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97. Health Care Facilities and Services

Chapter Editor: Annelee Yassi

Table of Contents

Tables and Figures

Health Care: Its Nature and Its Occupational Health Problems
Annalee Yassi and Leon J. Warshaw

Social Services
Susan Nobel

Home Care Workers: The New York City Experience
Lenora Colbert

Occupational Health and Safety Practice: The Russian Experience
Valery P. Kaptsov and Lyudmila P. Korotich

Ergonomics and Health Care

Hospital Ergonomics: A Review
Madeleine R. Estryn-Béhar

Strain in Health Care Work
Madeleine R. Estryn-Béhar

     Case Study: Human Error and Critical Tasks: Approaches for Improved System Performance

Work Schedules and Night Work in Health Care
Madeleine R. Estryn-Béhar

The Physical Environment and Health Care

Exposure to Physical Agents
Robert M. Lewy

Ergonomics of the Physical Work Environment
Madeleine R. Estryn-Béhar

Prevention and Management of Back Pain in Nurses
Ulrich Stössel

     Case Study: Treatment of Back Pain
     Leon J. Warshaw

Health Care Workers and Infectious Disease

Overview of Infectious Diseases
Friedrich Hofmann

Prevention of Occupational Transmission of Bloodborne Pathogens
Linda S. Martin, Robert J. Mullan and David M. Bell 

Tuberculosis Prevention, Control and Surveillance
Robert  J. Mullan

Chemicals in the Health Care Environment

Overview of Chemical Hazards in Health Care
Jeanne Mager Stellman 

Managing Chemical Hazards in Hospitals
Annalee Yassi

Waste Anaesthetic Gases
Xavier Guardino Solá

Health Care Workers and Latex Allergy
Leon J. Warshaw

The Hospital Environment

Buildings for Health Care Facilities
Cesare Catananti, Gianfranco Damiani and Giovanni Capelli

Hospitals: Environmental and Public Health Issues
M.P. Arias

Hospital Waste Management
M.P. Arias

Managing Hazardous Waste Disposal Under ISO 14000
Jerry Spiegel and John Reimer


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1. Examples of health care functions
2. 1995 integrated sound levels
3. Ergonomic noise reduction options
4. Total number of injuries (one hospital)
5. Distribution of nurses’ time
6. Number of separate nursing tasks
7. Distribution of nurses' time
8. Cognitive & affective strain & burn-out
9. Prevalence of work complaints by shift
10. Congenital abnormalities following rubella
11. Indications for vaccinations
12. Post-exposure prophylaxis
13. US Public Health Service recommendations
14. Chemicals’ categories used in health care
15. Chemicals cited HSDB
16. Properties of inhaled anaesthetics
17. Choice of materials: criteria & variables
18. Ventilation requirements
19. Infectious diseases & Group III wastes
20. HSC EMS documentation hierarchy
21. Role & responsibilities
22. Process inputs
23. List of activities


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The Physical Environment and Health Care

The Physical Environment and Health Care (4)

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Healthcare Workers and Infectious Diseases

Healthcare Workers and Infectious Diseases (3)

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Chemicals in the Health Care Environment

Chemicals in the Health Care Environment (4)

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Health error and critical tasks in remote afterloading brachytherapy: Approaches for improved system performance

Remote afterloading btachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources, close to a target (or tumour) in the body. Problems related to the dose delivered during RAB have been reported and attributed to human error (Swann-D'Emilia, Chu and Daywalt 1990). Callan et al. (1995) evaluated human error and critical tasks associated with RAB in 23 sites in the United States. Evaluation included six phases:

Phase 1: Functions and tasks. Preparation for treatment was considered to be the most difficult task, as it was responsible for the greatest cognitive strain. In addition, distractions had the greatest effect on preparation.

Phase 2: Human-system interferences. Personnel were often unfamiliar with interfaces they used infrequently. Operators were unable to see control signals or essential information from their workstations. In many cases, information on the state of the system was not given to the operator.

Phase 3: Procedures and practices. Because procedures used to move from one operation to the next, and those used to transmit information and equipment between tasks, were not well defined, essential information could be lost. Verification procedures were often absent, poorly constructed or inconsistent.

Phase 4: Training policies. The study revealed the absence of formal training programmes at most sites.

Phase 5: Organizational support structures. Communication during RAB was particularly subject to error. Quality-control procedures were inadequate.

Phase 6: Identification and classification or circumstances favouring human error. In all, 76 factors favouring human error were identified and categorized. Alternative approaches were identified and evaluated.

Ten critical tasks were subject to error:

  • patient scheduling, identification and tracking
  • applicator placement stabilization
  • large volume localization
  • dwell position localization
  • dosimetry
  • treatment set-up
  • treatment plan entry
  • source exchange
  • source calibration
  • record-keeping and routine quality assurance


Treatment was the function associated with the greatest number of errors. Thirty treatment-related errors were analysed and errors were found to occur during four or five treatment sub-tasks. The majority of errors occurred during treatment delivery. The second-highest number of errors were associated with the planning of treatment and were related to the calculation of dose. Improvements of eqiupment and documentation are under way, in collaboration with manufacturers.



The work of people in the medical profession has great social value, and in recent years the urgent problem of the labour conditions and the state of health of HCWs has been studied actively. However, the nature of this work is such that any preventive and ameliorating measures cannot eliminate or reduce the main source of the hazards in the work of physicians and other HCWs: contact with a sick patient. In this respect the problem of prevention of occupational illness in medical workers is rather complicated.

In many cases the diagnostic and medical equipment and the methods of treatment used in medical institutions can affect the health of HCWs. Therefore, it is necessary to follow hygienic standards and precautionary measures to control the levels of exposure to unfavourable factors. Studies carried out in a number of Russian medical institutions have revealed that the labour conditions at many workplaces were not optimum and could induce the deterioration of the health of medical and support personnel, and sometimes cause the development of occupational diseases.

Among the physical factors that can substantially affect the health of medical personnel in the Russian Federation, ionizing radiation should be ranked as one of the first. Tens of thousands of Russian medical workers encounter sources of ionizing radiation at work. In the past, special laws were adopted to limit the doses and levels of irradiation at which specialists could work for a long period without health risk. In recent years x-ray control procedures were extended to cover not only radiologists, but surgeons, anaesthetists, traumatologists, rehabilitation specialists and mid-level personnel. The levels of radiation at worksites and the x-ray doses received by these individuals sometimes are even higher than the doses received by the radiologists and radiology laboratory assistants.

Instruments and equipment generating non-ionizing radiation and ultrasound are also widespread in modern medicine. Since many physiotherapy procedures are used precisely because of the therapeutic benefits of such treatment, the same biological effects may be hazardous to those involved in administering them. Persons encountering instruments and machines generating non-ionizing radiation are often reported to have functional disturbances in the nervous and cardiovascular systems.

Studies of working conditions where ultrasound is used for diagnostic or therapeutic procedures revealed that the personnel were exposed during as much as 85 to 95% of their working day to levels of high frequency, low intensity ultrasound comparable to the exposures experienced by operators of industrial ultrasonic defectoscopy. They experienced such impairments of the peripheral neuro-vascular system as angiodistonic syndrome, vegetative polyneuritis, vegetative vascular malfunction and so on.

Noise is rarely reported as a substantial factor of occupational risk in the work of Russian medical personnel, except at dental institutions. When using high-speed drills (200,000 to 400,000 rev/min) the maximum energy of the sound falls at a frequency of 800 Hz. The noise levels at a distance of 30 cm from the drill placed in the mouth of the patient vary from 80 to 90 dBA. One-third of the whole sound spectrum falls within the range most harmful to the ear (i.e., between 1000 and 2000 Hz).

Many noise sources gathered in one place can generate levels exceeding permissible limits. To create optimum conditions it is recommended that anaesthetizing machines, respiratory equipment and artificial blood circulation pumps be taken out of operating rooms.

In surgery departments, especially in operating rooms and in rehabilitation and intensive care departments, as well as in some other special rooms, it is necessary to maintain the required parameters of temperature, humidity and air circulation. The optimal layout of modern medical institutions and the installation of ventilation and air-conditioning plants provide the favourable microclimate.

However, in operating suites built without optimal planning, occlusive clothing (i.e., gowns, masks, caps and gloves) and exposure to heat from lighting and other equipment lead many surgeons and other members of the operating teams to complain of “overheating”. Perspiration is mopped from surgeons’ brows lest it interfere with their vision or contaminate the tissues in the surgical field.

As a result of the introduction into medical practice of treatment in hyperbaric chambers, physicians and nurses now are often exposed to heightened atmospheric pressure. In most cases this affects surgical teams performing operations in such chambers. Exposure to conditions of increased atmospheric pressure is believed to lead to unfavourable changes in a number of body functions, depending on the level of the pressure and the duration of the exposure.

Working posture is also of great importance for physicians. Although most tasks are performed in sitting or standing positions, some activities require long periods in awkward and uncomfortable positions. This is particularly the case with dentists, otologists, surgeons (especially microsurgeons), obstetricians, gynaecologists and physiotherapists. Work requiring long periods of standing in one position has been associated with the development of varicose veins in the legs and haemorrhoids.

Continual, intermittent or casual exposure to potentially hazardous chemicals used in medical institutions also can affect medical personnel. Among these chemicals, inhalation anaesthetics are considered to have the most unfavourable influence on humans. These gases can accumulate in large amounts not only in operating and delivery rooms but also in pre-op areas where anaesthesia is induced and in recovery rooms where they are exhaled by patients coming out of anaesthesia. Their concentration depends on the content of the gas mixtures being administered, the type of equipment being used and the duration of the procedure. Concentrations of anaesthetic gases in the breathing zones of surgeons and anaesthetists in the operating room have been found ranging from 2 to 14 times the maximum allowable concentration (MAC). Exposure to anaesthetic gases has been associated with impaired reproductive capacity of both male and female anaesthetists and abnormalities in the foetuses of pregnant female anaesthetists and the spouses of male anaesthetists (see chapter Reproductive system and the article “Waste anaesthetic gases" in this chapter).

In the treatment rooms where many injections are performed, the concentration of a medicine in the respiration zone of nurses can exceed permissible levels. Airborne drug exposure can happen when washing and sterilizing syringes, removing air bubbles from a syringe, and while dispensing aerosol therapy.

Among chemicals which could affect the health of medical personnel are hexachlorophene (possibly causing teratogenic effects), formalin (an irritant, sensitizer and carcinogen), ethylene oxide (which has toxic, mutagenic and carcinogenic characteristics), antibiotics that cause allergies and suppressed immune response, vitamins and hormones. There is also the possibility of exposure to industrial chemicals used in cleaning and maintenance work and as insecticides.

Many of the drugs used in the treatment of cancer are themselves mutagenic and carcinogenic. Special training programmes have been developed to prevent workers involved in preparing and administering them from exposure to such cytotoxic agents.

One of the features of job assignments of medical workers of many specialties is contact with infected patients. Any infectious disease incurred as a result of such contact is considered to be an occupational one. Viral serum hepatitis has proved to be the most dangerous for the staff of medical institutions. Viral hepatitis infections of laboratory assistants (from examining blood samples), staff members of haemodialysis departments, pathologists, surgeons, anaesthetists and other specialists who had occupational contact with the blood of infected patients have been reported (see the article “Prevention of occupational transmission of bloodborne pathogens” in this chapter).

There has apparently been no recent improvement in the health status of HCWs in the Russian Federation. The proportion of cases of work-related, temporary disability remained at the level of 80 to 96 per 100 working doctors and 65 to 75 per 100 mid-level medical workers. Although this measure of work loss is quite high, it should also be noted that self-treatment and informal, unreported treatment are widespread among HCWs, which means that many cases are not captured by the official statistics. This was confirmed by a survey among physicians which found that 40% of the respondents were ill four times a year or more but did not apply to a practising physician for medical care and did not submit a disability form. These data were corroborated by medical examinations which found evidence of disability in 127.35 cases per 100 workers examined.

Morbidity also increases with age. In these examinations, it was six times more frequent among HCWs with 25 years of service than among those with less than 5 years of service. The most common diseases included circulatory impairments (27.9%), diseases of the digestive organs (20.0%) and musculoskeletal disorders (20.72%). Except for the last, most of the cases were non-occupational in origin.

Sixty per cent of doctors and 46% of mid-level personnel were found to have chronic diseases. Many of these were directly associated with job assignments.

Many of the observed diseases were directly associated with job assignments of those examined. Thus, microsurgeons working in an awkward posture were found to have frequent osteochondroses; chemotherapists were found to suffer frequently from chromosome abnormalities and anaemia; nurses who were in contact with a large variety of medicines suffered various allergic diseases, ranging from dermatoses to bronchial asthma and immunodeficiency.

In Russia, health problems of medical workers were first addressed in the 1920s. In 1923 a special scientific-consultative bureau was founded in Moscow; the results of its studies were published in five collections entitled Labour and Life of Medical Workers of Moscow and Moscow Province. Since that time other studies have appeared devoted to this problem. But this work has been carried on in the most fruitful way only since 1975, when the Laboratory of Labour Hygiene of Medical Workers was established in the RAMS Institute of Occupational Health, which coordinated all the studies of this problem. After analysis of the then-current situation, research was directed at:

  • studies of the features of labour processes in the main medical specialties
  • assessment of the factors of the occupational environment
  • analysis of the morbidity of medical workers
  • elaboration of measures for optimization of labour conditions, reduction of fatigue and prevention of morbidity.


Based on the studies carried out by the Laboratory and other institutions, a number of recommendations and suggestions were prepared, aimed at reduction and prevention of the occupational diseases of medical workers.

Instructions were established for pre-employment and periodic medical examinations of health care workers. The aim of these examinations was to determine the fitness of the worker for the job and to prevent common and occupational diseases as well as occupational accidents. A list of hazardous and dangerous factors in the work of medical personnel was prepared which included recommendations for frequency of examinations, the range of specialists to take part in the examinations, the number of laboratory and functional studies as well as a list of medical contra-indications for work with a specific hazardous occupational factor. For every studied group there was a list of occupational diseases, enumerating the nosological forms, approximate list of job assignments and hazardous factors which can cause the respective occupational conditions.

In order to control the working conditions in treatment and prevention institutions, a Certificate of Sanitary and Technical Conditions of Labour in the health care institutions was developed. The certificate can be used as a guide for conducting sanitary measures and improvement of labour safety. For an institution to complete the certificate, it is necessary to carry out a study, with the help of specialists in sanitary service and other respective organizations, of the general situation in the departments, rooms and wards, to measure the levels of health and safety hazards.

Departments of hygiene of the preventive medicine institutions have been established in the modern centres of sanitary-epidemic inspections. The mission of these departments includes perfecting measures for the prevention of nosocomial infections and their complications in hospitals, creating optimal conditions for treatment and protecting the safety and health of HCWs. Public health doctors and their assistants conduct the preventive monitoring of design and construction of buildings for health care institutions. They see to the compliance of the new premises with the climate conditions, required arrangement of worksites, comfortable labour conditions and systems of rest and nutrition during the work shifts (see the article “Buildings for health care facilities” in this chapter). They also control technical documentation for the new equipment, technological procedures and chemicals. The routine sanitary inspection includes the monitoring of the occupational factors at the worksites and accumulation of the received data in the above-mentioned Certificate of Sanitary and Technical Conditions of Labour. Quantitative measurement of working conditions and prioritization of health improvement measures are established according to hygienic criteria for assessments of labour conditions which are based on indicators of the hazard and danger of labour environment factors and the heaviness and intensity of the working process. The frequency of laboratory studies is determined by the specific needs of each case. Each study usually includes measurement and analysis of microclimate parameters; measurement of indicators of air environment (e.g., content of bacteria and hazardous substances); assessment of the effectiveness of ventilation systems; assessment of the levels of natural and artificial illumination; and measurement of noise levels, ultrasound, ionizing radiation and so on. It is also recommended that time-keeping monitoring of the exposures of the unfavourable factors be conducted, based on the guideline documents.

According to instructions of the Russian government, and in keeping with current existing practice, the hygienic and medical standards should be revised following the accumulation of new data.



Wednesday, 02 March 2011 15:06

Case Study: Violence in Health Care Work

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A psychotic patient in his thirties had been forcibly committed to a large psychiatric hospital in the suburbs of a city. He was not regarded as having violent tendencies. After a few days he escaped from his secure ward. The hospital authorities were informed by his relatives that he had returned to his own house. As was routine an escort of three male psychiatric nurses set out with an ambulance to bring the patient back. En route they stopped to pick up a police escort as was routine in such cases. When they arrived at the house, the police escort waited outside, in case a violent incident developed. The three nurses entered and were informed by the relatives that the patient was sitting in an upstairs bedroom. When approached and quietly invited to come back to hospital for treatment the patient produced a kitchen knife which he had hidden. One nurse was stabbed in the chest, another a number of times in the back and the third in the hand and the arm. All three nurses survived but had to spend time in hospital. When the police escort entered the bedroom the patient quietly surrendered the knife.



Massive use of home care workers in New York City began in 1975 as a response to the needs of the growing population of chronically ill and frail elderly and as an alternative to more expensive care in nursing homes, many of which had long lists of such people waiting for admission. Additionally, it allowed for more personal assistance at a time when nursing homes were perceived as impersonal and uncaring. It also provided entry-level employment to unskilled individuals, mostly women, many of whom were recipients of welfare.

Initially, these workers were employees of the City’s Department of Human Resources but, in 1980, this service was “privatized” and they were recruited, trained and employed by non-profit, community-based social agencies and traditional health care organizations such as hospitals which had to be certified by the State of New York as providers of home care services. The workers are categorized as home makers, personal care workers, health aides, home care attendants and housekeepers, depending on their levels of skills and the kinds of services they provide. Which of these services a particular client uses depends on an evaluation of that person’s health status and needs which is conducted by a licensed health professional, such as a physician, nurse or social worker.

The Home Care Workforce

Home care workers in New York City present a conglomerate of characteristics that provide a unique profile. A recent survey by Donovan, Kurzman and Rotman (1993) found that 94% are female with an average age of 45. About 56% were not born within the continental US and about 51% never completed high school. Only 32% were identified as married, 33% were separated or divorced and 26% were single, while 86% have children, 44% with children under 18 years of age. According to the survey, 63% live with their children and 26% live with a spouse.

The median family income for this group in 1991 was $12,000 per year. In 81% of these families, the home care worker was the primary breadwinner. In 1996, the annual salary of full-time home care workers’ ranged between $16,000 and $28,000; part-time workers earned less.

Such low earnings represent significant economic hardship to the survey respondents: 56% said they could not afford adequate housing; 61% reported being unable to afford furniture or household equipment; 35% said they lacked funds to purchase enough food for their families; and 36% were ineligible for Medicare and unable to afford needed medical care for themselves and their families. As a group, their financial status will inevitably worsen as cuts in government funding force curtailment of the amount and intensity of home care services being provided.

Home Care Services

The services provided by home care workers depend on the needs of the clients being served. Those with greater disability require assistance with the “basic activities of daily living”, which consist of bathing, dressing, toileting, transferring (moving in or out of bed and chairs) and feeding. Those with higher levels of functional capacity need help with the “instrumental activities of daily living”, which comprise housekeeping (cleaning, bed making, dishwashing, and so forth), shopping, food preparation and serving, laundry, using public or private transportation and managing finances. Home care workers may give injections, dispense medications and provide such treatments as passive exercise and massage as prescribed by the client’s physician. A most appreciated service is companionship and assisting the client to participate in recreational activities.

The difficulty of the home care worker’s job is directly related to the home environment and, in addition to physical status, the behaviour of the client and any family members who may be on the scene. Many clients (and the workers as well) live in poor neighbourhoods where crime rates are high, public transportation often marginal and public services substandard. Many live in deteriorated housing with no or non-functioning elevators, dark and dirty stairwells and hallways, lack of heat and hot water, dilapidated plumbing and poorly functioning household appliances. Commuting to and from the client’s home may be arduous and time-consuming.

Many of the clients may have very low levels of functional capacity and require assistance at every turn. Clients’ muscle weakness and lack of coordination, loss of vision and hearing and incontinence of bladder and/or bowels add to the burden of care. Mental difficulties such as senile dementia, anxiety and depression and difficulties in communication because of memory loss and language barriers may also magnify the difficulty. Finally, abusive and demanding behaviour on the part of both clients and their family members may sometimes escalate into acts of violence.

Home Care Work Hazards

Work hazards commonly encountered by home care workers include:

  • working alone without assistance
  • lack of education and training and remote, if any, supervision
  • working in substandard housing in high risk neighbourhoods
  • back pain and musculoskeletal injuries incurred while lifting, transferring and supporting clients who may be heavy, weak and poorly coordinated
  • violence in the home and in the neighbourhood
  • infectious diseases (the health care worker may not have been fully informed of the client’s medical status; recommended gloves, gowns and masks may not be available)
  • household chemicals and cleaning supplies (often incorrectly labelled and stored)
  • sexual harassment
  • work stress.


Stress is probably the most ubiquitous hazard. It is compounded by the fact the worker is usually alone in the home with the client with no simple way to report trouble or summon assistance. Stress is being exacerbated as cost-containment efforts are reducing the hours of service allowed for individual clients.

Prevention Strategies

A number of strategies have been suggested to promote occupational health and safety for home care workers and to improve their lot. They include:

  • development and promulgation of standards of practice for home care accompanied by improved education and training so that home care workers can meet them
  • education and training in the recognition and avoidance of chemical and other hazards in the home
  • training in lifting, carrying and giving physical support to clients as needed in the course of providing services
  • preliminary needs assessment of clients supplemented by inspections of their homes so that potential hazards can be identified and eliminated or controlled and needed materials and equipment can be procured
  • periodic meetings with supervisors and other home care workers to compare notes and receive instruction. Videotapes may be developed and used for skills demonstrations. The meetings may be supplemented by telephone networks through which workers may communicate with each other to exchange information and alleviate any feelings of isolation.
  • establishment of a health and safety committee within each agency to review work-related accidents and problems and develop appropriate preventive interventions
  • establishment of an Employee Assistance Programme (EAP) through which the workers may receive counselling for their own psychosocial problems both on- and off-the-job.


Educational and training sessions should be conducted during working hours at a place and time convenient for the workers. They should be supplemented by the distribution of instructional materials designed for the low educational levels of most of the workers and, when necessary, they should be multilingual.

Case study: Violence in health care work

A psychotic patient in his thirties had been forcibly committed to a large psychiatric hospital in the suburbs of a city. He was not regarded as having violent tendencies. After a few days he escaped from his secure ward. The hospital authorities were informed by his relatives that he had returned to his own house. As was routine an escort of three male psychiatric nurses set out with an ambulance to bring the patient back. En route they stopped to pick up a police escort as was routine in such cases. When they arrived at the house, the police escort waited outside, in case a violent incident developed. The three nurses entered and were informed by the relatives that the patient was sitting in an upstairs bedroom. When approached and quietly invited to come back to hospital for treatment the patient produced a kitchen knife which he had hidden. One nurse was stabbed in the chest, another a number of times in the back and the third in the hand and the arm. All three nurses survived but had to spend time in hospital. When the police escort entered the bedroom the patient quietly surrendered the knife.

Daniel Murphy



Wednesday, 02 March 2011 15:03

Social Services

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Overview of the Social Work Profession

Social workers function in a wide variety of settings and work with many different kinds of people. They work in community health centres, hospitals, residential treatment centres, substance-abuse programmes, schools, family service agencies, adoption and foster care agencies, day-care facilities and public and private child welfare organizations. Social workers often visit homes for interviews or inspections of home conditions. They are employed by businesses, labour unions, international aid organizations, human rights agencies, prisons and probation departments, agencies for the ageing, advocacy organizations, colleges and universities. They are increasingly entering politics. Many social workers have full- or part-time private practices as psychotherapists. It is a profession that seeks to “improve social functioning by the provision of practical and psychological help to people in need” (Payne and Firth-Cozens 1987).

Generally, social workers with doctorates work in community organization, planning, research, teaching or combined areas. Those with bachelor’s degrees in social work tend to work in public assistance and with the elderly, mentally retarded and developmentally disabled; social workers with master’s degrees are usually found in mental health, occupational social work and medical clinics (Hopps and Collins 1995).

Hazards and Precautions


Studies have shown that stress in the workplace is caused, or contributed to, by job insecurity, poor pay, work overload and lack of autonomy. All of these factors are features of the work life of social workers in the late 1990s. It is now accepted that stress is often a contributing factor to illness. One study has shown that 50 to 70% of all medical complaints among social workers are linked to stress (Graham, Hawkins and Blau 1983).

As the social work profession has attained vendorship privileges, managerial responsibilities and increased numbers in private practice, it has become more vulnerable to professional liability and malpractice suits in countries such as the United States which permit such legal actions, a fact which contributes to stress. Social workers are also increasingly dealing with bioethical issues—those of life and death, of research protocols, of organ transplantation and of resource allocation. Often there is inadequate support for the psychological toll confronting these issues can take on involved social workers. Increased pressures of high caseloads as well as increased reliance on technology makes for less human contact, a fact which is likely true for most professions, but particularly difficult for social workers whose choice of work is so related to having face to face contact.

In many countries, there has been a shift away from government-funded social programmes. This policy trend directly affects the social work profession. The values and goals generally held by social workers—full employment, a “safety net” for the poor, equal opportunity for advancement—are not supported by these current trends.

The movement away from spending on programmes for the poor has produced what has been called an “upside-down welfare state” (Walz, Askerooth and Lynch 1983). One result of this, among others, has been increased stress for social workers. As resources decline, demand for services is on the rise; as the safety net frays, frustration and anger must rise, both for clients and for social workers themselves. Social workers may increasingly find themselves in conflict over respecting the values of the profession versus meeting statutory requirements. The code of ethics of the US National Association of Social Workers, for example, mandates confidentiality for clients which may be broken only when it is for “compelling professional reasons”. Further, social workers are to promote access to resources in the interest of “securing or retaining social justice”. The ambiguity of this could be quite problematic for the profession and a source of stress.


Work-related violence is a major concern for the profession. Social workers as problem-solvers on the most personal level are particularly vulnerable. They work with powerful emotions, and it is the relationship with their clients which becomes the focal point for expression of these emotions. Often, an underlying implication is that the client is unable to manage his or her own problems and needs the help of social workers to do so. The client may, in fact, be seeing social workers involuntarily, as, for example, in a child welfare setting where parental abilities are being evaluated. Cultural mores might also interfere with accepting offers of help from someone of another cultural background or sex (the preponderence of social workers are women) or outside of the immediate family. There may be language barriers, necessitating the use of translators. This can be distracting at least or even totally disruptive and may present a skewed picture of the situation at hand. These language barriers certainly affect the ease of communication, which is essential in this field. Further, social workers may work in locations which are in high-crime areas, or the work might take them into the “field” to visit clients who live in those areas.

Application of safety procedures is uneven in social agencies, and, in general, insufficient attention has been paid to this area. Prevention of violence in the workplace implies training, managerial procedures and modifications of the physical environment and/or communication systems (Breakwell 1989).

A curriculum for safety has been suggested (Griffin 1995) which would include:

  • training in constructive use of authority
  • crisis intervention
  • field and office safety
  • physical plant set-up
  • general prevention techniques
  • ways to predict potential violence.


Other Hazards

Because social workers are employed in such a variety of settings, they are exposed to many of the hazards of the workplace discussed elsewhere in this Encyclopaedia. Mention should be made, however, that these hazards include buildings with poor or unclean air flow (“sick buildings”) and exposures to infection. When funding is scarce, maintenance of physical plants suffers and risk of exposure increases. The high percentage of social workers in hospital and out-patient medical settings suggests vulnerability to infection exposure. Social workers see patients with conditions like hepatitis, tuberculosis and other highly contagious diseases as well as human immunodeficiency virus (HIV) infection. In response to this risk for all health workers, training and measures for infection control are necessary and have been mandated in many countries. The risk, however, persists.

It is evident that some of the problems faced by social workers are inherent in a profession which is so centred on lessening human suffering as well as one which is so affected by changing social and political climates. At the end of the twentieth century, the profession of social work finds itself in a state of flux. The values, ideals and rewards of the profession are also at the heart of the hazards it presents to its practitioners.



Wednesday, 02 March 2011 15:02

Are They Health Care Workers, Too?

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Often overlooked when considering the safety and well-being of health care workers are students attending medical, dental, nursing and other schools for health professionals and volunteers serving pro bono in healthcare facilities. Since they are not “employees” in the technical or legal sense of the term, they are ineligible for workers’ compensation and employment-based health insurance in many jurisdictions. Health care administrators have only a moral obligation to be concerned about their health and safety.

The clinical segments of their training bring medical, nursing and dental students into direct contact with patients who may have infectious diseases. They perform or assist in a variety of invasive procedures, including taking blood samples, and often do laboratory work involving body fluids and specimens of urine and faeces. They are usually free to wander about the facility, entering areas containing potential hazards often, since such hazards are rarely posted, without an awareness of their presence. They are usually supervised very loosely, if at all, while their instructors are often not very knowledgeable, or even interested, in matters of safety and health protection.

Volunteers are rarely permitted to participate in clinical care but they do have social contacts with patients and they usually have few restrictions with respect to areas of the facility they may visit.

Under normal circumstances, students and volunteers share with health care workers the risks of exposure to potentially harmful hazards. These risks are exacerbated at times of crisis and in emergencies when they step into or are ordered into the breech. Clearly, even though it may not be spelled out in laws and regulations or in organizational procedure manuals, they are more than entitled to the concern and protection extended to “regular” health care workers.



Health care is a labour intensive industry and, in most countries, health care workers (HCWs) constitute a major sector of the workforce. They comprise a wide range of professional, technical and support personnel working in a large variety of settings. In addition to health professionals, laboratory technicians, pharmacists, social workers and others involved in clinical services, they include administrative and clerical personnel, housekeeping and dietary staff, laundry workers, engineers, electricians, painters and maintenance workers who repair and refurbish the building and the equipment it contains. In contrast with those providing direct care, these support workers usually have only casual, incidental contact with patients.

HCWs represent diverse educational, social and ethnic levels and are usually predominantly female. Many, particularly in home care, are employed in entry-level positions and require considerable basic training. Table 1 lists samples of health care functions and associated occupations.

Table 1. Examples of health care functions and associated occupations


Occupational category *

Specific occupations

Direct patient care

Health-diagnosing occupations

treating occupations


Registered nurses
Physicians’ assistants
Therapists (e.g., inhalation
and physical)
Dietitians and nutritionists
Social workers

Technical support

Health technicians

Clinical laboratory technicians
Dental hygienists
Health record technicians
Radiology technicians
Licensed practical nurses
Emergency services


Health services

Food services

Personal services
Laundry services
Building services

Security services
Transportation services

Dental assistants
Health aides, other than
Nursing aides, orderlies and
Kitchen workers
Barbers and hairdressers
Laundry workers
Plumbers, electricians and
other crafts
Janitors and cleaners
Boiler room operators
Gardeners and
Ambulance drivers

Administrative support

Clerical services

Billing clerks
Records processing
Computer equipment
Physicians’ office workers
Telephone operators


Scientific occupations

Laboratory workers

Scientists and research
Laboratory technicians
Animal caretakers

* Occupational categories are, in part, adapted from those used by the US Department of Labor, Bureau of Labor Statistics.

A segment of the health sector (unfortunately, often too small and under-resourced in most communities) is devoted to direct and indirect preventive services. The major focus of the health care industry, however, is the diagnosis, treatment and care of the sick. This creates a special set of dynamics, for the sick exhibit varying levels of physical and emotional dependencies that set them apart from the customers in such personal services industries as, for example, retail trade, restaurants and hotels. They require, and traditionally receive, special services and considerations, often on an emergency basis, provided frequently at the expense of the HCWs’ personal comfort and safety.

Reflecting their size and numbers of employees, acute and long-term care facilities constitute perhaps the most prominent elements in the health care industry. They are supplemented by outpatient clinics, “surgicenters” (facilities for outpatient surgery), clinical and pathological laboratories, pharmacies, x-ray and imaging centres, ambulance and emergency care services, individual and group offices, and home care services. These may be located within a hospital or operated elsewhere under its aegis, or they may be free-standing and operated independently. It should be noted that there are profound differences in the way health services are delivered, ranging from the well-organized, “high tech” care available in urban centres in developed countries to the underserved areas in rural communities, in developing countries and in inner-city enclaves in many large cities.

Superimposed on the health care system is a massive educational and research establishment in which students, faculty, researchers and support staffs often come in direct contact with patients and participate in their care. This comprises schools of medicine, dentistry, nursing, public health, social work and the variety of technical disciplines involved in health care.

The health care industry has been undergoing profound changes during the past few decades. Ageing of the population, especially in developed countries, has amplified the use of nursing homes, domiciliary facilities and home care services. Scientific and technological developments have not only led to the creation of new types of facilities staffed by new classes of specially-trained personnel, but they have also de-emphasized the role of the acute care hospital. Now, many services requiring inpatient care are being provided on an ambulatory basis. Finally, fiscal constraints dictated by the continuing escalation of health care costs have been reconfiguring the health care industry, at least in developing countries, resulting in pressure for cost-containment to be achieved through changes in the organization of health care services.

HCWs who are in direct contact with the sick, wherever they work, are exposed to a number of unique hazards. They face the risk of acquiring infections from the patients they serve, as well as the risk of musculoskeletal injuries when lifting, transferring or restraining them. Support staff not directly involved in patient care (e.g., laundry and housekeeping and materials handling workers) are not only routinely exposed to chemicals, such as cleaning agents and disinfectants of industrial strength, but are also exposed to biological hazards from contaminated linens and wastes (see figure 1). There is also the ethos of health care which, especially in emergency situations, requires HCWs to put the safety and comfort of their patients above their own. Coping with the stress of therapeutic failures, death and dying often takes its toll in worker burnout. All this is compounded by shift work, deliberate or inadvertent understaffing and the necessity of catering to the sometimes unreasonable demands from patients and their families. Finally, there is the threat of abuse and violence from patients, particularly when the job requires them to work alone or takes them into unsafe areas. All these are described in greater detail in other articles in this chapter and elsewhere in this Encyclopaedia.

Figure 1. Handling contaminated biological material


Health Sciences Centre, Winnipeg, Manitoba, Canada

The US National Institute for Occupational Safety and Health (NIOSH) reported that needle punctures, musculoskeletal sprains and back injuries probably were the most common injuries in the health care industry (Wugofski 1995). The World Health Organization (WHO) Conference on Occupational Hazards in 1981 identified as its five main areas of concern:

  • cuts, lacerations and fractures
  • back injuries
  • lack of personal safety equipment
  • poor maintenance of mechanical and electrical systems
  • assault by patients.


Are they health care workers, too?


Often overlooked when considering the safety and well-being of health care workers are students attending medical, dental, nursing and other schools for health professionals and volunteers serving pro bono in healthcare facilities. Since they are not “employees” in the technical or legal sense of the term, they are ineligible for workers’ compensation and employment-based health insurance in many jurisdictions. Health care administrators have only a moral obligation to be concerned about their health and safety.

The clinical segments of their training bring medical, nursing and dental students into direct contact with patients who may have infectious diseases. They perform or assist in a variety of invasive procedures, including taking blood samples, and often do laboratory work involving body fluids and specimens of urine and faeces. They are usually free to wander about the facility, entering areas containing potential hazards often, since such hazards are rarely posted, without an awareness of their presence. They are usually supervised very loosely, if at all, while their instructors are often not very knowledgeable, or even interested, in matters of safety and health protection.

Volunteers are rarely permitted to participate in clinical care but they do have social contacts with patients and they usually have few restrictions with respect to areas of the facility they may visit.

Under normal circumstances, students and volunteers share with health care workers the risks of exposure to potentially harmful hazards. These risks are exacerbated at times of crisis and in emergencies when they step into or are ordered into the breech. Clearly, even though it may not be spelled out in laws and regulations or in organizational procedure manuals, they are more than entitled to the concern and protection extended to “regular” health care workers.

Leon Warshaw


Biological Hazards

Biological hazards, which pose a risk for infectious disease, are common throughout the world, but they are particularly problematic in developing countries. While the hepatitis B virus (HBV) is a nearly universal threat to HCWs, it is particularly important in African and Asian countries where this virus is endemic. As discussed later in this chapter, the risk of HBV transmission after percutaneous exposure to hepatitis B surface antigen (HBsAg) positive blood is approximately 100-fold higher than the risk of transmitting the human immunodeficiency virus (HIV) through percutaneous exposure to HIV-infected blood (i.e., 30% versus 0.3%). Nonetheless, there has indeed been an evolution of concern regarding parenteral exposure to blood and body fluids from the pre-HIV to the AIDS era. McCormick et al. (1991) found that the annual reported incidents of injuries from sharp instruments increased more than threefold during a 14-year period and among medical house officers the reported incidents increased ninefold. Overall, nurses incur approximately two-thirds of the needlestick injuries reported. Yassi and McGill (1991) also noted that nursing staff, particularly nursing students, are at highest risk for needlestick injuries, but they also found that approximately 7.5% of medical personnel reported exposures to blood and body fluids, a figure that is probably low because of underreporting. These data were consistent with other reports which indicated that, while there is increased reporting of needlesticks reflecting concerns about HIV and AIDS, certain groups continue to underreport. Sterling (1994) concludes that underreporting of needlestick injuries ranges from 40 to 60%.

Certain risk factors clearly enhance the likelihood of transmission of bloodborne diseases; these are discussed in the article “Prevention of occupational transmission of bloodborne pathogens”. Frequent exposure has indeed been associated with high seroprevalence rates of hepatitis B among laboratory workers, surgeons and pathologists. The risk of hepatitis C is also increased. The trend towards greater attention to prevention of needlestick injuries is, however, also noteworthy. The adoption of universal precautions is an important advance. Under universal precautions, it is assumed that all blood-containing fluid is potentially infectious and that appropriate safeguards should always be invoked. Safe disposal containers for needles and other sharp instruments are increasingly being placed in conveniently accessible locations in treatment areas, as illustrated in figure 2. The use of new devices, such as the needle-less access system for intravenous treatment and/or blood sampling has been shown to be a cost-effective method of reducing needlestick injuries (Yassi and McGill 1995).

Figure 2. Disposal container for sharp instruments and devices


Health Sciences Centre, Winnipeg, Manitoba, Canada

Blood and body fluids are not the only source of infection for HCWs. Tuberculosis (TB) is also on the rise again in parts of the world where previously its spread had been curtailed and, as discussed later in this chapter, is a growing occupational health concern. In this, as in other nosocomial infections, such concern is heightened by the fact that so many of the organisms involved have become drug-resistant. There is also the problem of new outbreaks of deadly infectious agents, such as the Ebola virus. The article “Overview of infectious diseases” summarizes the major infectious disease risks for HCWs.

Chemical Hazards

HCWs are exposed to a wide variety of chemicals, including disinfectants, sterilants, laboratory reagents, drugs and anaesthetic agents, to name just a few of the categories. Figure 3 shows a storage cabinet in an area of a large hospital where prosthetics are fabricated and clearly illustrates the vast array of chemicals that are present in health care facilities. Some of these substances are highly irritating and may also be sensitizing. Some disinfectants and antiseptics also tend to be quite toxic, also with irritating and sensitizing propensities that may induce skin or respiratory tract disease. Some, like formaldehyde and ethylene oxide, are classified as mutagens, teratogens and human carcinogens as well. Prevention depends on the nature of the chemical, the maintenance of the apparatus in which it is used or applied, environmental controls, worker training and, in some instances, the availability of correct personal protective equipment. Often such control is straightforward and not very expensive. For example, Elias et al. (1993) showed how ethylene oxide exposure was controlled in one health care facility. Other articles in this chapter address chemical hazards and their management.

Figure 3. Storage cabinet for hazardous chemicals


Health Sciences Centre, Winnipeg, Manitoba, Canada

Physical Hazards and the Building Environment

In addition to the specific environmental contaminants faced by HCWs, many health care facilities also have documented indoor air quality problems. Tran et al. (1994), in studying symptoms experienced by operating room personnel, noted the presence of the “sick building syndrome” in one hospital. Building design and maintenance decisions are, therefore, extremely important in health care facilities. Particular attention must be paid to correct ventilation in specific areas such as laboratories, operating rooms and pharmacies, the availability of hoods and avoidance of the insertion of chemical-laden fumes into the general air-conditioning system. Controlling the recirculation of air and using special equipment (e.g., appropriate filters and ultraviolet lamps) is needed to prevent the transmission of air-borne infectious agents. Aspects of the construction and planning of health care facilities are discussed in the article “Buildings for health care facilities”.

Physical hazards are also ubiquitous in hospitals (see “Exposure to physical agents” in this chapter). The wide variety of electrical equipment used in hospitals can present an electrocution hazard to patients and staff if not properly maintained and grounded (see figure 4). Especially in hot and humid environments, heat exposure may present a problem to workers in such areas as laundries, kitchens and boiler rooms. Ionizing radiation is a special concern for staff in diagnostic radiology (i.e., x ray, angiography, dental radiography and computerized axial tomography (CAT) scans) as well as for those in therapeutic radiology. Controlling such radiation exposures is a routine matter in designated departments where there is careful supervision, well-trained technicians and properly shielded and maintained equipment, but it can be a problem when portable equipment is used in emergency rooms, intensive care units and operating rooms. It can also be a problem to housekeeping and other support staff whose duties take them into areas of potential exposure. In many jurisdictions these workers have not been properly trained to avoid this hazard. Exposure to ionizing radiation may also present a problem in diagnostic and therapeutic nuclear medicine units and in preparing and distributing doses of radioactive pharmaceuticals. In some cases, however, radiation exposure remains a serious problem (see the article “Occupational health and safety practice: The Russian experience”  in this chapter).

Figure 4. Electrical equipment in hospital


Health Sciences Centre, Winnipeg, Manitoba, Canada

Contradicting the prevailing impression of hospitals as quiet workplaces, Yassi et al. (1991) have documented the surprising extent of noise-induced hearing loss among hospital workers (see table 2). The article “Ergonomics of the physical work environment” in this chapter offers useful recommendations for controlling this hazard, as does table 3.



Table 2. 1995 integrated sound levels

Area monitored

dBA (lex) Range

Cast room

76.32 to 81.9

Central energy

82.4 to 110.4

Nutrition and food services (main kitchen)
Cooking area
Pot wash
Cart drivers
Salad area
Nutrition and food services (dishrooms)
Oasis café
Rehab kitchen
Courtyard café (runner)
Tunnel café—(runner)


85.4 to 85.8


71.4 to 80.0
90.0 to 100.00

Flat ironers
Compressed air jets
Rough dry
Sewing room

85.7 to 98.7
83.3 to 89.7
79.4 to 86.5

Linen service

76.3 to 91.0

Post meter


Equipment and furnishings

81.6 to 82.4
80.5 to 83.4

Materials handling

88 to 89

Print shop
Press operator

74.9 to 81.5
80.7 to 90.0

Rehabilitation engineering
Machine shop

80.0 to 94.3
80.1 to 80.1

Note: “Lex” means the equivalent sound level or the steady sound level in dBA which, if present in a workplace for 8 hours, would contain the same acoustic energy.



Table 3. Ergonomic noise reduction options

Work area


Control options

Central energy

General area

Enclose the source
Personnel acoustic booth


Pot washer

Automate process
Use sound barriers and



Purchasing criteria



Isolate and reduce vibration
Use sound barriers and
Damping materials
Modify air jets
Reposition machines


Stamp machine

Purchasing criteria


Various equipment

Purchasing criteria
Proper maintenance
Damping materials

Materiel handling and
transport/linen service


Smoother floors
Reduce vibration
Damping materials

Print shop

Press operator

Purchasing criteria
Enclose source
Relocate machines
Sound barriers and deflectors



Purchasing criteria
Sound absorbing materials
Sound barriers and deflectors


By far the most common and most costly type of injury faced by HCWs is back injury. Nurses and attendants are at greatest risk of musculoskeletal injuries due to the large amount of patient lifting and transferring that their jobs require. The epidemiology of back injury in nurses was summarized by Yassi et al. (1995a) with respect to one hospital. The pattern they observed mirrors those that have been universally reported. Hospitals are increasingly turning to preventive measures which may include staff training and the use of mechanical lifting devices. Many are also providing up-to-date diagnostic, therapeutic and rehabilitation health services that will minimize lost time and disability and are cost-effective (Yassi et al. 1995b). Hospital ergonomics has taken on increasing importance and, therefore, is the subject of a review article in this chapter. The specific problem of the prevention and management of back pain in nurses as one of the most important problems for this cohort of HCWs is also discussed in the article “Prevention and management of back pain in nurses” in this chapter. Table 4  lists the total number of injuries in a one-year period.

Table 4. Total number of injuries, mechanism of injury and nature of industry (one hospital, all departments), 1 April 1994 to 31 March 1995

Nature of injury sustained












tional condi-


























Breaking fall
























































Caught in/






















Staff abuse





































Scalpel cuts
















Unknown (no


















1 No blood/body fluid.  2 This includes rashes/dermatitis/work-related illness/burning eyes, irritated eyes.  3 Exposure to chemical or physical agents but with no documented injuries affects. 4 Accident not reported.  5 Exposure to cold/heat, unknown.


In discussing musculoskeletal and ergonomic problems, it is important to note that while those engaged in direct patient care may be at greatest risk (see figure 5) many of the support personnel in hospital must contend with similar ergonomic burdens (see figure 6 and figure 7). The ergonomic problems facing hospital laundry workers have been well-documented (Wands and Yassi 1993) (see figure 8, figure 9  and figure 10) and they also are common among dentists, otologists, surgeons and especially microsurgeons, obstetricians, gynaecologists and other health personnel who often must work in awkward postures.

Figure 5. Patient lifting is an ergonomic hazard in most hospitals


Health Sciences Centre, Winnipeg, Manitoba, Canada

Figure 6. Overhead painting: A typical ergonomic hazard for a tradesworker


Health Sciences Centre, Winnipeg, Manitoba, Canada

Figure 7. Cast-making involves many ergonomic stresses


Health Sciences Centre, Winnipeg, Manitoba, Canada

Figure 8. Laundry work such as this can cause repetitive stress injury to the upper limbs


Health Sciences Centre, Winnipeg, Manitoba, Canada

Figure 9. This laundry task requires working in an awkward position


Health Sciences Centre, Winnipeg, Manitoba, Canada

Figure 10. A poorly designed laundry operation can cause back strain


Health Sciences Centre, Winnipeg, Manitoba, Canada

Organizational Problems

The article “Strain in health care work” contains a discussion of some of the organizational problems in hospitals and a summary of the principal findings of Leppanen and Olkinuora (1987), who reviewed Finnish and Swedish studies of stress among HCWs. With the rapid changes currently under way in this industry, the extent of alienation, frustration and burnout among HCWs is considerable. Added to that is the prevalence of staff abuse, an increasingly troublesome problem in many facilities (Yassi 1994). While it is often thought that the most difficult psychosocial problem faced by HCWs is dealing with death and dying, it is being recognized increasingly that the nature of the industry itself, with its hierarchical structure, its growing job insecurity and the high demands unsupported by adequate resources, is the cause of the variety of stress-related illness faced by HCWs.

The Nature of the Health Care Sector

In 1976, Stellman wrote, “If you ever wondered how people can manage to work with the sick and always stay healthy themselves, the answer is that they can’t” (Stellman 1976). The answer has not changed, but the potential hazards have clearly expanded from infectious diseases, back and other injuries, stress and burnout to include a large variety of potentially toxic environmental, physical and psychosocial exposures. The world of the HCW continues to be largely unmonitored and largely unregulated. None the less, progress is being made in addressing occupational health and safety hazards in hospitals. The International Commission on Occupational Health (ICOH) has a sub-committee addressing this problem, and several international conferences have been held with published proceedings that offer useful information (Hagberg et al. 1995). The US Centers for Disease Control and Prevention (CDC) and NIOSH have proposed guidelines to address many of the problems of the health care industry discussed in this article (e.g., see NIOSH 1988). The number of articles and books addressing health and safety issues for HCWs has been growing rapidly, and good overviews of health and safety in the US health care industry have been published (e.g., Charney 1994; Lewy 1990; Sterling 1994). The need for systematic data collection, study and analysis regarding hazards in the health care industry and the desirability of assembling interdisciplinary occupational health teams to address them have become increasingly evident.

When considering occupational health and safety in the health care industry, it is crucial to appreciate the enormous changes currently taking place in it. Health care “reform”, being instituted in most of the developed countries of the world, is creating extraordinary turbulence and uncertainty for HCWs, who are being asked to absorb rapid changes in their work tasks often with greater exposure to risks. The transformation of health care is spurred, in part, by advances in medical and scientific knowledge, the development of innovative technological procedures and the acquisition of new skills. It is also being driven, however, and perhaps to an even greater extent, by concepts of cost-effectiveness and organizational efficiency, in which “downsizing” and “cost control” have often seemed to become goals in themselves. New institutional incentives are being introduced at different organizational levels in different countries. The contracting out of jobs and services that had traditionally been carried out by a large stable workforce is now increasingly becoming the norm. Such contracting out of work is reported to have helped the health administrators and politicians achieve their long-term goal of making the process of health care more flexible and more accountable. These changes have also brought changes in roles that were previously rather well-defined, undermining the traditional hierarchical relationships among planners, administrators, physicians and other health professionals. The rise of investor-owned health care organizations in many countries has introduced a new dynamic in the financing and management of health services. In many situations, HCWs have been forced into new working relationships that involve such changes as downgrading services so that they can be performed by less-skilled workers at lower pay, reduced staffing levels, staff redeployments involving split shifts and part-time assignments. At the same time, there has been a slow but steady growth in the numbers of such physician surrogates as physician assistants, nurse practitioners, midwives and psychiatric social workers who command lower rates of pay than the physicians they are replacing. (The ultimate social and health costs both to HCWs and to the public, as patients and payers, is still to be determined.)

A growing trend in the US that is also emerging in the UK and northern European countries is “managed care”. This generally involves the creation of organizations paid on a per capita basis by insurance companies or government agencies to provide or contract for the provision of a comprehensive range of health services to a voluntarily-enrolled population of subscribers. Their aim is to reduce the costs of health care by “managing” the process: using administrative procedures and primary care physicians as “gatekeepers” to control the utilization of expensive in-patient hospital days, reducing referrals to high-priced specialists and use of costly diagnostic procedures, and denying coverage for expensive new forms of “experimental” treatment. The growing popularity of these managed care systems, fuelled by aggressive marketing to employer- and government-sponsored groups and individuals, has made it difficult for physicians and other health care providers to resist becoming involved. Once engaged, there is a variety of financial incentives and disincentives to influence their judgement and condition their behaviour. The loss of their traditional autonomy has been particularly painful for many medical practitioners and has had a profound influence on their patterns of practice and their relationships with other HCWs.

These rapid changes in the organization of the health care industry are having profound direct and indirect effects on the health and safety of HCWs. They affect the ways health services are organized, managed, delivered and paid for. They affect the ways HCWs are trained, assigned and supervised and the extent to which considerations of their health and safety are addressed. This should be kept in mind as the various occupational health hazards faced by HCWs are discussed in this chapter. Finally, although it may not appear to be directly relevant to the content of this chapter, thought should be given to the implications of the well-being and performance of HCWs to the quality and effectiveness of the services they provide to their patients.




Part I. The Body
Part II. Health Care
Part III. Management & Policy
Part IV. Tools and Approaches
Part V. Psychosocial and Organizational Factors
Part VI. General Hazards
Part VII. The Environment
Part VIII. Accidents and Safety Management
Part IX. Chemicals
Part X. Industries Based on Biological Resources
Part XI. Industries Based on Natural Resources
Part XII. Chemical Industries
Part XIII. Manufacturing Industries
Part XIV. Textile and Apparel Industries
Part XV. Transport Industries
Part XVI. Construction
Part XVII. Services and Trade
Part XVIII. Guides