Guyatt G, Ciliska D. (2005)
Evidence based nursing: a guide to
clinical practice. St Louis, MO: Elsevier
Fletcher R, Fletcher S, Wagner EH. (1982)
Clinical Epidemiology—the essentials.
Baltimore, MD: Williams & Wilkins.
Gordis L. (2000) Epidemiology. (2nd ed.)
Philadelphia, MD: W.B. Saunders
Murray CJL, Lopez AD, eds. (1996) The
Global Burden of Disease: a comprehensive assessment of mortality and
disability from diseases, injuries, and risk
factors in 1990 and projected to 2020.
Cambridge: Harvard University Press.
Pennick, V. (2011) Informing your practice with evidence—where to find it;
Vicki Pennick, rn, mhsc ([email protected] is a nurse who holds a
Masters Degree in Health Science—Health
Administration. She is currently working as
a Freelance writer and editor. She is the
past Managing Editor of the Cochrane
Back Review Group and was a Lecturer with
the Dalla Lana School of Public Health,
University of Toronto until June 2011. She
collaborated with and has presented to
international and local clinical researchers, rehabilitation service providers and
trainees and has a number of publications and continues to be active with her
nursing and management professional
organizations. Vicki is a past member of the
Registered Nurses’ Association of Ontario
(RNAO) Board of Directors; past Director of
Communications, RNAO Nurses’ Research
Interest Group; and Past President of the
Board of Flemingdon Health Centre, a
Community Health Centre in Toronto.
Throughout her career, Vicki worked with
individuals in the community who were living with a variety of injuries, diseases and
disabilities and has come to appreciate the
challenges faced by them, their families
and their treatment team. This experience
helped to inform her research, academic
and volunteer activities.
Qualitative research tries to make
sense of human experience, beliefs and
actions. Researchers collect information
that occurs naturally by interviewing
and observing people, analyzing documents and conversations. They do not
try to manipulate the environment.
Qualitative research describes and
explains a situation and is often used to
generate hypotheses for experimental
studies. (At Work, #64).
In the next issue, I will review some
OOHNA Journal n winter 2011
Research n
Predicting RTW following acute
low-back pain by Cindy Moser
As an Occupational Health nurse,
knowing what factors contribute to
work absences following an episode
of acute low-back pain can help identify those workers likely to run into
trouble in returning to work. It can also
help in the design of workplace programs and individual care plans that
keep workers with low-back pain on
the job—or help them return to work
as soon as safely possible.
A systematic review completed in
August 2011 by the Institute for Work
& Health (IWH) has helped identify
these factors. Led by IWH Associate
Scientist Dr. Ivan Steenstra, the review
points to a number of issues present
at the beginning of a work absence
due to low-back pain, such as recovery
expectations and the offer of modified
work, that affect the length of time
before returning to work.
“By identifying these factors, we can
potentially use them to screen those
workers at high risk of long-term disability,” says Steenstra. “We can also try
to modify those practices or factors that
are shown to negatively affect return-towork in order to improve outcomes.”
In this review, Steenstra and his team
searched the research literature for
studies that reported on low-back pain
and sick leave that lasted more than
one day but less than six weeks (i.e. they
were not studying chronic, or long-term,
back pain). They looked for evidence on
the relationship between return-to-work
(RTW) outcomes and factors related to
the low-back pain itself, the worker, the
job and/or the psychosocial work environment. In the end, the team identified
30 relevant publications from 25 studies.
The findings: recovery
expectations strong predictor
of RTW
The team found strong evidence
(consistent findings in multiple high-
What factors affect how long it
will take workers to return to work
following an episode of acute lowback pain? A recent systematic review
from the Institute for Work & Health
points to a number of them, including
workers’ recovery expectations and the
offer of modified work.
quality studies) that the following
factors influence RTW among those
with acute low-back pain:
• workers’ recovery expectations
(i.e., their predictions about how
likely it is they will return to work
and/or how long it will be before
they are able to return);
• work-related factors, including
physical demands, job satisfaction
and the offer of modified work;
• workers’ self-reported pain and
functional limitations;
• the presence of radiating pain (as a
marker for injury severity); and
• the type of health-care provider
(e.g., chiropractic versus other
types of care).
Screening for some of these factors can help health-care professionals
predict who may be at high risk of
poor outcomes and need extra help
returning to work, Steenstra says.
In particular, asking about recovery
expectations, functional limitations,
pain intensity and job satisfaction during the early stages of a low-back pain
episode may be particularly telling.
What’s more, some of these factors are potentially changeable and,
therefore, can be addressed to help
improve RTW outcomes, Steenstra
says. He points to the finding about
the importance of recovery expectations—the prognostic factor
supported by the most evidence in
this systematic review. “Health-care
providers can provide patients with
positive information about prognosis in low-back pain,” he says.
“By doing this, they can influence a
patient’s recovery expectations and
help the patient in his or her return
to work.”
As well, offering modified work
can also improve outcomes. Steenstra
adds that modified work means just
that: returning the injured worker to
his or her old job, which has been
changed to accommodate the worker’s functional limitations. “It doesn’t
mean returning a worker to a different
job, like returning a shop floor worker
to a desk job in the office,” he says.
Interestingly, the evidence did not
point to depression as a factor affecting RTW in the early phase of low-back
pain. “It appears that mental health
is not a predictor of return-to-work
until back pain becomes chronic,”
says Steenstra.
OOHNA Journal n winter 2011
Predicting RTW following acute low-back pain n Research
Discrepancies withВ practice
Armed with these prognostic factors,
Steenstra decided to investigate if
these factors were also understood on
the front lines of helping workers with
low-back pain. Earlier in 2011, he and
his team conducted two workshops
in Winnipeg, Manitoba, with 34 participants—clinicians, work-disability
professionals and workers’ compensation case managers and medical
examiners. More recently, in October
2011, he conducted a similar workshop with 12 leading chiropractors in
Participants were given cards that
represented the most often reported
prognostic factors identified in the
systematic review. They were then
asked to discuss the importance of
each factor and determine how relevant it was to RTW, based on their
own experiences.
If you are like those who took part
in the workshop, the beliefs you bring
to your practice about the factors that
affect return-to-work among those
with acute low-back pain may not
accord with those found in the systematic review. “There were discrepancies
between research and practice,” says
…modified work means just that: returning the injured worker to
his or her old job …
Steenstra of the workshop’s results
(see Table 1 below).
However, Steenstra says it’s heartening that practitioners and the research
evidence agree that modified duties
are important. “This is something over
which the workplace parties, including
occupational health nurses, exercise
a fair degree of control,” he says.
“Therefore, this is something they
can address to improve return-to-work
The systematic review was funded
by Manitoba’s Workers Compensation
Board. The Manitoba Board is now
funding further research by Steenstra
on RTW and low-back pain—this time
on the prognostic factors that affect
RTW among workers with chronic
back pain.
Dr. Steenstra’s full systematic review
can be downloaded from: www.iwh.
pain-rtw-prognostic-factors. To keep
up on other research and news from
IWH, sign up for the Institute’s free
e-alerts at:
Cindy Moser is Communications Manager
at the Institute for Work & Health
([email protected])
The Institute for Work & Health is a
Toronto-based, independent, not-for-profit
research organization. Its research focuses
on two main areas: (1) the prevention
of work-related injury and illness, and
(2) the prevention, management and
compensation of workplace disability.
Table 1: RTW and low-back pain: Agreement between research and practice
Important according to practice
Evidence from review
Moderate evidence for NO effect
Fear avoidance beliefs
Insufficient evidence
Fear of movement (kinesiophobia)
Insufficient evidence
Non-work psychosocial factors
Insufficient evidence
Workplace psychosocial environment
Moderate evidence
Workplace modified duties
Strong evidence
Claim-related factors
Moderate evidence
No consensus, but strong evidence of having an effect: type of health-care provider (9/10)*, recovery
expectations (8/10), pain (8/10), disability (7/10), workplace-physical factors (7/10), radiating pain (5/10). *
This means nine of the 10 groups (of four to five professionals each) in the three workshops agreed on the
importance of the factor.
OOHNA Journal n winter 2011
Research n
Predicting prolonged work absences
among nurses by Cindy Moser
A recent study from IWH examined
prognostic factors concerning work
absences among Canadian nurses.
The study looked at the personal and
work-related factors that contribute
to absences longer than two weeks
among nurses.**
The study collected information
on almost 12,000 female, direct-care
Canadian nurses from Statistics Canada’s
2005 National Survey of the Work and
Health of Nurses. Factors related to
nurses’ personal health and their workplaces were examined relative to three
categories of work absences: none,
short-term (one to 10 work days) and
prolonged (11 or more work days).
Worker health factors—namely pain
that interfered with the ability to work,
more severe pain, depression and having a higher number of chronic health
conditions (such as arthritis, migraine
and back pain)—had the biggest effect
on the length of nurses’ work absences.
Workplace factors had a smaller effect
overall, with those having the most
impact being emotional or physical
abuse by a patient, visitor or co-worker,
and low respect and low support at work.
Given this finding and the fact that the
health-care sector has the highest rate
of lost-time claims and work absence
in the country, Occupational Health
nurses in Canada’s health-care organizations may want to join forces with
their counterparts in human resources
to implement violence prevention and
respectful workplace programs. “Our
findings suggest that violence prevention is also work absence prevention,”
says IWH Adjunct Scientist Dr. RenГ©eLouise Franche, a clinical psychologist
at Vancouver General Hospital who
led the study looking at the impact
of worker and workplace factors on
absenteeism among nurses.
The study’s findings suggest a
number of ways in which health-care
organizations can help decrease time
away from work among nurses.
“According to our study, being
abused or assaulted on the job is
strongly associated with nurses having
prolonged work absences,” Franche
continues. “It is also indirectly connected by creating a poorer workplace
culture and lower respect and support from co-workers, both of which
are associated with increased work
absence duration.”
The combined effect of worker and
workplace factors was the most novel
finding in this study, as few previous
studies have examined this. Take painrelated work interference, for example,
the factor most strongly associated
with prolonged absences among nurses. “It looks like pain interference is a
product of both worker and workplace
factors,” says Franche. “That is, the
degree to which pain interferes with
work may depend not only on a nurse’s
pain level, but also on the demands,
both physical and social, of the environment in which she works.” Potential strategies to reduce
long absences
The study’s findings suggest a number
of ways in which health-care organizations can help decrease time away
from work among nurses. Franche
points to these potential strategies:
Implement or augment violence
prevention programs. “Many healthcare organizations have implemented
violence prevention programs since
the 2005 study year,” says Franche.
“But they need to keep vigilant on
this front.”
Address respect, support and
organizational culture. This includes
nurses’ feelings of control over their
practice and autonomy at work, as
well as their relationships with doctors
and co-workers.
Focus disability management practices on workers who are still on the
job but struggling with multiple physical and mental health conditions.
Offer self-management programs
that address pain and depression,
focusing on the work environment.
“The workplace doesn’t have full control of workers’ pain and depression,
but it can help deal with issues by
offering self-management approaches,” says Franche. “For example, more
workplaces are offering relaxation and
meditation courses, and these could
be extended to include strategies on
how to manage symptoms and episodes at work.”
Cindy Moser is Communications Manager
at the Institute for Work & Health
([email protected])
The Institute for Work & Health is a
Toronto-based, independent, not-for-profit
research organization. Its research focuses
on two main areas: (1) the prevention of
work-related injury and illness, and (2) the
prevention, management and compensation of workplace disability.
** The study was funded by the Ontario Workplace Safety and Insurance Board’s Research Advisory Council. Its findings were published in the August 2011 issue of the Journal of
Occupational and Environmental Medicine (vol. 53, no. 8, pp. 919-927). Reprinted with permission.
OOHNA Journal n winter 2011
n practice
Ethical Dilemmas in the Workplace
by Dr. Tom Foreman
Editor’s note: Based on the overwhelming positive feedback received from attendees at Dr. Foreman’s March
2011 Ethics webinar, the OOHNA Journal asked Dr. Foreman to write an article.
Case 1
You have an employee who may
be diabetic and works around moving equipment. The employee has
informed his co-workers that he doesn’t
take his medication or snacks as he
should and believes that his diabetic status is nonsense. The co-workers
have informed the supervisor that at
times the employee appears to “not be
himself”, but cannot explain what they
mean by this. The supervisor contacts
the Occupational Health nurse (OHN)
stating that he has not observed the
behavior directly but has spoken to the
employee about this. The employee
believes that his co-workers have “ratted him out” and denies that he is
diabetic. How does the OHN address
patient choice in this instance while
at the same time respecting patient
privacy as well as protecting other
employees from potential harm?
Case 2
The OHN sees an employee who is
claiming a work-related back injury that
occurred on Tuesday morning while
lifting a box in the store room. He
has reported the incident and has filed
his WSIB form. Both the OHN and
employee are volunteer fire fighters
and you had a strenuous training on
the Saturday prior. You observed the
employee rub his lower back; the area
which he is now claiming was hurt at
work on Tuesday. What do you do?
Do the above scenarios sound familiar? Perhaps they are too familiar. As
Occupational Health nurses you are
often faced with difficult and complex issues which are multi-faceted
and not easily resolved. As in the first
instance above they may be as much
about interpersonal conflict as they
OOHNA Journal n winter 2011
How do you balance a patient’s right
to privacy against your obligation to
prevent abuse of the system?
are about good nursing or, as in the
second instance, as much about your
own personal values as they are about
obligations to your employer. How do
you balance a patient’s right to privacy against your obligation to prevent
abuse of the system? How can you
receive information from employees
that may protect the health and safety
of a co-worker and at the same time
not become enmeshed in the interpersonal conflicts ever present in any
work environment? Are there tools and
frameworks available to assist you in
balancing the conflicting obligations
and responsibilities you face as an
Occupational Health nurse?
The College of Nurses of Ontario
(CNO) lists a number of professional
standards that nurses are expected to
uphold, these include:
• Promoting the values of patient wellbeing
• Respecting patient choice
• Assuring privacy and confidentiality
• Respecting quality of life
• Maintaining commitments
• Respecting truthfulness
• Ensuring fairness in the use of
Another way of understanding these
standards is to see them as values or
principles. Common ethical principles
• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Respect for Human Life and Dignity
• Accountability
• Balancing Individual v. Collective
When understood in this way, we
can apply ethical decision making tools
to assist us in situations where we have
competing values. In health care ethics,
it is commonly understood that when
two or more values are in conflict, an
ethical dilemma exists. When faced with
such ethical dilemmas health care ethics can provide us with a system of
principles and rules of conduct to determine right from wrong actions when
values clash. Broadly speaking, ethics
can help us decide what we should
do (what decisions are morally right or
acceptable), explain why we should do
it (justifying our decision in moral terms)
and describe how we should do it (the
method or manner of our response). An
additional complicating factor related to
many ethical dilemmas is that there is not
one clear right answer. Instead there are
often multiple appropriate approaches.
It is not always a matter of choosing
between a good and bad response and
outcome but rather choosing between a
bad and worse outcome. The very nature
of an ethical dilemma is such that we are
dealing with shades of grey rather than
black and white. If the answer were clear
and unambiguous there would be no
A common strategy for addressing
ethical dilemmas when they arise in the
course of work is to employ the IDEA
methodology. Developed by Albert
Jonsen and Mark Siegler as a practical
approach to ethical decision making
in health care, the IDEA methodology
practice n
provides a framework that Occupational
Health nurses can utilize when faced
with ethical dilemmas. The four components of the IDEA framework are:
• Identify the Facts
• Determine the Relevant Ethical
• Explore the Options
• Act on your Decision and Evaluate
Identify the Facts
When identifying the facts it is important
to determine that the medical indications are clearly established. What you
know as well as what you do not know
can have significant implications when
addressing ethical issues. There are
often unstated assumptions or unknown
facts hidden in what can on the surface
present as a rather straight forward
issue. One of the challenges present in
health care is that ethical issues can be
present but hidden; buried deep within
the complexities of the case. Teasing
out whether there is indeed an ethical issue present requires attention to
detail. In the first case above it would
be important to determine if indeed
the employee was not attending to their
diabetes or to be aware of possible hidden agendas on the part of both the
co-workers and the supervisor.
Determine the Relevant Ethical
One of the more difficult aspects when
faced with a complex situation or case,
is determining whether or not there is
actually an ethical dilemma or whether
there are other issues masquerading
as ethical issues. Often a lack of communication, inattention to details or
hidden agendas presented as ethical
dilemmas. In the cases above we can
clearly identify competing obligations
such as respecting patient privacy and
confidentiality v. employee safety or the
obligation to prevent fraud or the misuse of resources v. obligation to respect
privacy and so forth. The process of
determining the relevant ethical issues
requires the Occupational Health nurse
to seek input and guidance from other
employees, most significantly their
immediate supervisor. It is important to
recognize that discussing the complex
Ethical dilemmas in the workplace
issue is a necessary step in checking
your own inclinations and that these
consultations enrich the discussion and
provide a broad range of perspectives.
Ethics is best done as a collaborative
endeavor rather than as an individual
Explore the Options
One of the characteristics of any ethical
dilemma is that there are multiple viable
options to consider. It is important to
explore all of the available options to balance and weigh which one would be the
most appropriate to pursue in the particular instance at hand. In the second case
for instance, the Occupational Health
nurse has several possible options available to them; they could speak directly
to the employee regarding their observations over the weekend; they could
say nothing at all and simply accept the
employee’s statement or report their
weekend observations to their supervisor. Each of the available options will
have its strengths and weaknesses and
should be considered, evaluated and
then dismissed or chosen based on the
merits of these deliberations. Again, it is
best during this step to consult with others regarding the options available and
why one would be chosen over the others. As was stated earlier, the available
options may not be a matter of choosing
the right from wrong course of action
but instead can often be a matter of distinguishing between a bad and worse or
good and better course of action.
Act on your Decision and
Once the first three steps have been
completed and you have made a decision as to which of the available options
is best to pursue there should be a plan
developed to act on that option. As
in many other areas of Occupational
Health nursing the development and
implementation of a plan of action is
required. To simply discuss and identify
an ethical issue without having a mechanism for addressing the issue can lead
to moral distress or a complication of
the issue at hand. It may be necessary
to discuss the plan with supervisors in
order to ensure that there is appropriate
support and backup in the event that
the outcome does not satisfy all concerned parties. In addition, seeking this
level of support provides you with the
opportunity to provide an explanation
and justification for your chosen plan
of action and seek input as to how best
to proceed with the plan. Evaluation of
the outcome of the plan is an essential
component and should not be omitted.
It is in the evaluation phase that lessons
are learned and models for addressing
future similar situations developed. In
the absence of evaluating and learning from cases, time and energy can
be expended in reinventing the wheel.
Developing processes and procedures
for addressing like cases can be of great
benefit not only to your department but
to the organization at large.
Addressing ethical dilemmas in your
work can be complex and difficult.
Seeking broad participation in the process will enhance the decision making
and diffuse the stress related to such
issues. There are significant benefits
when addressing ethical issues in your
work including a reduction in moral distress, the improvement of process and
procedures and the enhancement of
the relationship between Occupational
Health and employees. Being aware of
ethical issues and having a willingness
to address them when they arise is not
only a professional obligation but can
also be personally beneficial.
Jonsen, A.R., Siegler, M., Winslade, W.J.
(2002). Clinical Ethics: A practical
approach to ethical decisions in clinical medicine. (5th edition). New York,
McGraw-Hill Companies
Dr. Thomas Foreman ([email protected])
holds a Doctor of Health Care Ethics degree
from Duquesne University as well as a
post-doctoral Fellowship in Clinical and
Organizational Ethics from the University
of Toronto, Joint Centre for Bioethics.
He is currently Director of Clinical and
Organizational Ethics at The Ottawa
Hospital and Clinical Investigator at the
Ottawa Hospital Research Institute.
OOHNA Journal n winter 2011
2:33 PM
Page 1
• Be a non-smoker and avoid second-hand smoke.
• Eat healthy food.
• Be active on a regular basis.
• Be sensible in the sun.
• Follow cancer screening guidelines.
• Report changes in your health.
• Use caution with hazardous materials.
For the information you need, contact us.
Write on!
The OOHNA Journal welcomes letters to the editor, guest editorials,
articles, book reviews, original photographs as well as suggestions from
readers for articles you’d like us to write and interviews with health
care and safety professionals that you’d like to know more about. We
have the staff to help first time writers – so experience is not necessary. For more information or to submit ideas, articles, etc. please
contact Frances MacCusworth at [email protected]
OOHNA Journal n winter 2011
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OOHNA Journal n winter 2011
It is important that the CBT practitioner you select
applies the right cognitive behavioural therapy for
the right patient for the right diagnosis.
For over 25 years, Dr. Richard Marlin (Director,
Odyssey Health Services) and his team have
effectively employed the right evidence-based CBT
to achieve outstanding back to work outcomes –
even with the most complex cases.
Dr. Marlin is this year’s OOHNA Conference opening
keynote speaker. Please join us as he addresses the
topic “Is It Possible to Overdose on Cognitive
Behavioural Therapy?” Thursday June 9th at
9:00 a.m.
To learn more about the “right” Cognitive Behavioural Therapy, or to request a
complimentary review of a current case, please contact Janet Marlin.
[email protected]
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OOHNA JOurNAl n wiNter 2011
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