OOHNA U winter 2011 | Volume 30 | number 3 Journal Journal of the Ontario Occupational Health Nurses Association Practice Ethics Practice How to run a successful Flu campaign Practice Integrated Health Services Program Practice Epidemiology 101 Publications Mail #40026127 OOHNA Journal Journal of the Ontario Occupational Health Nurses Association winter 2011 | Volume 30 | number 3 Board of Directors President: Table of Contents Karen Watson RN, BHSc(N), COHN(C), CRSP secretary Angela Wrobel RN, COHN(C) Directors 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) 2 EDITOR’S NOTES | 3 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 Toronto Dundas Jane Lemke RN, BHSc(N), M.Ed., COHN(C) Burlington Shelley Skerlan RN Dundas 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 7 Practice | Development of an Integrated Health Services Program by Rebecca Kwiatkowski 11 Practice | MSc, DOHS, RN, COHN(C), COHN-S/CM, FAAOHN 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] Website: www.oohna.on.ca 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. subscription rates OOHNA Journal is published 3 times a year. $36.00 plus 13% HST (Canada); $45.00 Canadian Funds (USA & International). Single Issues available at $12.00 + 13% HST (Canada); $15.00 Canadian Funds (USA & International). Advertising rates upon request. Subscriptions may be obtained from the Association Office by sending a cheque or money order in Canadian funds to the “Ontario Occupational Health Nurses Association.” All submissions are considered to be the views of the author and do not necessarily reflect the policies or views of the Ontario Occupational Health Nurses Association or the Editorial Committee of the Journal. ISSN: 0828-542X Return undeliverable Canadian addresses to: Ontario Occupational Health Nurses Assocation Suite 605, 302 The East Mall, Etobicoke, ON M9B 6C7 E-mail: [email protected] 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 1 EDITOR’S NOTES n Brian Verrall, Technical Editor MSc, DOHS, RN, COHN(C), COHN-S/CM, FAAOHN 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 canada. 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. 2 OOHNA JOurNAl n wiNter 2011 n practice How to run a successful Flu Campaign by Teresa McCormack Introduction 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, Group 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. 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 3 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, Niagara-on-the-Lake Accommodation at White Oaks Spa and The Hilton KEYNOTE SPEAKER Noted Canadian Author and mental health advocate RONA MAYNARD 4 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 included: • 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 resources • 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 afterwards. 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 process 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 5 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. Pitfalls 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). May 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 Resources Influenza Vaccinations. www.cno.org/ National Foundation for Infectious Diseases. (2004). Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients. publications-list/list-of-all-publications Canadian Healthcare Influenza immunization Network. (2010). Successful Influenza immunization Campaigns for Healthcare Personnel: A Guide for Campaign Planners. (www.chiin.ca) 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 Practices. www.cdc.gov/mmwr en/learn-about-standards-guidelines/ 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 Epidemiology. OOHNA member, Teresa McCormack, 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) Conclusion A successful Flu campaign is like a game of chess. In chess, you need to 6 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 forms • Inadequate documentation • Inefficient staff utilization • Metrics captured not analyzed • No accountability—no structure • Inadequate clinic assessment processes • Breaching current privacy laws (Legal) • Increased litigation potential (Legal) • 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 (EAPs) 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 Operations 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 claims. 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 productivity. After extensive research, Arcelor 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. 7 Development of an Integrated Health Services Program Claims Management Processes (STD, LTD, WSIB) 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 Assessment 1.1 Measure total costs of claims paid and associated metrics 2. Gap Analysis 2.1 Review provider contract details 3.Claims Audits 3.1Provider audit to determine compliance, performance standards and adherence to best practices 4. Quarterly reviews with providers 5. Monthly reviews with internal stakeholders { Figure 1: Risk with Non-Integrative Thinking Prevention Education via Wellness 8 Primary Paramedical Services (Control of Finances) Drug Utilization Design (+ Financial Risk) Rehabilitation Secondary Short Term Disability (Control of Finance) Return to Work Efforts Tertiary Systems Thinking Leads to Better Outcomes Copyright © 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 redeployment/transfer; • 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 provider; • 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; • PDA’s sent to claims and forwarded to Business Unit Manager for review and validation; Integrated Health Program— Example 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 Depart ment proceeds to job match; • Report sent to HR and Business Unit Manager with recommendations. Copyright © 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 steps: n PLAN 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 n CHECK k Schedule a quarterly meeting with a representative from claims, Clinic Services Manager of Integrated Health, Wellness and EAP Coordinator to discuss contentious claims. n ACT kContinuously re-evaluate efforts kMake benchmarking continuous Conclusion 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, including: • 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 benchmarking. 9 practice n Development of an Integrated Health Services Program Figure 4: Organizational Realignment Most Effective at Reducing Costs Most Effective at Improving Employee Health • Clinical case management • Written transitional return-to-work plans • Physical health risk screening • Operation Manager involvement in absence management • Performance standards for vendors • Written transitional return-to-work plans • 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 conditions Most Effective at Improving Employee Satisfaction Most Effective at Increasing Productivity • Work/life balance • Fitness subsidy/ onsite • Written transitional return-to-work plans • Return-to-work plans specific to mental illness • Educational programs for chronic conditions • Mental health risk screening • Ergonomic work stations • Mental health risk screening • Return-to-work plans specific to mental illness • Written transitional return-to-work plans • Physical health risk screening • Educational programs for chronic conditions • 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. Reference Watson Wyatt (2008) Staying@work Toronto Rebecca Kwiatkowski, rn, bscn, 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 © ArcelorMittalDofasco McCague Borlack Barristers & Solicitors LLP The Right Balance McCague Borlack LLP is the largest litigation and insurance boutique in Canada. We have a wide variety of practice groups poised to implement the right legal strategy for you. While much of our work focuses on litigation, both plaintiff and defence work, our law firm has a wide range of practice areas and diverse skills. We often draw on ADR methods for early resolution of legal disputes, and our lawyers have extensive experience before all levels of court, from trial to appeal. If you have a legal problem, our lawyers can help. McCague Borlack llp Suite 2700, The Exchange Tower, 130 King Street West, Toronto, Ontario M5X 1C7 Tel: 416-860-0001 Fax: 416-860-0003 www.mccagueborlack.com A member of Canadian Litigation Counsel, a nationwide affiliation of independent law firms 10 OOHNA Journal n winter 2011 n practice INFORMING YOUR PRACTICE WITH EVIDENCE—EPIDEMIOLOGY 101 FOR OCCUPATIONAL HEALTH NURSES. PART 2. 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% (Côté 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. 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) 11 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- 12 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. 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. OBSERVATIONAL STUDIES 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). EXPERIMENTAL STUDIES 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 controlled. 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). QUALITATIVE STUDIES of the analyses, strengths and limitations of each of these study designs. Please do not hesitate to contact me if you have specific questions. REFERENCES 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 Resource. http://mathworld.wolfram.com/NormalDistribution.html (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 October 31, At Work, Issue 64, Spring 2011: Institute for Work & Health, Toronto Côté 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: S60-S74. DiCenso A, Guyatt G, Ciliska D. (2005) Evidence based nursing: a guide to clinical practice. St Louis, MO: Elsevier Mosby. 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 Company. 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; www.who.int/topics/global_burden_ 2011) Vicki Pennick, rn, mhsc (vpennick@ sympatico.ca) 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 13 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- 14 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 with 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 Toronto. 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 outcomes.” 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. on.ca/sys-reviews/acute-low-back- pain-rtw-prognostic-factors. To keep up on other research and news from IWH, sign up for the Institute’s free e-alerts at: www.iwh.on.ca/e-alerts. 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 Depression 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 15 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. RenéeLouise 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. 16 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? Discussion 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 resources Another way of understanding these standards is to see them as values or principles. Common ethical principles include; • Autonomy • Beneficence • Nonmaleficence • Justice • Respect for Human Life and Dignity • Accountability • Balancing Individual v. Collective Interest 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 dilemma. 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 17 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 Issues • 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 Issues 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 18 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 exercise. 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 Evaluate 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. Conclusion 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. Reference 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 MensHealth_Ad_H 10/17/05 2:33 PM Page 1 MEN, TAKE CONTROL OF YOUR HEALTH • 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 19 It’s time to renew your OOHNA Journal subscription. If you want to continue your OOHNA Journal subscription for 2012, now is the time to renew. All OOHNA members receive the award-winning OOHNA Journal as part of their membership. Individuals and organizations who are not members of the Ontario Occupational Health Nurses Association can download the subscription renewal form at www.oohna.on.ca/journal or contact the OOHNA office at 416-239-6462 (1-866-664-6276); Email [email protected] OR complete the renewal form below and return to the OOHNA office. OOHNA JOURNAL SUBSCRIPTION FORM Please PRINT Subscription for one issue (2012-Canada) $13.56 ($12.00+ 13% ($1.56) HST) Spring-March Fall-November Winter-December Name Company Name Address City/Province Postal Code Email Tel. S ubscription for 2012 (3 issues) Canada $40.68 ($36.00 + 13% ($4.68) HST) USA $45.00 Canadian Funds International $45.00 Canadian Funds METHOD OF PAYMENT – PLEASE COMPLETE Paid by: Company Credit Card Self MasterCard VISA Company Cheque (If payment by credit card, amount due MUST Include an additional $2.00 fee and will be applied if not included) CVC Code – last 3 digits on back of card AMOUNT Remitted $ MasterCard/VISA # Month Year last 3 digits on back of card Expiry Date Signature Name of Card Holder Please PRINT Today’s Date (DD/MM/YY) Payments by Credit Card can be faxed to: 416-239-5462 Payments by Cheque – Please Remit Payment with Registration Form to: Ontario Occupational Health Nurses Association 302 The East Mall, Suite 605 Toronto, ON M9B 6C7 G.S.T. #104-001-318 20 OOHNA Journal n winter 2011 COGNITIVE BEHAVIOUR THERAPY (CBT) SCIENTIFICALLY PROVEN TO SUCCESSFULLY TREAT MENTAL AND PHYSICAL HEALTH CONDITIONS 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. 1-866-311-0110 [email protected] www.odysseyhealthservices.com Your Complete Health and Safety Software Solution! Online Consent Forms (Kics) – NEW! - easily create consents, N95 questionnaires, etc. Track immunizations, N95 fit testing , outbreaks, compliance Manage/report on WSIB/WCB claims and statistics—including new violence/harassment section Record your Risk/Ergo Assessments – NEW! Check out the Parklane website and see what others are saying about Kics! www.parklanesys.com OOHNA JOurNAl n wiNter 2011 Parklane is a proud sponsor of the Ontario Occupational Health Nurses Association 21 22 OOHNA JOurNAl n wiNter 2011
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