| 1.0 INTRODUCTION
1.1 Representing almost 32,000 persons, the New Zealand Nurses Organisation (NZNO) is the largest professional and industrial body of nurses and health workers in New Zealand.
1.2 The membership of NZNO comprises registered nurses, midwives, enrolled nurses, student nurses, caregivers and a small number of health technicians – anaesthetic technicians and medical radiation therapists.
1.3 Health and safety in the workplace is a critical issue for NZNO. Our members overwhelmingly support legislation to improve health and safety practices in their workplaces. More than 750 individual submissions were submitted by NZNO members and have been sent to the Transport and Industrial Relations Select Committee.
1.4 This NZNO member response has reinforced to us the importance of this issue for nurses and health workers. Their responses have emphasised the urgency they feel about the need for change, the unacceptable risks they face, and the inadequacy of the current health and safety protections and legislation. It has reinforced to NZNO that a strengthening of health and safety legislation is required to improve health and safety practices and to address New Zealand's appalling rates of workplace deaths, accidents and work-related medical conditions.
2.0 THE HEALTH AND SAFETY IN EMPLOYMENT AMENDMENT BILL
2.1 The provisions of the Health and Safety in Employment Act (1992) are insufficient to ensure adequate protection for nurses and health workers and do not provide for effective participation in health and safety systems.
2.2 NZNO views the most important provisions of the amended Bill as:
The development of systems that provide for health workers and professionals to participate in structured health and safety systems.
- The identification and confirmation of stress and fatigue as serious occupational hazards.
- An increase in fines to encourage improved compliance with health and safety requirements.
2.3 In the last ten years some health and safety programmes and systems have been established in major work sites. But the establishment of systems and health and safety programmes has not been widespread and they have met with variable support and success.
2.4 The requirements of successful health and safety programmes include: support from management, allocated resources, injury prevention and early intervention approaches, employee participation, training, and efficient management of claims.
2.5 The establishment of health and safety systems can not be based on a voluntary approach. The hazards in hospitals, and similar work sites, are too great to permit this. The establishment of health and safety systems is, and must be, a mandatory requirement.
2.6 This submission focuses on:
Hazards faced by health workers and nurses
- The health sector culture
- Effective health and safety initiatives
- General comments on the Bill
- Specific clauses of the Bill
3.0 HAZARDS IN THE HEALTH SECTOR
3.1 The health sector could be expected to be a leading player in health and safety management and practices. This is far from the case. It is indeed a paradox that the health sector is lagging in the establishment of health and safety systems in the workplace.
3.2 Nurses and health workers constantly face serious health and safety risks. There are particular features of the health sector that require recognition and special attention. Some of the risks and hazards in the health sector are:
Violence in the workplace
3.3 An Australian Institute of Criminology report identified the health industry as the most violent industry in Australia. A study focusing on emergency departments identified the following as reasons: long waiting times, the use of weapons, inadequate security systems, a culture of silence, lack of institutional concern, the demands of the client population and triage nursing (Jones, Lyneham, 2000). The study of emergency department nurses found most nurses are not satisfied with the response of administration to violent incidents in hospitals and highlighted that violence is an important professional issue for nurses but that it is concealed as part of the job. The New Zealand experience is similar for the same reasons.
3.4 In many other health service areas nurses and health workers face the risk of violence. Illness and injury can cause unpredictable behaviour, and physical assaults of nurses and health care workers are not infrequent. In the aged care sector, violence against care-workers is increasingly common.
Musculo-skeletal injuries and back pain
3.5 There is a high prevalence of musculo-skeletal injuries in the health sector. Nurses have higher rates of back pain and back injury than the general population. High levels of back pain are associated with heavy lifting and nursing is a physically demanding occupation involving heavy lifting. A New Zealand study (Coggan,1994) identified particular areas of nursing as having higher rates of back pain: medical, rehabilitation geriatric and orthopaedic areas.
3.6 Other activities, integral to nursing, are associated with higher levels of back pain. Stooping, which comprises about 22% of a nurse's work time, is associated with higher levels of back pain (Troup,1984).
3.7 Another significant grouping of injuries which nurses and health care workers face at work are trips, slips and falls.
Chemical sensitivity
3.8 Latex, which is used in many medical supplies, is a significant occupational hazard in the health sector. It is estimated between 8-20% of health workers have latex allergies (International Council of Nurses, 2000). Allergic reactions to latex can be fatal.
Chemical Agents
3.9 Gluteraldehyde, a chemical agent used in sterilisation, is recognised as causing serious harm. Though use of this agent has decreased, NZNO frequently has health professionals contacting NZNO staff about the inappropriate and unsafe use of gluteraldehyde in medical practices and hospitals.
Exposure to Infectious Diseases and Organisms
3.10 Health workers and nurses are exposed to high levels of infectious disease and organisms e.g. all health workers are likely to encounter patients with positive methicillin resistant staph aureus (MRSA) status. Exposure to hepatitis A& B and HIV virus are also common occupational hazards. Nurses and health workers who become MRSA positive require expensive treatment and time away from work.
Other hazards
3.11 Radiation, occupational overuse syndrome and needle-stick injuries are all significant occupational hazards encountered in the health system.
4.0 THE HEALTH SECTOR CULTURE
4.1 Health workers and nurses work in demanding environments. There are increasing demands from, increased patient acuity, higher turnover of patients, short staffing, the increased use of technology, and fiscal restraints. Nurses work in increasingly complex political, social, cultural and clinical settings.
4.2 Along with all of the above is the need for nurses and health care workers to respond positively, humanely and competently to vulnerable and sick patients, and their families. Patient stress is a major factor for nurses and health workers to manage. A Christchurch nurse is quoted: "dealing with seriously ill patients is stressful - they are anxious and so are their relatives - there are multiple demands on us" (Christchurch Press 2/11/2001).
The Duty of Care Ethic
4.3 Nurses and health workers constantly face the difficult dilemma of having to make decisions on whose needs to respond to in clinical situations. Nurses and health care workers respond to immediate and urgent patient needs. These situations range from emergency responses to meeting basic bodily function needs and many clinical situations present risk of injury. The nurse or health worker has to choose between responding to the patient's needs or protecting her/himself from injury. The instinctive reaction in these situations is to respond to patient needs first. The health and safety concerns of the nurse or health worker are usually a secondary concern - i.e. health professionals respond firstly to the "duty of care" professional ethic. This instinctive reaction places nurses and health care workers constantly at high risk.
4.4 Research undertaken examining nurses' perceptions about the causes of work-related back pain in a Christchurch hospital found nurses take risks lifting patients and expose themselves to risk of injury, because patient needs are pressing and human demands so difficult to refuse (Brown, 1999). The nurse/health worker gives precedence to meeting patient needs over protecting her/himself from risk of injury.
Health Sector Relationships
4.5 The Employment Contracts Act encouraged an antagonistic environment and attitude between employers and health workers. The Employment Relations Act lays a foundation for improving employment relationships. The amended Health and Safety in Employment Bill extends that foundation. Giving authority to employees for health and safety management creates a joint responsibility between employers and employees. This is a responsibility that nurses and health workers value.
4.6 Differences in the perception of risk between health managers and health workers have been identified. A study in the United Kingdom (Grinyer,1995) identified considerable difference in how risk of the Human Immuno Deficiency Virus (HIV) was perceived by health authorities and health workers. This study recommended an integrated approach from health policy makers and the relevant workforce for managing occupational risk. It is our contention, and this is supported empirically, that perception of risk as a cause of work related accidents and stress is under-rated. Nurses and health workers state that health managers are unaware of the risks their employees face.
5.0 HEALTH AND SAFETY INITIATIVES
5.1 There are many successful examples of health and safety initiatives and the health sector is in an ideal place to establish health and safety initiatives. Nurses and health care workers are highly motivated and knowledgeable about health and safety issues.
5.2 Health and safety programmes and systems create a health and safety culture. This is done by involving employees in the establishment of health and safety committees, the development and publication of policies, the training of employees and managers on health and safety concerns, and pursuing initiatives that keep health and safety issues on the workforce agenda.
5.3 When a health and safety culture is developed, dramatic improvements can be made in health and safety practices and can be demonstrated in measurable outcomes - improving employee health, reducing staff costs and improved productivity.
5.4 The introduction of a health and safety management programme in a Christchurch hospital demonstrates the effectiveness of a health and safety approach. The programme has been established for three years and a reduction in work-related sick leave is one powerful indicator of its effectiveness. Prior to this programme, 120 sick days were lost one calendar month to work-related accidents. Two years later, following the introduction of an injury management programme, two sick days were recorded as being lost to work-related accidents. The pattern of sick leave over three years shows a strong and consistent reduction in sick days due to work-related accidents being taken.
Employee Involvement in Health and Safety Systems
5.5 Our experience in the establishment of health and safety committees is that under the present legislation they have been erratic and insufficiently resourced and supported. Good health and safety outcomes will not be maintained without health and safety programmes being resourced adequately and ongoing management support and involvement. Too frequently health and safety programmes have collapsed because a key person has resigned.
5.6 Employee participation is essential to ensure acceptance from the workforce. For this to occur, nurses and health care workers must have assigned responsibilities and time allocated to attend health and safety meetings. Obtaining leave to attend health and safety meetings is a significant difficulty for nurses and health workers.
6.0 GENERAL COMMENTS ON COMPONENTS OF THE BILL
Stress and Fatigue
6.1 This is one of the most important aspect of the new Bill for nurses and health workers. Stress among nurses and health workers has increased significantly. Stress is exacerbated by higher acuity levels, sicker patients, increased occupancy, an increase in technological demands, short staffing and financial pressures. All of these pressures impact directly on nurses and health care workers.
6.2 In New Zealand hospitals and nursing departments there is chronic understaffing. Excessive workloads are the norm - not the exception. A result of understaffing is that routine safety precautions get overlooked.
6.3 The understaffing in the health sector, caused by the current nursing shortage, means that nurses are working long hours and significant amounts of overtime. Excessive fatigue is related to mishaps and mistakes.
6.4 Increasing technological demands are significant stressors. A study of 433 operating theatre nurses found that medical technologies had contributed to increased workloads and higher levels of stress (Johnstone, 1999).
5.5 Stress is reported by the manager of a health and safety programme in an acute metropolitan hospital to be the biggest workplace hazard and concern and accounts for the greatest amount of sick leave. For nurses at this hospital, time loss from occupational stress is eight times greater than the next highest cause – back injury/pain.
6.6 NZNO welcomes the specific identification of stress and fatigue as occupational hazards in legislation and believes it is long overdue. The relationship between mental stress and physical ill-health is indisputable. Stress and fatigue must get the same recognition that other accidents and occupationally caused conditions receive. It is archaic for it not to receive the same consideration.
6.7 The suggestion that inclusion of stress will result in employees manufacturing stress and fatigue is refuted. Excessive stress is a real and serious condition and concern. Employers have a responsibility to ensure employees are not under undue stress and that stress is managed positively and appropriately. The effects of not managing stress proactively and appropriately are seen in increased sick leave, increased costs, absenteeism, lowered work performance standards and poor morale in the workplace.
6.8 The identification of stress as a workplace hazard will result in improved management of stress. NZNO organisers welcome tools to assist in recognising and ensuring employer responsibility for excessive work stress.
Incentives and Penalties
6.9 NZNO believes the current costs of health and safety are seriously under recognised and under-rated. The record keeping of work-related accidents and conditions in many district health boards and health services is unco-ordinated and not up to date. This leads to an incomplete picture of the costs of work-related accidents, illnesses and conditions.
6.10 Ineffective attention to health and safety results in professional, social and psychological costs as well as economic costs in the health service and nursing profession.
6.11 The cost of health and safety legislation is being cited as a reason for employers not to implement the legislation in its current form. Yet, when employers are supplied with statistics on the likely costs of work-related accidents and conditions, they are very keen to implement injury management programmes to reduce the costs incurred from work- related accidents and illnesses. Economic incentives are a strong driver for implementing programmes and health and safety systems. Increased penalties will provide the same incentive.
6.12 The financial penalties in the current Act have been inadequate to serve as effective deterrents. In respect of small employers being concerned about the imposition of large fines we note the report of the Health and Safety in Employment Amendment Act Implementation Advisory Panel Compliance Panel who stated "it is reasonable to assume.... that the financial state of the offender, both employer and employee, will be taken into account in deciding the level of the fine".
6.13 Only when health and safety breaches result in a death, or a serious incident, is the investigation and significant review from the Occupational Health and Safety Service. This is inadequate and prevents effective enforcement of the legislation.
6.14 We have many examples of where serious breaches of health and safety have occurred and where management, despite repeated approaches from NZNO over health and safety concerns, have taken no action.
5.15 In one situation NZNO approached a district health board repeatedly about health and safety concerns in an acute psychiatric unit. The response from management was "NZNO was being over reactive". Stress in this workplace has, however, taken a terrible toll. Work-related sick days are high, many staff have left the unit, staff have incurred serious injures, and horizontal violence is a feature of the work environment. Staff who complain about health and safety concerns are bullied and intimidated. We believe there is a strong relationship between poor health and safety management and adverse patient outcomes. This episode is currently the subject of an official statutory investigation.
Participation of Employees in Health and Safety Standards
5.16 Regulations must be developed to ensure effective occupational health and safety in the health industry. This requires the development of standards that identify acceptable safety and health practices and management. Those who are exposed to the risks, and who have the expertise and experience with the hazards and work environment, must be involved in setting the standards. Standards must then be set in codes of practice, regulations and legislation. Codes of practice and policies need to be distributed, publicised and incorporated into work-force training programmes.
7.0 SPECIFIC CLAUSES OF THE BILL
7.1 NZNO is an affiliate of the Council of Trades Unions (CTU) and supports the CTU submission on this Bill. There are specific amendments and clauses the CTU has commented upon which we affirm.
Part 1 Preliminary Provisions
7.2 NZNO welcomes the purpose statement, especially the intention to promote compliance with International Labour Convention 155, concerning Occupational Health and the Working Environment.
7.3 Clause 7
Protective clothing must be supplied by the employer. NZNO supports the CTU position.
7.4 Clause 8
NZNO supports the CTU amendment that employees are given Information about all hazards which employees are, or may be exposed to, in the course of their work.
7.5 Clause 11
7.5.1 Proposed Section 19 b (1)
We support the right of employees to request the review and redesign of existing health and safety workplace systems.
7.5.2 Proposed 19 b (5)
The current wording does not provide for employees to have union officials to represent them, should they elect to do this. NZNO supports an amendment to enable this, which has been NZNO's practice in a number of workplaces and has been effective.
7.5.3 Proposed Section 19C (2)
We support the CTU amendment calling for health and safety representatives to be identified as representing 'designated work areas'. This is the practice now and work areas are usually easily identified. A code of practice has been suggested as identifying a designated work area. This is useful in the event of a dispute about what constitutes a designated work area.
7.5.4 Proposed Section 19I
The employer must be explicitly required to ensure health and safety representatives have adequate time and resources allocated to fulfil their health and safety functions.
NZNO supports the CTU amendment " ... & given sufficient time and resources to perform their role effectively".
7.5.5 Proposed section 19J
NZNO supports that health and safety representatives can be trained to the level of competency envisaged by the proposed s46 – two days paid leave each year.
7.5.6 Clause 14 Section 28A (1) & (2)
We support the concern that the 'right to refuse work on reasonable grounds that it is likely to cause serious harm', is inadequate as a standard.
The CTU proposed amendment replacing the words "likely to" with "may" and in the title of 28A with "which may" is strongly supported.
7.6 PART 111
Standards
NZNO supports the establishment of a tripartite Occupational Safety and Health Commission to supervise standards setting processes, provide advice to the Minister and be a vehicle to develop policies that will contribute to the creation of a health and safety culture in New Zealand workplaces.
7.7 We recognise the work and commend the work of the Health and Safety in Employment Amendment Bill Implementation Panel.
7.8 Clause 18
7.8.1 Proposed Section 46A (1)
There are specific areas in workplaces where training about specific hazards will not be able to be undertaken in two days and more specific training will be required. This needs to be supported by the employer.
6.7.2 We believe the two day's training a year provides most health and safety representatives with the competencies necessary to deliver a hazard notice.
7.8.3 A hazard notice is in our view a written record of an incident/event. This replicates the current practice already in hospitals and health settings and will replace or complement the existing system of 'incident reports'.
7.8.4 In the past some of the incident reports have not been followed up appropriately. We believe the system proposed increases the likelihood of an appropriate response and action as a result of a hazard notification notice.
7.9 The First Schedule to the Act
7.9.1 NZNO notes the definition of serious harm is insufficient.
7.9.2 It is inadequate and out of line with current medical management to identify serious harm as needing to be associated with hospitalisation within 48 hours.
BIBLIOGRAPHY
Brown, E. (1999). Nurses and Back Pain: Nurses' perceptions of the causative factors (unpublished dissertation). University of Otago, Dunedin.
Coggan, C., Norton, R. Roberts, I., & Hope, V. (1994). Prevalence of back pain among nurses. New Zealand Medical Journal, 107 (10 August), 306-308.
Christchurch Press (2001). Workers Welcome Stress Recognition, 2/11/2001.
Grinyer, A. (1992). Risk, the real world and naïve sociology: Perceptions of risk from occupational injury in the health service. In J. Gabe (Editor) Medicine Health and Risk. Oxford: Blackwell Publishers Ltd.
Johnstone, P.L. (1999) Occupational stress in the operating theatre suite: Should employers be concerned? Australian Health Review Vol 22: No 1; 60-80.
Jones, J., Lynham, J., (2000) Violence: Part of the Job for Australian Nurses?
Australian Journal of Advanced Nursing: Vol 18, No 2: 27-31.
International Council of Nurses (2000) Fact Sheet: International Council of Nurses in Latex, Geneva, Switzerland.
Troup, J.D.G. (1984). Causes. Prediction and Prevention of Back Pain at Work. Scandinavian Journal of Work Environment Health, 10, 414-428.
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