remote health workforce safety & security report january 2017 · remote health workforce safety...

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REMOTEAREAWORKFORCESAFETY&SECURITYPROJECT

REMOTEHEALTHWORKFORCESAFETY&SECURITYREPORT:

LITERATUREREVIEW,CONSULTATION,&SURVEYRESULTS

Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 1

CRANApluswouldliketoacknowledgeassistancefromtheCommonwealthDepartmentofHealth,andthecontributionoftheRemoteAreaWorkforceSafety&SecurityProjectExpertAdvisoryCommitteemembers:

JulianneBryce,SeniorFederalProfessionalOfficerANMF;DrJenniferMay,DepartmentofRuralHealth,TamworthNSW;HeatherKeighley,ActingChiefNursing&MidwiferyOfficer,NT;RobStarling,ChiefInformationOfficer,NACCHO,ACT;TonyVaughan,ChiefOperatingOfficer,RFDS,SA;MarieBaxter,ExecutiveDirectorNursing&Midwifery,WA;MichelleGarner,ExecutiveDirectorNursing&Midwifery,MountIsaQLD;Assoc.ProfSueLenthall.CentreforRemoteHealth,NT;LesleyPearson,DirectorofClinicalOperations,SilverChainWA;JohannaNeville,RAN/MApunipimaCapeYork,QLD;BobbiSawyer,SocialWorker,TeamManager,CAMHS,SA;ChristopherCliffe,CEOCRANAplus,QLD;GeriMalone,DirectorProfessionalServices,CRANAplus,SA;andRodMenere,ProfessionalOfficer,CRANAplus,NSW.

Thankstoallthosewhocompletedthequestionnaireandparticipatedinprojectsymposiaandinterviews.

Citation:CRANAplus2017.RemoteHealthWorkforceSafetyandSecurityReport:Literaturereview,ConsultationandSurveyreport.CRANAplus,Cairns

CompiledbyRodMenere,ProfessionalOfficer,CRANAplusNationalSafetyandSecurityProject

Thisworkiscopyright.Itmaybereproducedinwholeorpartfortrainingpurposessubjecttotheinclusionofanacknowledgementoftheauthorandsource,andnocommercialusageorsale.Reproductionforpurposesotherthanforthoseindicated,requiresthewrittenpermissionoftheCRANAplus.RequestsandenquiriesconcerningreproductionandrightsshouldbeaddressedtotheChiefExecutiveOfficer,CRANAplus,POBox7410,Cairns,QLD4870.

TABLEOFCONTENTS

EXECUTIVESUMMARY...................................................................................................................................5Introduction......................................................................................................................................................5Methodology.....................................................................................................................................................5LiteratureReviewResults..................................................................................................................................6Consultationandsurveyresults........................................................................................................................7Conclusion.........................................................................................................................................................8

1 INTRODUCTION......................................................................................................................................11

1.1 BACKGROUND:THEWORKINGSAFEINRURAL&REMOTEAUSTRALIAPROJECT............................111.2 Scopeofthetwoprojects.................................................................................................................121.3 Extrapolatingconclusionsfromthe‘WorkingSafe’survey...............................................................121.4 Methodology.....................................................................................................................................12

1.4.1 LiteratureReview:strategy&methodology................................................................................131.4.2 Symposia,ConsultationandSurvey:strategyandmethodology.................................................14

PARTA:LITERATUREREVIEW

2 LITERATUREREVIEW..............................................................................................................................162.1 Workplacecontext............................................................................................................................162.2 Remoteareaworkforceoccupationalstressandsafety...................................................................162.3 Respondingtoremoteareaworkforcesafetyandsecurityissues...................................................182.4 Characteristicsofremoteareaworkforceviolentevents.................................................................192.5 ImplementingWorkplaceHealthandSafetyregulationsinremoteareas.......................................212.6 Riskassessment................................................................................................................................212.7 Zerotolerancetoviolence................................................................................................................212.8 Educationandtrainingforremoteareaworkforcesafetyandsecurity...........................................222.9 SocialMedia......................................................................................................................................222.10 Workplacesafetyguidelines.............................................................................................................22

3 SUMMARYOFTHELITERATURE..............................................................................................................22

3.1 Whatisknown..................................................................................................................................223.2 Gapsintheliterature........................................................................................................................23

PARTB:CONSULTATIONREPORT

4 CONSULTATIONREPORT........................................................................................................................254.1 Introduction......................................................................................................................................254.2 RecruitmentandretentionofAboriginal&TorresStraitIslanderHealthWorkers..........................254.3 SafetyofAboriginal&TorresStraitIslanderHealthWorkers...........................................................264.4 Providingservicesincommunitiesexperiencingsocialdisruption...................................................264.5 Dogbite/dogattack.........................................................................................................................264.6 RemoteAreaWorkforcerecruitment,turnoverandchurn..............................................................274.7 RANfatigue.......................................................................................................................................274.8 Roadtravelinremoteareas..............................................................................................................284.9 Actionandinactiontoprioritisesafety&security............................................................................284.10 Bullyingandharassment:down,up,andhorizontal.........................................................................284.11 Challengesofremotemanagementandsupervision.......................................................................304.12 Asbestos............................................................................................................................................30

5 CLINICIANSURVEY.................................................................................................................................31

5.1 Questionnaireresultsanddiscussion...............................................................................................31

6 SUMMARYOFCONSULTATIONANDSURVEYRESULTS...........................................................................37

PARTC:CONCLUSION

7 CONCLUSION..........................................................................................................................................407.1 PriorityIssuesandRecommendations..............................................................................................40

8 REFERENCES...........................................................................................................................................43

TABLESTable1:Priorityhazardsasidentifiedbyexpertpanel.........................................................................17

Table2.Significant/ViolenteventswithRANasvictim,10/2015-11/2016...........................................20

Table3.ConsultationandSurveyparticipants......................................................................................25

APPENDICESAppendix1.ExecutiveSummary,RDAAWorkingSafeinRuralandRemoteAustraliareport..............45

Appendix2.CRANAplus2016Membersurveyresults..........................................................................50

Appendix3.CRANAplusNationalSafetyandSecurityProjectQuestionnaire......................................51

TableofAbbreviations

AHW AboriginalandTorresStraitIslanderHealthWorker,includingAHPRAregisteredIndigenousHealthProfessionals.Whilethefulltermwillusuallybeidentified,AHWisusedintablesanddocumentswhereformatlimitsspace

AMRRIC AnimalManagementinRural&RemoteIndigenousCommunities

COAG CouncilofAustralianGovernments

CRANAplus PeakprofessionalbodyfortheremoteandisolatedhealthworkforceofAustralia

CRANApulse CRANAplusweeklyemailnewsletter

CPPT Culture,Prevention,Protection,Treatment

CPTED CrimePreventionThroughEnvironmentalDesign

FIFO Fly-InFly-Out

4WD FourWheelDrive

GPS GlobalPositionSystem

IHP IndigenousHealthProfessional

IVMS InVehicleMonitoringSystem

MEC MaternityEmergencyCare

OHS OccupationalHealthandSafety–usedwhenreferringtothetitleofpastresearch&publications,andincludingcurrentVictorian&WesternAustralianlegislation

PLB PersonalLocatorBeacon

PTSD Post-TraumaticStressDisorder

RAWS&S RemoteAreaWorkforceSafetyandSecurity

RDAA RuralDoctorsAssociationofAustralia

RAN RemoteAreaNurse

RRMA RuralRemoteMetropolitanArea

WA WesternAustralia

WHS WorkplaceHealthandSafety

WSR WorkplaceSafetyRepresentative

ExecutiveSummaryIntroductionRemotehealthworkforcesafety&securityhasbeenalong-standingconcern.Inearly2016,assaultsonRemoteAreaNurses(RAN)andthemurderofRANGayleWoodfordsparkedagroundswellofangeranddistresswithinthehealthindustry,professionalorganisations,thepublic,andpoliticalleaders.GovernmentandIndustrylookedforresponsestrategiestopromoteworkforcesafetyandsecurity.

TheRemoteAreaWorkforceSafety&SecurityProjectisatwelve-monthCRANAplusinitiativefundedbytheCommonwealthDepartmentofHealth.Theprojectoutputscomprise:

1. Facilitatinganationalconversationaboutconcernsandideasregardingthesafetyandsecurityoftheremotehealthworkforce–stakeholderconsultation.

2. Developingpracticalsafetyandsecurityguidelinesforremotehealthpractice

3. Undertakingaliteraturereview,tobuildonexistingworkdoneonsafetyandsecurityinremotehealth

4. Developinganindustryhandbookon‘BeingSafeinRemoteHealth’

5. Creatinganeasytousesafetyandsecurity‘self-assessmenttool’

6. Developingafreeonlinelearningmoduleon‘WorkingSafeinRemotePractice’

7. ProvidinginputintotheCRANAplusApptoincludethe‘BeingsafeinRemoteHealth’information;and

8. Ensuringappropriateresourcesaremadefreelyavailableforusebythebroaderremoteandruralworkforce.

Thisreportdocumentstwoprojectoutcomes:

• Aliteraturereviewonsafetyandsecurityinremotehealthwillbeavailable,buildingonthe2012‘KeepingPeopleSafe’LiteratureReviewoftheWorkingSafeinRuralandRemoteAustraliaProject

• Facilitatinganationalconversationaboutconcernsandideasregardingthesafetyandsecurityoftheremotehealthworkforce.

TheRuralDoctorsAssociationofAustralia(RDAA)implementedaruralandremoteworkforcesafetyprojectin2011.TheRDAAWorkingSafeinRuralandRemoteAustraliaprojectreportisrecommendedasvaluablebackgroundreadingonthisissue.Thetwoprojectshavedifferentguidelinesandtargetpopulations,socareneedstobetakenwithextrapolatingtheresultsfromoneprojecttotheother.

MethodologyTheRemoteAreaWorkforceSafetyandSecurityprojecthasinvolvedthecompletionofaliteraturereview,theconductofstakeholderinterviews,andasurveycompletedbyninetycurrently/recentlypracticingremoteareaclinicians.Thecompilationofthesethreecomponentsformthebasisofadraftreportthatwasprovidedtotheproject’sExpertAdvisoryGroup,withfeedbackresultinginminoreditingbeforepublication.

TheProjectusedamulti-facetedapproachtoidentifyandcollectpublishedand‘grey’literaturefortheliteraturereview.WiththeassistanceoftheAustralianNationalUniversityResearchLibrarystaffoftheCanberraHospitalLibrary,searcheswereundertakenofseveralelectronicdatabases.

Duringnationalconsultation,symposiawereheldinvolving194participants.Meetingswerealsoheldwith68representativesfrom23governmentandcommunityorganisations;andquestionnaireswerecompletedby90healthclinicianswhowerecurrentlyorrecentlyworkinginremoteareas.

Atmeetings,individualdiscussionsandthroughquestionnaires,itwasreinforcedthattheproject’sgoalistodocumentinformationand,throughthisprocess,identifypositiveresponsesandinterventionsavailabletopromoteimprovementtoremotehealthworkforcesafetyandsecurity.

AllStateandTerritoryHealthDepartmentswerewrittentoregardingtheprojectandwereinvitedtocontributeanypolicyorstrategicinitiativesorevidencetohelpinformtheproject.

LiteratureReviewResultsTheliteraturereviewidentifiedthatthenationalhealthcareworkforceisexperiencinganincreasedrateofassault.Staffworkingaloneandinisolationareatgreaterriskofseriousassaultduetotheirlimitedaccesstorapidsecurityresponsesystems.RemoteandveryremotepopulationsinAustraliaexperiencehigherratesofdiseaseandhealthrisks.Theremotehealthworkforceisalsoexposedtomanyoftheseriskswhilebeingunderconsiderableburdentoprovideservicesinadifficultandresourcelimitedenvironment.Considerableefforthasbeenmadetoresearchanddocumenttheremotehealthworkforce’sperceptionofriskfactors,impactofriskfactorsoncliniciansand,toalesserextent,optionstopromoteworkforcesafetyandsecurity.ExistingrecommendationsshouldbeconsideredfurtheraccordingtoWorkplaceHealthandSafetyregulations.

Theremotehealthworkforceisageing,andworkforcenumbersper100,000populationhavedecreased.Availabilityofadequatenumbersofexperiencedandnewstaffisimportanttomaintainingworkforcesafety,securityandwellbeing,aswellasprovidinganappropriatelevelofservicetoremotecommunityresidents.

ApartfromtheWorkingSafeinRuralandRemoteAustraliaproject,researchhasprimarilyfocusedonrisksandviolencetotheremoteareanursingworkforce.Analysisofknownsevereepisodesofinjuryanddeathoftheremotehealthworkforceoverthepasttwelvemonthssuggeststhatbeingfemale,inoraroundyourownaccommodation,andafterhours’timesareriskfactors.Whileavailableinformationislikelyincomplete,itappearsthatsevereassaultsaremorecommonlycriminaleventsthanactualworksiteviolence.Itisnotclearhowfrequentlyperpetratorsaremotivatedbyintendedsexualassault,howeverthisisariskfactorrequiringrecognitioninstaffinductionandorientation.

WorkplaceHealthandSafetyregulationsprovidealegalstructureidentifyingtherightsandresponsibilitiesofemployersandemployees.However,therearegapsinimplementingregulations,andeffectivemonitoringofregulationcomplianceisdifficultinremotehealthservices.TheindustrywillbenefitfromallstakeholdersdevelopingabetterunderstandingofWHSlegislationandregulation,andhowitcanbeusedtopromotesafetyandsecurity.

Violenceandgeneralriskassessmenttoolshavearoleinsupportingthesafetyandsecurityoftheremotehealthworkforce.However,theiractualcontributiontoensuringsafetyislimited,andavailability/useofsuchtoolsdoesnotshiftemployerWHSresponsibilitiesontotheindividual.

Researchtodatehaspredominantlyidentifiedperceptionsofviolenceandriskissues,withlittleresearchidentifyingthecharacteristicsandeffectivenessofdifferentinterventions.Thisisneededtoinformtheindustryabouthowtobenefitfromresourcesavailabletopromoteworkforcesafetyandsecurity.Positiveinformationandsuccessfulinitiativesneedtobemorefrequentlyidentifiedinliteratureandthemedia.

Industryspecificliteraturehasfocusedonviolence,tothedetrimentofothersignificantthreatstoremotehealthworkforcesafetyandsecurity.Otherissueswarrantingresearchandinterventioninclude:Vehicleandtravelsafety;Dogattack;bullyingandharassment;andpersonalhealthandwellbeing.

ConsultationandsurveyresultsTwenty-fivepercentofquestionnaireparticipantsreportedthattheAboriginalandTorresStraitIslandercommunitiesinwhichtheyworkedhadnoAboriginalorTorresStraitIslanderHealthWorkers.TheabsenceofIndigenousclinicalstaffimpactsnegativelyonboththeculturalsafetyofservicesavailabletocommunities,andthesafetyofRANsandothermembersoftheremotehealthworkforce.

AboriginalandTorresStraitIslanderHealthWorkersidentifiedthatsomehazardsandriskstheyexperiencedwerethesameasthoseexperiencedbyRANs,butmanyweredifferent.Ifanangryordrugaffectedpersoncametotheclinicintendingtoharmstaff,everyonewouldbeatsimilarrisk.AboriginalandTorresStraitIslanderhealthstaffweremoresusceptibletointernalfamilyandcommunityviolence–domesticviolence,communitypunishment,orassaultbyotherstryingtoprojectblameontoothers.

RANsandotherhealthstaff,wereatincreasedriskbecausetheyfrequentlydidnotknowthepersonalityorbackgroundofcommunityresidentsorvisitors.Theywerealsoatincreasedriskattimes,astheywereusuallylasttobeawareoftensionsinthecommunityandthelikelihoodofviolence.Externalstaffwereattimesmoresusceptibletopropertydamageandviolencebecauseinvestigationandpunishmentfortheoffencewasaslow,unwieldyprocesswhichoftenremainedincomplete.

Thecharacteristicsofremotecommunitieswereoftenidentifiedasimpactingonpopulationhealthandstaffsafety.Severalrespondentsnotedthatmanycommunitiesthemselvesareexperiencingsocialdisruption,creatingdifficultyincontributingtosustainedsafetyactivities.Ratherthanblamingsmallcommunitiesfortheirproblems,respondentsidentifiedthatcommunitiesneededassistancetoengagemoreinhealthactivities.Asoneclinicianstated,‘Communitieshavetobethesolution,nottheproblem’.

Whilenotidentifiedinresearch,dogattackwasthemostfrequentlyidentifiedworkrelatedriskraisedbyRANs.Dogattackalsoimpactsonserviceprovision,asitkeepscliniciansfromengagingwiththecommunity.

Remotehealthworkforcerecruitment,turnoverandchurnimpactsonserviceprovisionandstaffsafety.Healthservices,twogovernmentsupportedstaffmobilisingagenciesandapproximately130NurseRecruitmentAgenciesoperatethroughoutAustralia.Allagenciesandmobilisingservicescontactedacknowledgedsomeresponsibilitytoensurethathealthservicesandnewrecruitsweremadeawareofsafetyissuessuchasinsecureaccommodation&recentassaults.Theywerealsoamenabletoensuringstaffwereprovidedwithworkplacesafetyguidelinesifthiswasidentifiedasindustrybestpractice.

Whilesomeemployersseemtoachievereasonablestaffingcontinuity,thereisatrendforclinicianstoapproachremoteareaworkasalimiteddurationinterest.Someclinicianslimittheirplannedremoteexperiencetooneplacementofafewmonthstotwoyears.Othercliniciansstartwithlongtermplans,onlytocutbacktoshortcontractsasremoteareaworkwearsthemdown.Manycliniciansidentifiedthattheycouldcopewithfrequentworkplacechange,butwerelessabletocopewithworkingcontinuallyinonelocation.

Roadtravelinremoteareasinvolvesincreasedrisks,andusesdrivingandvehicleskillsnotgenerallyrequiredbyurbanresidents.Mosthealthservicesstipulatethatamanualdriver’slicenseismandatory.However,fewerserviceshaveclearideasaboutwhatdrivingskillsandtrainingtheirstaffneed.Manyremoteworkforcememberswerequitescathingaboutthelackofpreparationofstaffforbushdriving.Itwasnotedthatevenbasic4WDcoursesdidnotprepareonefordrivinglongdistancesondirtroadsinvaryingweatherconditions.

Thetraumaticeventsof2016havemotivatedremotehealthstakeholderstoprioritiseworkforcesafetyandsecurity.Projectconsultationhasidentifiedthatpracticalinterventionsareoccurringatalllevels,althoughnotinalllocations.Itisimportanttoacknowledgeeffortsmade,andsupportwideruptakeoftheseinitiatives.

However,progressandcompliancetodatehasnotbeenconsistent.Someservicesandmanagersdonotseemtounderstandtheirlegislatedresponsibilities,stillbelievingthatcliniciansareprimarilyresponsiblefortheirownsafety.Similarly,somecliniciansareunderminingsafetyandsecuritysystems.Manyclinicianshaveidentifiedthattheyfeltbulliedintonotimplementingsafetyguidelinesbystaffwhodidnotbelieveriskexists,orwhopreferredtoworkalone,allegedlysotheirownpoorclinicalpracticewasnotobservedbyothers.

Manyparticipantsintheremotehealthindustryidentifybullyingasbeingasignificantstressor.Whilesomeexamplesseemtoreflecttheemotionalpressuresexperiencedbymanymanagersandclinicians,otherexamplesallegedunprofessionalbehaviour.Severalcliniciansreportedthatbullyingbymanagementhadresultedintheirnowonlyworkingthroughrecruitmentagencies.AfewRANsprovidedevidenceofmanagersusingAHPRAcomplaintnotificationsystems.Onlymonthslater,aftersignificantemotional,professionalandfinancialcost,didtherelevantBoarddeterminethattheclinicianconcernedhadnocasetoanswer.

Managersidentifiedfewerexamplesofbullying.SomeRANshadbeenknowntothreatentoresignifspecifieddemandswerenotmet.Also,somemanagershavebeenplacedintheimpossiblepositionofbeingrequiredtoimproveservicesafetywhilemeetingperformanceindicatorsthatinvolvebudgetefficiencies.

Horizontalviolence–thatperpetratedbycliniciansagainstpeers,usuallyworkinginthesameclinic,wasthetypeofbullyingmostfrequentlyidentifiedduringprojectconsultation.FIFOstaffidentifiedbullyingbypeersasthemostcommonreasonforthemdecliningtoreturntoaclinic.Theyalsoidentifiedthathaving‘goodstaff’atalocationwasasignificantmotivatorforthemtoapplyfororacceptfurtherofferedcontracts.

Thelessonfromthisfeedbackisthattheworkforceitselfhasacoreroleinpromotingorweakeningsafetyandsecurity.Sometimesdifferencesofopinionwillbestberesolvedthroughusinginterpersonalcommunication.Atothertimes,proactivemanagementinterventionsarerequiredtopromotethesafetyandsecurityofstaff.

ConclusionPartAofthisdocument,theLiteratureReview,builtonthe2012WorkingSafeinRuralandRemoteAustraliaProjectreport,andnotedtheconclusionsofadditionalavailableresearchpublishedfrom2011onwards.NationalModelWorkplaceHealthandSafetyguidelinespromptedre-considerationofsomepre-2010researchfindingandrecommendations.Analysisofviolent/traumaeventsinvolvingtheremotehealthworkforceoverthepast12monthsresultedinre-evaluationofwhatwaspreviouslyacceptedasthemajorhazardsandrisksaffectingstaffsafetyandsecurity.

PartBofthisdocumentcollatedinformationprovidedduringindustryandcommunityconsultation.Italsoreportsonfindingsfromthequestionnairecompletedby90currentlyorrecentlypracticingmembersoftheremotehealthworkforce.Thisinformationreinforcedmanyofthepriorityissuesidentifiedintheliteraturereview.Consultationalsoidentifiedsignificantsafetyandsecurityissuesnotprioritisedinresearch,andprovideduptodateinformationabouttheopinionsandmotivationofFly-InFly-OutRANs,anincreasinglysignificantcomponentofthetotalremotehealthworkforce.

Inpreparingthisreport,theprojecthasgatheredcomprehensiveinformationaboutissuesinfluencingremotehealthworkforcesafetyandsecurity.Thisprovidesasoberingaccountofthechallengesfacedbycliniciansandmanagers.

Manyoftheidentifiedissuescanberespondedtopositivelywithlimitedcostimplications,althoughthecontributionofindustrystakeholdersisrequiredtoprogresschange.However,otherinitiativesinvolveconsiderablecosts.Procurement,repairandmaintenanceoffacilities,accommodationandequipmentwillrequirethecontributionoffundingagencies.

Usingtheinformationcompiledfromtheliteraturereviewandindustryconsultation,theprojectisnowwellplacedtoprogresswiththecompletionofotheroutputs.Thesewillsupportremotehealthstakeholderstopromoteworkforcesafetythroughtheeffectiveuseofworkplaceguidelines,riskassessmenttools,training,andindustryresources.Otherstrategies,suchaseducationofincomingcliniciansaboutsafetyandsecurityissues,cliniciancommunicationandde-escalationtraining,andorientationoptionsforFly-InFly-Outstaffwillrequirefutureinputsbyemployersandprofessionalorganisations.

Australia’sremotehealthsectoriscommittedtoengageintheirroleandcontributefurthertothehealthofthecommunity.However,thetraumaticeventsoccurringthrough2016havechallengedtheircapacitytodothis.Athree-prongedresponserequires:Reducingtheriskofassault;Improvingworkforceknowledgeandskillsinactivitiesthatsupportsafeimplementationoftheirclinicalrole;andReducingbullyingandpromotingpersonalwellbeingacrosstheindustrythrougheducation&supportivesupervisionbymanagement.

Activitiesbasedaroundthisapproachwillimprovethecapacityofstafftoenter,practice,andremainsafelyintheremotehealthworkforce.

Thefollowingsummaryofissuesandrecommendationsprovidesaguideforward:

Issue Recommendations

1 Workforceinjuryanddeath

Analysisofknownsevereepisodesofinjuryanddeathoftheremotehealthworkforceoverthepasttwelvemonthsindicatesthatbeingfemale,inyouraccommodation,andafterhours’timeswereriskfactors.Assaultsarecommonlyperpetratedwithcriminalintent.

• Securityofaccommodationneedstobebasedoncrimeprotectionthroughenvironmentaldesign,qualityconstructiontechniques,andtimelymaintenance.

• Allfacilitiestobeauditedannuallyforcompliancewithsafety&securityguidelines.

• Incomingstaffneedtobeinformedofriskissuesandeducatedaroundeffectiveandconsistentuseofsafetyguidelinesbeforecommencingwork.

• Allepisodesofassaultorinjurytobereportedbytheworkforceandcollatedbyemployersthroughaformalisedreportingprocess.

2 StaffassaultedduringBusinessHours&On-CallPastresearchandprojectconsultationhasidentifiedunacceptablelevelsofviolenceandaggressiontowardsstaff.

• WorkplacesafetyguidelinesshouldidentifythatRANsarealwaysaccompaniedon-callandatotherworktimeswhenriskissuesareidentified

• Allcall-outsshouldbeexternallymonitoredandidentifytime,natureofcall-out,patient/callerIDandsafecompletionoftheepisodeofcare.

• Allremotehealthservicesshoulddevelop,resource,implementandreviewworkplacesafetyguidelines.

• Priortocommencingwork,stafforientationshouldidentifysafetyissues&safeworkguidelines.

3 Respondingtocriticalevents

Researchreportsthatstafffeelunderskilledinassessment,communication,&de-escalationofcriticalevents.

• TrainingshouldbedevelopedandrolledoutfortheremotehealthworkforcewithcontentincludingRiskAssessment,Communication,andDe-escalationskills.

4 Locatingandassistingstaffwhensomethinggoeswrong

Theremoteandisolatedhealthworkforcelacksconsistent&effectiveearlyresponseandlocatorprocess.

• Clinic,accommodation,andifrequired,personalalarmsystemsshouldbeassessed&asnecessaryupgradedtoemitaloudlocalalarmaswellasalertoff-sitemonitoringservices.

• RemotehealthvehiclesshouldbefittedwithaGPStrackingdevice.Dependingonworklocation&use,anEpirb(locatorbeacon)andmorecomplexrealtimevehiclemonitoringsystemsshouldbeconsidered.

• Personalalarmsshouldbeconsideredforlargerandmorecomplexhealthcentresandservices.

5 Workforcedrivingskills,MVAs

Staffreportedinadequatepreparationforhazardsresultingfromdriving4WDvehiclesinvaryingclimateconditionsonremotedirtroads.

• Staffwhohaveformalfirstrespondent(Ambulance)responsibilitiesshouldbeeducatedandresourcedas‘emergencyserviceworkers’inaccordancewiththejurisdictionsfirstrespondentprocesses.

• Trainingandexperienceisrequiredinsafeandeffectivebasicmaintenance,trouble-shootingandchangingaflattyre.

• Trainingandexperienceinbasic4WDskills.

• Trainingandexperienceonlongdistancedrivinginremoteareasondirtroadsinvaryingweatherconditions.

6 Workforceemergencycommunicationequipment

Manystaffareuntrainedandlackexperienceineffectiveuseofemergencycommunicationequipment.Staffreportedthatsatellitephonecommunicationwasoftenunreliable

• AllremotehealthvehiclesshouldbeequippedwithaSatellitephone.

• TrainingandpracticeinSatellitephoneset-up,useandtroubleshootingofreceptionissuesshouldbecompletedpriortostaffworkingon-call.

• Whereinuse,training&practicewithHFradiotransceiversshouldbecompletedpriortostaffworkingon-call.

• Annualcommunicationequipmentmaintenanceshouldbeincludedwiththehealthvehiclemaintenanceschedule.

7 WorkforceFatigue

Environment,workload&wellbeingpressuresresultinfatigue,reducingstaffcapacitytoworkeffectivelyandrespondrapidlytocriticalevents.Staffareexpectedtoself-monitorwellbeingratherthanthisbeingasharedemployer&employeeresponsibility.

• Employersshouldactivelymanagefatiguethroughafatiguemanagementprogram/process.Includingmonitoringofrosters,on-callhoursworked,timelyuseofleave,andsupportivestaffsupervisiontoidentifyandrespondtofatigueandchallengestowellbeing.

• Professional/Clinicalsupervisionshouldbeavailableforandrequiredofallremotehealthcliniciansandmanagers.

8 StaffretentionStaffattrition,turnoverandchurnchallengescapacitytoconsistentlyimplementsafetyandsecurityguidelines.Thetransientworkforcehaslimitedopportunitytoengagewithcommunitiesinwhichtheywork.

• ManagershavetheprimaryresponsibilityofproactivelymonitoringtheworkplaceenvironmentandinterveningwhererequiredtofulfillWHSobligations.

• FurtherrolloutoftheCRANAplusBullyingAppandotherresourcesisrequiredtosupportindividualcliniciansandengagetheworkforceinhowtomanageworkplacebullying.

9 Violenceandtraumadata

Thereislimitedstatisticalinformationavailableonwhichtoidentifyandanalysetheincidenceandcharacteristicsofviolentandtraumaticeventsinvolvingtheremotehealthworkforce.

• AregisterofRemoteHealthWorkforceAssaultandTraumashouldbemaintainedtomonitorincidenceandnatureofeventstobetterinformpreventiveactions.Theregistershouldbecross-jurisdictionalanduseastandardiseddataset.

• Researchshouldbeundertakenabouttheincidenceandcharacteristicsofworkplaceviolenceperpetratedagainstremotehealthstaff,andeffectivepreventiveandresponsestrategies.

10 ReducednumberofAboriginal&TorresStraitIslanderHealthWorkersinmanyindigenouscommunitiesThelackofAHWsinmanyhealthcentresincreasesworkforcesafetyrisksanddiminishesthecapacityofservicestoprovideculturallysafehealthcare.

• Relevantorganisationsshouldbesupportedtoundertakefurtherworkaboutthisworkforceshortage.

11 DogattackDogattack/dogbiteisafrequentlyoccurringformofinjuryexperiencedbytheremotehealthworkforce.

• Educationresourcese.g.AMRRICvideostobeamandatorycomponentofremotehealthworkforceorientation.

• HealthServicesandprofessionalorganisationstoinitiatecontactwithanimalmanagementservicestopromoteworkingsafelyarounddogs.

12 Workforcesafety&securitynotadequatelypromotedLackofnationalsafety&securitystandardscontributestovaryingqualityof,andcompliancewithemployersafetyguidelines.

• NationalremotehealthworkforcesafetyandsecuritystandardsarerequiredtoprovidecompliancebenchmarksforhealthserviceSafety&Qualityprograms

• Sharinginformationaboutsuccessfulinterventionsthroughindustrypresentations&othercommunicationsmotivatesmanagersandclinicianstotakecontrolofimplementingeffectiveworkforcesafetyinitiatives.

__________________________

1 INTRODUCTIONRemotehealthworkforcesafety&securityhasbeenalong-standingconcern.Ithasbeenaconsistentlyidentifiedthemeinindustryliteraturesincethe1990’s1.Inearly2016,assaultsontwoRemoteAreaNursesandthemurderofRANGayleWoodfordsparkedamajorgroundswellofangeranddistresswithintheindustry,professionalorganisations,advocacygroups,thepublic,andpoliticalleaders.Atnationallevel,consultationlookedforresponsestrategiestosupporttheindustryandisolatedcommunities.

TheRemoteAreaWorkforceSafety&SecurityProjectisaCommonwealthDepartmentofHealthinitiativeimplementedbyCRANAplus.TheprojectistobecompletedovertwelvemonthsfromJuly2016toJune2017.Projectoutputscomprise:

1. Facilitatinganationalconversationaboutconcernsandideasregardingthesafetyandsecurityoftheremotehealthworkforce–stakeholderconsultation.

2. Developingpracticalsafetyandsecurityguidelinesforremotehealthpractice

3. Undertakingaliteraturereview,tobuildonexistingworkdoneonsafetyandsecurityinremotehealth

4. Developinganindustryhandbookon‘BeingSafeinRemoteHealth’

5. Creatinganeasytousesafetyandsecurity‘self-assessmenttool’

6. Developingafreeonlinelearningmoduleon‘WorkingSafeinRemotePractice’

7. ProvidinginputintotheCRANAplusApptoincludethe‘BeingsafeinRemoteHealth’information;and

8. Ensuringappropriateresourcesaremadefreelyavailableforusebythebroaderremoteandruralworkforce.

Theprojecttargetgroup–theremotehealthworkforce-isidentifiedasincludingRemoteAreaNurses&Midwives,AboriginalandTorresStraitIslanderHealthWorkers,AlliedHealthstaff,MedicalOfficers,on-sitesupportstaff(drivers,administrators)aswellasvisitingcliniciansandhealthservicemanagers.

Itis,however,recognisedthatRANsaretheprofessionalgroupmostfrequentlylivingaloneinremotecommunities,mostfrequentlyidentifiedasassaultvictims,andwhosesafetyandsecurityissueshavebeenmostwidelydocumented.Whiletheprojectfocusisontheremotehealthworkforce,itisrecognisedthatprojectdocumentation&resourcesmayalsobeofusetootherremoteareaworkersandresidents.Thisreportdocumentstwoprojectoutcomes:

• Aliteraturereviewonsafetyandsecurityinremotehealthwillbeavailable,buildingonthe2012LiteratureReviewoftheWorkingSafeinRuralandRemoteAustraliaProject

• Facilitatinganationalconversationaboutconcernsandideasregardingthesafetyandsecurityoftheremotehealthworkforce.

1.1 Background:Theworkingsafeinrural&remoteAustraliaprojectTheWorkingSafeinRural&RemoteAustraliaprojectwasimplementedbytheRuralDoctorsAssociationofAustralia(RDAA)in20122.TheprojectwasthecollaborativeworkoftheRDAA,TheAustralianCollegeofRuralandRemoteMedicine,theAustralianNursing&MidwivesFederation,thePoliceFederationofAustralia,theQueenslandTeachers’Union,andCRANAplus.Theprojectreport&literaturereviewprovidesacomprehensivebackgrounddescriptionandanalysisofsafety&securityissuesaffectingTeachers,PoliceandHealthstaffinruralandremoteAustralia.Thereportreviewedinternationalandnationalliteraturefromthelate1990’sto2011.

TheRDAAreportisrequiredreadingforanyoneseekingtounderstandthebackgroundtocurrentsafety&securityissuesaffectingtheremotehealthworkforce.Thereport’sExecutiveSummaryisincludedasAttachment1ofthisliteraturereview.ThecompleteWorkingSafeinRural&RemoteAustraliareportisavailableon-lineathttps://crana.org.au/files/pdfs/RDAA_draft_final_report_-_October_2012_20121018030356(1).pdf

WhiletheWorkingSafereportprovidesessentialbackgroundinformation,therearesignificantdifferencesbetweentheRDAAProjectandtheSafety&SecurityProject.

1.2 ScopeofthetwoprojectsTheRDAAliteraturereviewequated‘workingsafe’to‘availableliteratureontheprevalence,riskfactorsandimpactofworkplaceviolenceinruralandremoteAustralia’.Additionally,ofthethreeidentifiedcategoriesofworkplaceviolence(External,clientinitiated,andinternal),theLiteratureReviewfocusedonclientinitiatedviolence–thatinflictedonworkersbycustomersorclients.

TheRemoteAreaWorkforceSafety&Securityprojectidentifiesabroaderinterpretationofthetopic,includingthethreeidentifiedcategoriesofworkplaceviolenceaswellasothersignificantsafety&securityissuesincluding:after-hours/on-callroles;vehicle/travel&communications;accommodation;animalmanagement;andimpactoftheremotecontextonpersonalsafetyandwellbeing.

TheRDAAprojecttooka‘wholeofcommunity’approach’,lookingbroadlyathowviolenceimpactingonthetargetindustriescouldbereducedinrural&remoteAustralia,allocatingrespondentsaccordingtoRural,RemoteandMetropolitanAreas(RRMA)4-7.ThemandateandoutputsoftheRemoteAreaWorkforceSafety&Securityprojectrequirethatitfocusesonremote&veryremoteareas(RRMA7)andtheremotehealthworkforce.

1.3 Extrapolatingconclusionsfromthe‘WorkingSafe’surveyTheWorkingSafeinRuralandRemoteAustraliasurveydididentifyissuesoutsideworkplaceviolencee.g.‘drivingforworkonroadsinruralorremoteAustralia’and‘stayinginworkaccommodationwhentravelling’.Thesurveyincluded624respondents,ofwhom57%(354)werehealthprofessionals.Ofthisgroup,19%(67)identifiedasworkinginapopulationoflessthan1000,andanother29%identifiedasworkinginapopulationoflessthan5000.Whilesuchcommunities(e.g.Kununurra,Birdsville,Katherine)areremotelylocated,theyarelikelytohavesupermarkets,hospitals,librariesandotheramenitiesnotnecessarilyavailableinthesmallveryremotecommunities,usuallywithapopulation100-2500people,thatareservicedbytheremotehealthworkforceidentifiedaspartofthisproject.

Similarly,RemoteAreaNursesandotherremotecliniciansdonotsharethecareercharacteristicsofpoliceandmostteachersworkinginsmall,veryremotecommunities.AllPoliceandmostTeachersarepublicserviceemployeeswhoseetheirremoteexperienceasa2-3yearcomponentofalonger-termcareer.

RemotecliniciansareaslikelytoworkforthePrivateSector,Non-GovernmentOrganisationsorAboriginalMedicalServicesastheyaretobegovernmentemployees,withmanybeingrecruitedthroughprivaterecruitmentagencies.Theyarefarmorelikelytobeworkinga1-2monthFly-inFly-outcontract,withveryfewcontractingtoremaininonelocationformorethanone-twoyears.

IdentifyingsuchissuesisnotacritiqueoftheWorkingSafeinRuralandRemoteAustraliaproject.However,itisimportanttoappreciatethattheprojectshavesimilaritiesanddifferences.Considerationneedstobegivenbeforeextrapolatinginformationfromoneprojecttotheother.

1.4 MethodologyTheRemoteAreaWorkforceSafetyandSecurityprojectcompletedaliteraturereview,conductedstakeholderinterviews,andcollecteddatafromquestionnairescompletedbyninetycurrently/recentlypracticingremotehealthclinicians.QuestionnairerespondentswerecomprisedofaconveniencesampleofcliniciansparticipatinginRemoteEmergencyCarecourses,andothersmetduringnationalconsultation.ParticipantsontheRemoteAreaWorkforceSafety&SecurityFacebookgroupwerealsoinvitedtoparticipate.Approximately30percentofrespondentswereCRANAplusmembers.

Consultationwasnotanticipatedtoengagealltheremotehealthworkforceandstakeholders.However,withintheresourcesandtimelineavailable,arepresentativesamplewasabletocontribute.Thedraftreportwasthenprovidedtotheproject’sExpertAdvisoryGroup,withfeedbackresultinginminoreditingbeforepublication.

1.4.1 LiteratureReview:strategy&methodologyTheRemoteAreaWorkforceSafety&SecurityprojectliteraturereviewisafocusedreviewbuildingontheWorkingSafeinRural&RemoteAustralialiteraturereview.Whilethe‘WorkingSafe’projecttookawhole-of-communityapproachforbothrural&remoteareas,thisproject’smandateistofocusontheremotehealthworkforce.

TheRemoteAreaWorkforceSafety&SecurityliteraturereviewacknowledgestheconclusionsoftheWorkingSafedocumentrelatingtointernational/nationaldefinitionsofworkforce,workplaceviolence&remotesettings,anddoesnotattempttorepeatthiswork.Asaresult,theRemoteAreaWorkforceSafety&Securityliteraturereviewcouldfocusonthe(relativelylimited)volumeofremoteareahealthspecificliteraturepublishedsince2010.

TheRemoteAreaWorkforceSafety&Securityprojectusedamulti-facetedapproachtoidentifyandcollectpublishedand‘grey’literatureforthisreview.WiththeassistanceoftheAustralianNationalUniversityResearchLibrarystaffoftheCanberraHospitalLibrary,searcheswereundertakenofthefollowingelectronicdatabases:

i. HealthManagement(Proquest)acollectionofresourcesinthefieldofhealthadministration,

includingjournalsanddissertations.

ii. AustralianHealthCollection.AUSThealth1966+Indexes-AustralianHealthandMedicalliterature.Itiscomprisedofanumberofseparatedatabases:AMI(AustralianMedicalIndex)1968-2009APAIS-Health(AustralianPublicAffairsInformationService)1978+,ATSIhealth(AboriginalandTorresStraitIslanderHealthBibliography)1900+,AusportMED,CINCHHealth1968+,DRUGdatabase1974+,Health&Society1980+,HIVA1980+,HEALTHCollection1977+,RURAL1966.

iii. Nursing&AlliedHealth(Proquest).Includesfull-textjournalsanddissertations,Evidence-BasedResources(SystematicReviews,EvidenceSummaries,andBestPracticeInformationSheets)fromtheJoannaBriggsInstitute,andtheMedcomVideoTrainingProgramCollection.

iv. HealthandMedicalComplete(Proquest)indexesjournalcoveringclinicalandbiomedicaltopics,consumerhealth,andhealthadministration.

v. MEDLINE(OvidSP)1946-presentTheU.S.NationalLibraryofMedicine´sbibliographicdatabasecoveringthefieldsofclinicalmedicine,nursing,dentistry,veterinarymedicine,thepreclinicalsciences,healthadministration,andthehealthcaresystem.MedlineusestheMeSH(MedicalSubjectHeading)thesaurustoindexeacharticle.

vi. PubMed.ProducedbytheU.S.NationalLibraryofMedicinePubMedcontainsmorethan21millioncitationsforbiomedicalliteraturefromMEDLINE,lifesciencejournals,andonlinebooks.

Combinationsandkeywordsusedwhensearchingincluded:

Occupationalhealth&safetyremote;Remoteareaworkforcejobdescriptions;Remotehealthworkforcesafetyandsecurity;Clinic/healthservicesafetyandsecurityguidelines;‘Neveralone’;Remoteareanursing;Remoteareanurses;workinginremoteareas;safetyinremoteareas;workplacesafetyrural&remoteareas;Workplaceviolenceorworkplaceviolence;Workplacebullying;Violence/prevention&control/psychology;Occupationalstress;andWorkplacehealth&safety.Allsearcheswerelinkedwithruralandremote.

LiteraturewasalsoaccessedbyundertakingsearchesusingGoogle,Googlescholar,andsearchingthewebsitesofgovernment,peakbodies,associationsandhealthservicesforrelevantpolicy,WorkplaceHealth&Safety(WHS)documentsandworkplacesafety&securityguidelines.Astheproject’sscopeofsafetyandsecuritywasdetermined,literaturetopertinentissuessuchasriskassessment,FourWheelDrive(4WD)safety,andanimalmanagementinremotecommunitieswasalsoreviewed.

Astheliteraturereviewwastoinformprojectguidelinesandresourcedevelopment,thereviewremainedlimitedtothisgoal,withonlykeydocumentsincludedinthereview.Thisisnotawidelydocumentedareaofpractice.Ofapproximately200itemsidentified,only60ofthemostrelevantliteratureanddocumentswerereviewedindetail.Theseincludedgovernmentpoliciesandguidelines,academicarticles(presentations&publications),andworkplacedocuments.

1.4.2 Symposia,ConsultationandSurvey:strategyandmethodologyInthecourseofnationalconsultation,symposiawereheldinvolvingatotalofapproximately190participants.Thesymposiaprovidedvaluableopportunitiestoinformindustryrepresentativesabouttheprojectandinitiatecontactwithclinicians&employers,howeverlargegroupsessionsdidnotprovideanopportunityformoredetaileddiscussionaboutissuesandinterventions.

Twostrategieswereusedtobetteridentifythepositiveandnegativesafety&securityexperiencesofbothclinicians,healthservicemanagers,andothersrelevanttotheproject.

1. Meetingswereheldwith68representativesfrom23differentorganisations.

2. Questionnaireswerecompletedbymorethan90remotehealthclinicianswhowerecurrentlyworkingremoteorhadbeenremotelocatedwithinthepastsixmonths.Therearecurrenteffortsbeingmadetoimproveremotehealthworkforcesafety&security.Thesix-monthcut-offwasusedtoensurerespondentswereprovidingcurrentlyrelevantinformation.AcopyofthequestionnaireisincludedasAttachment2

Recentandcontinuingeffortsarebeingmadetoimprovesafetyandsecurityoftheremotehealthworkforce.Asaresult,questionnaireparticipationwasrestrictedtocurrentlypracticingremoteareaclinicians,andthosewhohadbeenworkingremotewithinthepastsixmonths.Theseselectioncriteriawereusedtoensurethatinformationprovidedbyinformantswascurrent.Previousresearchhasidentifiedpastissuesandthisprojectdidnotseektoreplicatepastwork.

Participationofclinicianscompletingthequestionnaireincludedamixedconvenienceandopportunisticsampleincluding:ClinicianswhowereattendingCRANAplustrainingcourses;Clinicianswhoparticipatedininterviewsandsymposia;andCliniciansparticipatingintheproject’sRemoteAreaWorkforceSafetyandSecurityFacebookgroup.

QuestionnaireswerealsodistributedbydifferentHealthServices,includingthoseemployingAlliedHealthclinicians.Confidentialityofrespondentswasprotectedbytheirsendingresponsesdirectlytotheproject’sProfessionalOfficer.

Approximately30%ofthosewhocompletedthequestionnairewereCRANAplusmembers.

Toencouragerespondentstocontributeopenlyaboutwhatcanattimesbechallenginganddistressingissues,strictconfidentialityguidelineswereidentified.Thecommitmentmadetorespondentsandthoseparticipatingininterviewswasthatprojectdocumentationandreportswouldnotidentifyindividuals,locations,ororganisations.

Atmeetings,1:1discussionsandthroughquestionnaires,itwasreinforcedthattheproject’sgoalwastodocumentinformationand,throughthisprocess,identifypositiveresponsesandinterventionsavailabletopromoteimprovementtoremotehealthworkforcesafetyandsecurity.Thislimitsidentificationofthoseinterviewed.

__________________________

PartA:LITERATUREREVIEW

2 LITERATUREREVIEW2.1 WorkplacecontextTheliteraturereviewidentifiedthatnationally,thehealthcareworkforceisexperiencinganincreasedrateofassault.TheHealthcare&SocialAssistancesector(AustralianBureauofStatisticsclassificationgroup)hasalowindustrymortalityrate(0.2/100,000)comparedtotheAgriculture,Forestry&Fishingsector(17/100,000).However,theHealthcare&SocialAssistancesectorhasoneofthehighestinjuryrates.Whileachievementinreducinginjurieshasbeensuccessfulinmanyoccupations,witha26%decreaseinseriousinjurynationallysince2011,theHealthcare&SocialAssistancesectorhasonlyachievedadecreaseof13%,withimprovementhavingplateauedoverthepast5+years.3,4

ResearchexaminingviolenceinAustralianhospitalsfoundthatallemergencynurses(n=266)whoparticipatedinthestudyreportedexperiencingsometypeofviolenceintheworkplace.Verbalabuseoccurredeitherface-to-face(58%)oroverthephone(56%),physicalintimidationorassaultwasreportedby14%,andthreatsmadeto29%ofparticipants5.2014DatafromtheAustralasianCollegeforEmergencyMedicineidentifiesthat92.2%ofemergencynursesanddoctorsexperiencedalcoholrelatedphysicalaggressionfrompatientsinthepastyear6.

RemotepopulationsofAustraliaexperienceahigherburdenofmanydiseasesincludingObesity,Coronaryheartdisease,Diabetes,Chronicobstructivepulmonarydisease,Alcoholandothersubstanceuse,Lungcancer,Suicide,andDomesticviolence–increasingthedemandforavailableservices.Someremoteareahealthhazardsimpactontheremotehealthworkforceaswellasthebroadercommunitye.g.Travellinglongdistancesonpoorroadconditionswithunfencedstock,Reducedaccessibilitytohealthinfrastructureandspecialistservices,Climateextremes,Highfreshfoodcosts,andLowratesofphysicalactivity7,8,9.

ThepoorhealthstatusofAustralia’sindigenouspopulationcontributestothedisparitybetweennationalhealthstatusandthatoftheruralandremotecommunity10.Ofsignificancetothesafetyandsecurityofremotehealthstaffisthereportedincrease–somesuggestepidemic-indomesticviolenceinruralandremoteAboriginalandTorresStraightIslandcommunities.‘Indigenousfemalesandmaleswere35and22timesaslikelytobehospitalisedduetofamilyviolence-relatedassaultsasotherAustralianfemalesandmales.’‘Forindigenousfemales,aboutoneintwohospitalisationsforassaultwererelatedtofamilyviolencecomparedtooneinfiveformales.Mosthospitalisationsforfamilyviolence-relatedassaultsforfemales(82%)werearesultofspouseorpartnerviolence.’11

InitssubmissiontotheVictorianRoyalCommissionintoFamilyViolence,theAboriginalFamilyViolencePreventionandLegalServiceidentifiedthat‘familyviolencereportshadtripledinthefewyearspriorto2014’,andthat‘90%ofVictorianAboriginalchildreninoutofhomecarewereremovedbecauseoffamilyviolence’.12

Identifyinginformationaboutanyspecifichealthorsocialissueresultsincollatingnegativedata.It’simportanttoacknowledgethatthisinformationispartofabigger,usuallymorepositivepicture.AsidentifiedintheAustralianIndigenousHealthInfoNet(2016)SummaryofAboriginalandTorresStraitIslanderhealth13,

“Australia'sAboriginalandTorresStraitIslanderpeople’shealthcontinuestoimproveslowlyalthoughtheyarestillnotashealthyasnon-Indigenouspeopleoverall.ThereasonswhythehealthofIndigenouspeopleisworsethanfornon-Indigenouspeoplearecomplex,butrepresentacombinationofgeneralfactors(likeeducation,employment,incomeandsocioeconomicstatus)andhealthsectorfactors(likenothavingaccesstoculturallyappropriateservicesorsupport).”

2.2 RemotehealthworkforceoccupationalstressandsafetyAcademicsandclinicianshavecompletedavaluablebodyofresearchoverthelasttenyears,buildingonworkconductedduringthe1990’s.ThelimitationofexistingresearchforthisprojectisthatthefocushasbeenonRemoteAreaNurses(RANs)ratherthanthebroaderremotehealthworkforce.Whilemanyofthefindingsofresearchcanbeconsideredrelevanttoallremotehealthstaff,itmustberecognisedthatRANs–andveryoccasionallymedicalstaff-aremostfrequentlytheclinicianwhoisalong-termresidentinremotecommunities,withalliedhealthstaffandmanagersusuallyonlyvisitingforshorterperiods.RANs,andsometimesAboriginalandTorresStraitIslanderHealthWorkers,arelikelytobetheonlystaffwithafter-hoursandon-callclinicalresponsibilitiesinremotehealthservices.

Similarly,littleinformationisavailableaboutperspectivesonAboriginalandTorresStraitIslanderHealthWorkers’safety.SomerelevantinformationhasbeenidentifiedaspartoftheProject’sconsultationandsurvey.

Theremotenursingworkforceischaracterisedbyanageingpopulation,highstaffturnover,andareducingtotalworkforce.Rickard(2010)hasidentifiedthatmanyRANsworkforperiodsofonlytwomonths,withtheaveragecareerspanbeingapproximatelythreeyears.14Lenthall,WakermanandOpieetal(2011)15identifythatwhilenursingworkforcenumbershaveincreasedoverall,numberslocatedinveryremoteareasdroppedbyapproximately8%,from934to865per100,000population,duringtheperiod2003to2007.Itisnotknownwhetherthistrendhascontinuedthroughthefollowingdecade,however69%ofrespondentstothe2016CRANAplusmembershipsurveyidentifiedthattheywereover50yearsofage.AsummaryoftheCRANAplus2016MembershipSurveyisattachedasAppendix2.

DadeSmith(2016)16identifiesthatin2011theaverageageofnursesintheAustralianworkforcewas44.5years,withthoseover50makingup38.6%oftheworkforce.Thepercentageofnursesagedlessthan25hasdroppedfrom25%to8%ofthetotalworkforcesince2005.Adiminishingworkforceofshorttermageingstaffcannotprovideasoundfoundationforindustrysafetyandwellbeing.Itisnotsurprisingthattheworkforceneedsassistancetoimprovesafetyandsecurity.

JobdemandsmoststronglyassociatedwithincreasedlevelsofoccupationalstressforremoteareanurseswereidentifiedbyOpie,LenthallandDollard(2011).17Theyincluded:responsibilities&expectations;emotionaldemands;workload;theremotecontext&isolation;crossculturalissues&cultureshock;staffingissues;poormanagementpractices;difficultieswithequipment&infrastructure;andworkplaceviolence.

McCullough,WilliamsandLenthall(2012)18provideadetaileddescriptionofRANworkplacehazardswhichisbestidentifiedintheoriginallypublishedtable:

Table1:Priorityhazardsasidentifiedbyexpertpanel.Meanvalueswerecalculatedasfollows:Notahazard=0,MinorHazard=1,ModerateHazard=2,MajorHazard=3,ExtremeHazard=4.Theitemswiththehighestmeanrepresentedthegreatesthazard.

RankHazard MeanAgreement%Character1 Attendingtopatientsinyourownhome 3.5 88 Environment2 Inabilitytosecurelylockafter-hoursconsultingarea 3.4 80 Environment3 Lackofcommonsenseofnurse 3.4 90 Nurse4 Intoxicated(alcoholorillegaldrugs)client 3.4 80 Client5 Alcoholoutletinacommunity 3.3 80 Organisation6 Stressandburnoutofnurse 3.3 90 Nurse7 Singleentry/exittotheclinic 3.2 70 Environment8 Poorlydevelopedcommunicationskills 3.2 90 Nurse9 Inadequatesecurityofstaffresidences 3.1 80 Environment10 InexperienceasaRAN(<4years) 3.1 80 Nurse11 Underdevelopedinstinctiveresponses(‘gutfeeling’) 3.1 90 Nurse12 Workculturethattoleratesverbalabuseas‘partofthejob’ 3.1 80 Organisation13 Inadequateexternallighting(particularlyoveraccessroutes&externalutilities)3.0 70 Environment14 Rigidpersonalbeliefsystemsofnurse 3.0 80 Nurse15 Tirednessandfatigueofnurse 3.0 70 Nurse16 Historyofviolencebyclient 3.0 80 Client17 Insufficientexperienceinassessmentofmentalhealthissues 2.9 70 Nurse18 Lackofmanagementfollowupofviolentincidents 2.9 70 Organisation19 Lackofunderstandingoftheriskandeffectsofviolencebymanagement 2.9 70 OrganisationReference:McCullough,WilliamsandLenthall(2012)18

2010researchconductedbyOpie,Lenthall,Dollardetal19correlatedvaryingtypesofviolence(verbalaggression/obscenelanguage,propertydamage,physicalviolence/assault,sexualharassment,sexualabuse/assault,andstalking)withsymptomsconsistentwithPostTraumaticStressDisorder(PTSD):re-experiencingsymptoms–nightmares&flashbacks,hyperarousal–easilystartled,andavoidance/psychicnumbing–avoidingactivities,places&people.

Whiletheincidenceandimpactofexperiencesvaried,respondentsasagroupwereburdenedbytheirexperiences,withsubsequentnegativeimpactontheircapacitytocopewiththeirwork/livingenvironment,anddiminishedcapacitytocareforthemselvesandtheirpatients.

TheresearchdoesnotsuggestthatthestudygroupfulfilsPTSDdiagnosticcriteria.However,PTSD-likesymptomscaninclude:feelingemotionallyoverwhelmed;diminishedcapacitytomanagechallengingsituations;poorsleep;reducedmotivationandcapacitytomanageself-care;lowenergy;irritability;andasenseofdis-empowermentandinabilitytomakechange.Significantly,itisthispopulationofRANswhoareexpectedtoprovideon-sitementoringandorientationtonewandincomingshorttermstaff.

WorkplaceHealthandSafetylegislation&regulationsinallStatesandTerritoriesofAustraliaprioritisethesafetyofworkersabovetheirworkresponsibilities.However,selectivenegativemediarepresentationofissues–whereproblemsarehighlightedwithoutequalrepresentationofpositiveresponses-cancontributetodisempoweringworkersfrompromotingtheirownsafety&security.6

Workplacebullyingwasnotspecificallyidentifiedbytheaboveresearch.However,itisasignificantissueaffectingtheremotehealthworkforce.WilsonandAkers20provideacomprehensivedescriptionofthenatureofbullyingintheremotehealthworkforce,identifyingbothissuesandresponsestrategies,notingthat:Contactrebullyingaccountsfor40%ofthephonecallsreceivedbytheCRANAplusBushSupportServices;Someworkplaces,especiallythoseexperiencingtheirownmanagementdisruptionandturmoil,aremoresusceptibletobullying;andtheimpactofbullyingexperiencedinaruralorremotesettingmaybeamplifiedduetotherelativeshortageofsupportthatexistsincomparisontolargerregionalandmetropolitanareas.

DadeSmith16providessomeanalysisoftherangeofissuesassociatedwithremotehealthworkforceoccupationalstress,identifyingthatwhilepoormanagementisregardedasasignificantissue,theremotehealthmanagementpoolisverylimited,themanageroftenbeing‘thelastmanstanding’.Managerscanbeaneasytargetforclinicianfrustration.However,theAustralianBureauofStatisticsreportsmanagementinterventionstoimprovesafetyhavebeenoccurringforseveralyears.McCullough,Lenthall,WilliamsandAndrew(2012)21alsonotebrieflythat‘thedevelopmentandimplementationofasafetyplanmightbehamperedbyalackofinterestfromhealthcentrestaff’.

ApartfromtheworkofWilsonandAkers,mostavailableresearchidentifiesclinicianandexpertperceptionsofstressandviolenceratherthanmeasurementofactualincidence.AsidentifiedintheWorkingSafeinRuralandRemoteAustraliareport:2

“Ouranalysissoughttocorrelateconcernsaboutverbalabusefromcommunitymembers,physicalabusefromcommunitymembers,andbullyingorharassmentfromcolleagueswithactualexperiencesoftheseincidents.Theresultssuggestthatperceivedriskcouldbegreaterthanactualrisk.Oftherespondentsthatexpressedseriousorsomeconcern,…generallylessthanhalf(andinsomecases,wellunderhalf)reportedactuallyexperiencingtheseincidentsinthepast12months.Somekeyinformantsalsosuggestedthatperceivedriskwasgreaterthanactualrisk.Specifically,somekeyinformantssaidpeoplenewtorurallifeoftenperceivedgreaterlevelsofriskthanactuallyexisted,whereaspeoplewhohadlivedandworkedinruralandremoteAustraliaformanyyearstendedtofeelsafer.”

2.3 RespondingtoremotehealthworkforcesafetyandsecurityissuesOpie,LenthallandDollard(2011)17havecontributedtothistopicusingBrooks’etal2010‘Culture,Prevention,Protection&Treatment(CPPT)modelofinterventionlayersforthePreventionandManagementofAggression’todocumentstrategiesapplicabletotheremotehealthcontext.

ThisworkdocumentswhatappearstobeaveryuseablemodelofSupportStrategies,PrimaryPrevention,SecondaryProtection,andTertiaryTreatment/SupportwhichalignsreasonablycloselywithOHS/WHSresponsehierarchyguidelines.

UsingaPrimary⇒Secondary⇒TertiaryPreventionmodel,McCullough,Lenthall,WilliamsandAndrew(2012)21developeda‘ViolenceManagementToolbox’ofstrategiesundertheheadingsof:Educationandtraining;Professionalsupport;Organisationalresponsibilities;andCommunitycollaboration.Thecontentofthisresearchprovidesavaluablechecklisttoinformfurtherwork.

Whiletheapproachesdocumentedbytheseresearchersarebothsimilarandwidelyaccepted,furtherconsiderationofwhatinterventionswillmosteffectivelycontributetoimprovingsafetyandsecurityisneeded.

OccupationalHealth&Safetyprotocolsdonotfeaturesignificantlyineitheroftheabovedocuments.Baker-Goldsmith(2014)22identifiesseveralsignificantpointsinrelationtoWHSlegislationandregulation,including:

“Theprimarydutyholderinrelationtoworkplacehealthandsafetyistheemployer…becausethelawrecognisesthatitshouldplacethehigherlevelofdutyonthosewhohavecontroloftheissuesthatgiverisetoriskandthereforehavethecapacitytocontrolthem.Inthisway,thelawseekstomotivatethosewhohavecontroltoexercisethatcontroltotheextentthatitisreasonablypracticable.”

“Fundamentally,aworkerisrequiredtorefrainfromknowinglydoinganythingthatplacesthemselvesorothersatriskandtoworkwithinthesafesystemsofworkputinplacebytheiremployer.Theyarenotandcannotberequiredtotakeontheemployer’sresponsibilityfortheirhealthandsafetyatwork.”

“Adutyholder,inmanagingriskstohealthandsafety,must:(a)eliminateriskstohealthandsafetysofarasisreasonablypracticable;and(b)ifitisnotreasonablypracticabletoeliminateriskstohealthandsafety–minimisethoseriskssofarasisreasonablypracticable.

TheabsolutedutyistomanageriskandONLYifitisnotreasonablypracticabletoeliminaterisksentirelycananemployerlegallyresorttolowerorderriskcontrolsandthenmustdosoinahierarchicalway.Whereriskscannotbeeliminated,thedutyholdermustminimiserisks,sofarasisreasonablypracticable,bydoingoneormoreofthefollowing:

◦ substituting(whollyorpartly)thehazardgivingrisetotheriskwithsomethingthatgivesrisetoalesserrisk;

◦ isolatingthehazardfromanypersonexposedtoit;◦ implementingengineeringcontrols.

Ifariskthenremains,thedutyholdermustminimisetheremainingrisk,sofarasisreasonablypracticable,byimplementingadministrativecontrols.

Ifariskthenremains,thedutyholdermustminimisetheremainingrisk,sofarasisreasonablypracticable,byensuringtheprovisionanduseofsuitablepersonalprotectiveequipment.

Itcanbeclearlyseenfromtheaboveprovisionsthatitisnotconsistentwiththelawforanemployertogostraighttolowerorderriskcontrolssuchastrainingorproceduresincircumstanceswheretheyhavenotproperlyexploredwhetheritisreasonablypracticabletoimplementhigherordercontrolmeasures.Thisisespeciallysowhenthepotentialexistsfordeathorseriousinjury,theexposureisfrequentandanadverseoutcomecanbereasonablyforeseengivenhistoricalinformation.”

Recommendationstoreduceviolencedocumentedinrecentresearchhaveidentifiedissuesproposedbyresearchparticipantsandexperts,however,manyoftherecommendationsthemselvesdonotappeartohavebeenvalidated,E.g.self-defensetechniques21.Usinganotherexample,whiletheuseofsecurityalarmsisgenerallysupported,thereisnoclearanalysisandagreementaboutwhetheralarmsshouldbestgotoaremotemonitoringstation,emitalocallyaudiblewarning,orboth.

Remotehealthworkforcerepresentatives–managers,WSR’sandothers-needtodeveloptheskillstoeffectivelycompletehazardidentificationandriskassessment,consideringlikelihoodandconsequences,localcontextandresources,aswellaslegislatedguidelines.Oncehazardshavebeenidentifiedandrisksassessed,responsesneedtobeprioritisedandimplementedaccordingtotheOHS/WHShierarchyofriskcontrolinterventions.

2.4 CharacteristicsofremotehealthworkforceviolenteventsWorksafeAustraliastatisticsdonotprovideaccurateorcomprehensiveinformationaboutthenatureofviolenceperpetratedontheremotehealthworkforce,2howeversomeinformationaboutthecharacteristicsofrecentsignificanteventsisavailable.Theremotehealthworkforceiswidelyscatteredandrelativelysmallinnumbers.Itwouldnotbefairtothosewhohaveexperiencedviolenttraumatobere-traumatisedbyhavingeventdetailspublicised.However,someanalysisofpastassaultsisimportanttotargetresponsestospecificrisks.Informationinthefollowingtablewasaccessedfromarangeofacademic,mediaandpersonalcommunicationsources.

Table2.Characteristicsofsignificant/violenteventswithRANasvictim,10/2015-11/2016*

Gender Natureofevent Location B/HorA/H

Calledoutoncall

RANExperience>4years

SingleRNPost

Female SexualAssault StaffAccommodation A/H No Unknown Unknown

Female MVAdeath Road-Patienttransfer A/H Yes Yes Yes

Female SexualAssault StaffAccommodation A/H No Unknown Unknown

Female Murder StaffAccommodation/surrounds A/H Unknown Yes No

Female Assault Homevisit B/H B/H Yes No

Female Assault Homevisit A/H Yes Unknown No

Female Assault StaffAccommodation/surrounds A/H No Yes No

*Thisinformationdoesnotidentifyallviolenteventsexperiencedbytheremotehealthworkforceduringthepasttwelvemonths.Eventsnotidentifiedheremayhavebeenacutelydistressingandtraumatictothoseinvolved.

FromaWHSperspective,itisacknowledgedthatthelessfrequentlyaneventoccurs,themoredifficultitistopredictfuturesimilareventsandimplementeffectivepreventivemeasures.Whilethestatisticalsignificanceoftheaboveinformationisnotclear,itdoessuggestthatgender,afterhours,beingin/aroundtheRANsaccommodation,andremotevehicletravelareindicatorsofmoderatetosevererisk.

Whilesomedataisunknown,thistabledoesnotidentifyahighcorrelationbetweenriskandsinglenurseposts,orriskanddurationofremotehealthexperience.Thisdoesnotsuggestthatsinglenursepostsaresafe.AsdocumentedintheCRANApluspositionpaperonSingleClinicianPost,thereasonsforshuttingorexpandingsinglenursepostsarewelldocumentedandcompelling.23

Whatshouldbeconsideredfromthistable,isthetypeofsevereviolenceofwhichRANsarevictims.Violenceinandaroundtheworkplaceisidentifiedunderthreecategories2:

• Criminal(external)violence–wherethevictimistargetedforreasonspossiblynotrelatedhis/herworkroleE.g.sexualassault,orwithintenttostealresourcess/hehasaccessto(medications,vehicles)

• Workplace(Clientinitiated)violence–perpetratedbypatients,orpatientvisitors/familymembers

• Internalviolence–betweenco-workersandsupervisors/employers

ThisindicatesthatthemorecommontypeofsevereviolencetowhichRANsareatriskiscriminalratherthanworkplacerelated.

Thisisanimportantissuetoidentify,astherisksandperpetratorsofeachformofviolencediffermarkedly,asdotheviolencepreventionstrategiesthatareneededforeachgroup.2

Equallyimportantbutlessclearfromcurrentlyavailableinformation,istheroleofintendedsexualassaultintriggeringepisodesofviolencetowardsRANs.SexualharassmentremainsaseriouschallengeforemployersinAustralia.24SexualassaultisafrequentcauseofinjuryordeathforwomenintheUnitedStates,withwomenworkingalone/inisolationrecognisedasbeingatparticularrisk.25AvailableinformationidentifiesthatsimilarlevelsofriskexistinAustralia.26

Employershavearesponsibilitytolimitrisksassociatedwithsexualharassmentandsexualassault24.Itappearsthatpreventingandmanagingtheriskofsexualviolenceneedsahigherprofileinremotehealthworkforceinductionandorientation.

Theotherissueraisedbythistableisthatremotehealthworkforcesafetyandsecurityinvolvesmorethanmanagingworkplaceviolence.Vehicletravelinremoteareashasconsiderablerisk,withWorksafeAustraliastatisticsidentifyingitasbyfarthesinglegreatestcauseofsevereinjuryordeathoftheAustralianworkforce.27Othersafetyandsecurityrisksidentifiedduringtheprojectincludedthreatofdogattack,thepossiblepresenceofAsbestosinoldercommunitybuildings,andmaintainingpersonalwellbeing.Thesetopicsarenotcoveredintheliteraturereview,butareidentifiedelsewhereinthisreport.

2.5 ImplementingWorkplaceHealthandSafetyregulationsinremoteareasWHSregulationsincludespecificmentionoftheremoteareaworkforce,identifyingemployerresponsibilitytoprovidesafeandsecureaccommodationinlocationswhereprivaterentalisnotavailable.28ThereareguidelinesforsettingupWorkplaceSafetyCommittees(Employerinitiatedoratthewrittenrequestoffivefulltimeemployees),andprocessesforstafftocompleteWorkplaceSafetyRepresentative(WRS)training.Intheeventofasignificantriskbeingidentified,aWSRcaninitiateaPriorityImprovementNotice.ThistriggersaWorksafeAustraliavisit.IftheWSRconcernsareconfirmed,Worksafeassumesamonitoringrole,havingthecapacitytofineanemployerifproblemresolutiondoesnotoccurinatimelymanner.

Currently,theseguidelinesareverydifficulttoimplementinremotehealthlocations.Staffturnoverishigh,thesmallworkforceisscatteredovervastareas,andthepotentialforWorksafestafftoattendandreviewahazardisverylimited.

2.6 RiskassessmentThereisconsiderableenthusiasmforthedevelopmentanduseofriskassessmenttoolsbyclinicians.RiskassessmentisidentifiedaspartoftheViolencemanagementtoolbox.21Developmentof‘aneasytousesafetyandsecurityself-assessmenttool’isalsoanoutputofthisproject.Giventhis,itisusefultoreviewtheliteraturerelevanttothedevelopmentanduseofriskassessmentresources.

AcomprehensivecollationofcommunityinformationrelevanttotheRANsrole–essentiallyaCommunitySafetyAudit-isanessentialcomponentofanincomingclinician’sorientation.Topicsrequiredcouldinclude:Clinic&after-hourssafety,Accommodationsafety,VehicleandCommunicationssafety,andPersonalWellbeing.Additionally,abriefsafetyandsecurityself-assessmenttoolwouldassistnewstafftoframetheirresponsetoanemergingtenseorfrighteningsituation.However,riskassessmenttoolsareasupportto,ratherthananalternativetomorerobustsafetysystems.

Over100differentviolenceriskassessmenttoolsarefrequentlyinuse,withresearchidentifyingthatwhenusedtopredictviolentoffending,theyhadpredictivevaluesof27-60%.29Someareactuarial,involvingcomprehensivereviewofanindividual’shistory–notaviableoptionintheacutesetting.Somearediagnosisbased,whileothershaveabehavioralfocus.

Assessmentofoffenderthreat,combinedwithabriefchecklistbroadercontextissuescanbeofassistanceincontributingtosafecliniciandecisionmaking,especiallybyprovidingnew/incomingclinicianswithadecision-makingguide.MasonandJulian(2009)30identifiedthatthetoolusedbyTasmanianPolicewas‘animprovementoninformal,subjectiveassessments.

Caremustbetakenintheuseofsuchtools,incasecliniciansfeelover-confidentthatalowviolencepredictionresultmeanstheyaresafe.Additionally,Baker-Goldsmith22notesthatanyriskassessmentbyanindividualputs

“expectationandresponsibilityfordeterminingtheriskcontrolstrategyontheindividual…ratherthan(theemployer)puttinginplaceaclearandappropriatelydirectivesystem(fortheindividual)torelyon.”

Assessmenttoolshavearoleinpromotingsafetyandsecurity.However,aswithanyassessmentprocess,cliniciansneedtounderstandandusethetoolregularlytoenableitseffectiveuse.

2.7 ZerotolerancetoviolenceZerotolerancetoviolencepolicieshavebeenidentifiedinresearch,industryandworkplacepublicationsasabasisforexpectationsofpatient/communitybehaviour,andastaffrighttosafetyatwork.6,21Asdiscussiononthistopicidentifies,thesituationismorecomplexthanabriefposterstatementcanidentify.Zerotolerancecannotbethehealthindustryresponsetoviolenceassociatedwithheadinjury,dementiaandotherorganiccauses.Similarly,empathiccommunicationandde-escalation(ratherthanzerotolerance)arerecognisedprimaryresponsestoescalatinginterpersonaltensionsandwhenconfrontedwithaggression,bothintheclinicalenvironmentandthetearoom.

Clinicianshavealsoidentifiedconcernthatthezero-tolerancepolicyimplementationoftenbeginsandendswithposters,ashealthservicesoftendemonstratelittlecommitmenttoprosecutionofperpetrators.

However,withviolencetosomeserviceprovidersreachingepidemicproportions,somegovernmentsarestreamliningtheprosecutionprocess.6

2.8 EducationandtrainingforremotehealthworkforcesafetyandsecurityAnetsearchofeducationalinstitutionswasconductedtoidentifyifandhowavailablecourseswererespondingtoviolenceandothersafety/securityissuesidentifiedinremotehealthworkforceresearch.Thewebsitesof22organisationscomprisingtertiaryeducationinstitutions,professionalorganisations,andresearchcentreswerereviewed.Arangeofeducationandtrainingopportunitieswereoffered,includingshort,topicspecificcourses(e.g.Pharmacotherapeutics),GraduateCertificate,GraduateDiploma,MastersandDoctoralprogrammes.

Thissectionofthewebbasedliteraturereviewwasunabletolocateanycoursecontentabouttherangeofhealth,safetyandsecurityissuesidentifiedinresearchandthisreport.Somerelevantinformationmaybeprovidedwithinunitsfocusingonruralandremotehealthcontext,andresearchhasbeenconductedbypostgraduatestudentsoftheseorganisations.Itmaybethatthatsafetyandsecurityissuesareregardedasworkplaceorientationsubjectsratherthanaspectsofeducation.

2.9 SocialMediaSocialmediaisbeingincreasinglyacknowledgedasalegitimatepublicationlocationandrequiredareaofresearch.Somegroupswithintheremotehealthworkforce,notablyRANs,appearquiteactiveinsocialmedia,withfive+relevantFacebooksitescurrentlyactive.Whilesafetyandsecurityissuesarefrequentlyidentifiedonmostthesesites,aformalreviewofthiscontenthasnotbeenconductedaspartofthisproject.

Socialmediaresearchhasitsownsetofissues,includingthefactthatpeoplewhohavepostedcomments,documentsandlinkscanusuallydeleteorchangetheseatanytimeinthefuture.Additionally,SocialMediaover-represents‘PostTruth’tooeasily.Opinionandappealtoemotionscanframediscussion,andfactsbecomesecondarytobelief.

Facebookpageswithorganisationrepresentationresponsibilitiesdonotlendthemselvestothefreedomofideasandcommentrepresentedinthebroadersocialmediaenvironment.Additionally,therelativeanonymityofsocialmediahasoccasionallyresultedincyberbullying.Theremotehealthworkforcedoesappeartobesubjecttoboththepositiveandnegativepotentialofsocialmedia.

2.10 WorkplacesafetyguidelinesWhileworkplace(employer)safetyguidelinesprovideessentialinformationrelevanttopromotingremotehealthworkforcesafetyandsecurity,theyhavenotbeenincludedasabodyofworkintheliteraturereview.Someguidelinesarewebbasedandpublicallyaccessible.However,othersarelocation/servicespecific,contentisun-published,andundergoingregularreview.

3 SUMMARYOFTHELITERATURE3.1 Whatisknown

1. Nationally,thehealthcareworkforceisexperiencinganincreasedrateofassault.Staffworkingaloneandinisolationareatgreaterriskofseriousassaultduetothelimitedavailabilityofsecuritysupportsandrapidresponsesystems.

2. RemoteandveryremotepopulationsinAustraliaexperiencehigherratesofdiseaseandhealthrisks.Theremotehealthworkforceisalsoexposedtomanyoftheseriskswhilebeingunderconsiderableburdentoprovideservicesinadifficultandresourcelimitedenvironment.

3. Researchhasdocumentedtheworkforce’sperceptionofriskfactors,impactofriskfactorsoncliniciansand,toalesserextent,optionstopromoteworkforcesafetyandsecurity.ExistingrecommendationsneedtobeconsideredfurtherunderthebroadumbrellaofWHSregulation.

4. Theremotehealthworkforceisageing.Workforcenumbersper100,000populationhavedroppedbyapproximately8%.Availabilityofadequatenumbersofexperiencedandnewstaffisimportanttomaintainingservicequalityandconsistency,aswellasworkforcesafety,securityandwellbeing.

5. ApartfromtheWorkingSafeinRuralandRemoteAustraliaproject,researchhasprimarilyfocusedonrisksandviolencetotheremoteareanursingworkforce.Givensharedcontextandworkforcecharacteristics,itislikelythatRANfocusedresearchwillberelevanttothebroaderremotehealthworkforce.

6. Analysisofepisodesofsignificantinjuryanddeathoftheremotehealthworkforceoverthepasttwelvemonthssuggeststhatbeingfemale,athome,andafterhours’timesareriskfactors.

7. Availableinformationindicatesthatsevereeventsaremorecommonlyperpetratedwithcriminalintentratherthanbecauseofworkhazards.Itisnotclearhowfrequentlyperpetratorsaremotivatedbyintendedsexualassault,howeverthisisariskfactorrequiringrecognitioninstaffinductionandorientation.

8. Workplacehealthandsafetyregulationsrelevanttotheremotehealthworkforceprovideacomprehensivelegalstructureidentifyingtherightsandresponsibilitiesofemployersandemployees.Compliancewithlegislatedrequirementsisinconsistent,andeffectivemonitoringandimplementationofWHSregulationisdifficultinremotehealthservices.

9. Theindustrywillbenefitfromallstakeholders,includingemployers,employees,professionalorganisations,researchers,andeducators,developingabetterunderstandingofexistingWHSlegislationandregulation,andhowitcanbeusedtopromotesafetyandsecurity.

10. Violenceandgeneralriskassessmenttoolshavearoleinsupportingthesafetyandsecurityoftheremotehealthworkforce,howevertheircontributiontosafetyislimited.AvailabilityanduseofsuchtoolsdoesnotshiftemployerWHSresponsibilitiesontotheindividual.

11. Researchintoremotehealthworkforcesafetyandsecurityhasfocusedonaggression,abuse,violence,bullyingandharassment.

3.2 GapsintheliteratureLeavingasidewhatwouldbehelpfultoenrichourunderstandingofremotehealthworkforcesafetyandsecurity,themostsignificantgapsinourknowledgeare:

1. Thereislimitedinformationidentifyingtheincidenceandcharacteristicsofmoderateandsevereviolenteventsimpactingonthesafetyandsecurityoftheremotehealthworkforce.WHSstatisticsdonotprovidethisinformation,withourknowledgeofthisissuebeingfurtherlimitedbypoorreportingofeventsbyworkers,andpooridentificationofeventsbyemployers.

2. Researchhaspredominantlyidentifiedclinicianperceptionsofviolenceandriskissues,withlittleliteratureidentifyingthecharacteristicsandeffectivenessofdifferentinterventions.

Thisisneededtoinformtheindustryabouthowtogetthemostbenefitfromresourcesavailabletopromoteremotehealthworkforcesafetyandsecurity.Documentationofpositiveinformationandsuccessfulinitiativesisneededtobalancereportingthatfocusesonproblemsandtraumaticevents.

3. Researchandindustryliteraturehasfocusedonviolence,tothedetrimentofotherthreatstoremotehealthworkforcesafetyandsecurity.Significantotherissueswarrantingresearchandpublicationinclude:Vehicleandtravelsafety;Dogattack;Bullyingandharassment,andrisksto/promotionofpersonalhealthandwellbeing.

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PARTB:CONSULTATION&SURVEY

4 CONSULTATIONREPORT4.1 IntroductionProjectconsultationhasinvolvedconductingsymposiainSouthAustralia,theNorthernTerritory,Queensland,Tasmania,andWesternAustralia,withadditionalcontactmadewithCanberrabasedagencies.Wherepossible,meetingshavebeenarrangedwithProfessionalorganisations,Advocacygroups,HealthServiceManagers,andNursingRecruitmentAgencies.

CRANAplusRemoteEmergencyCare(REC)andMaternityEmergencyCare(MEC)courseshavebeenusedasapointofcontactwithprospectiveandcurrentlyemployedremoteareaclinicians–bothCRANAplusmembersandnon-members.AFacebookgroup‘RemoteAreaWorkforceSafetyandSecurity’wassetuptolinkinwithcliniciansnototherwiseabletoaccessprojectinformation,andprojectcontactoptionswereidentifiedontheCRANApluswebsiteandtheweeklyCRANApulsenewsletter.Presentationsabouttheprojectandsafety&securityissuesweremadeatthe2016Rural&RemoteHealthResearch&ScientificConference,Canberra,andthe2016CRANAplusNationalConferenceinHobart.Theproject’sworkhasalsobeenprofiledintheAustralianNurse&MidwiferyJournal.31Phonediscussionandemailcommunicationwasusedwithseveralorganisationsnototherwiseabletobecontacted.

AdditionalinputisbeingsourcedfromtheProjectExpertAdvisoryCommittee,howevertheCommittee’scontributionisnotidentifiedasanindividualcomponentoftheconsultationreport.

Itwasnotanticipatedorexpectedthatconsultationwouldbeabletoengageallremoteareaclinicians,howeverthegoalwastocollateinformationabouttherangeofissuesinfluencingtheremotehealthworkforcefromallmajorstakeholders.Bycompletionoftheproject’snationalconsultationphase,nosignificantnewinformationwasbeingidentified.

Confidentialitywasamajorissuefortheprojectandmanyrespondents.Thegoaloftheprojectistosupportallstakeholderstoimprovethesafetyandsecurityoftheremoteareworkforce.Allocationofresponsibilityforpasteventswasnotconsideredapartofthisprocess.

Tosupportconfidentiality,symposia,interviewsandquestionnairesallidentifiedthatprojectdocumentsandreportswouldnotidentifyindividuals,specificlocations,orhealthservices.Thislimitstheproject’scapacitytolistindividualconsultationparticipants,butcontributedtoHealthServicesandothersbeinggenerousinsharinginformationaboutsafetyissuesandprotocols.

Table3.ConsultationandSurveyparticipants

NumberofOrganisations/Activities Numberofparticipants

Organisations 26 49

Symposia 8presentations 189

Questionnaire - 85

Total: 35 323

Stakeholderdiscussionbroughttolightsomeissuesthatareveryrelevanttothesafetyandsecurityoftheremotehealthworkforce,butwerenotidentifiedintheliteraturereview.Wherepossible,literatureandresourcesontopicsthatcancontributetopromotingworkforcesafetyhavebeenreferenced.Thefollowingsignificantissueswereidentifiedduringstakeholderconsultation:

4.2 RecruitmentandretentionofAboriginal&TorresStraitIslanderHealthWorkersRespondentcommentidentifiedthatapproximately25%ofIndigenouscommunitieshadnoAboriginalorTorresStraitIslanderHealthWorkers.TheabsenceofIndigenousclinicalstaffimpactsnegativelyonboththeculturalsafetyofservicesavailabletocommunities,andthesafetyofRANsandothermembersoftheremotehealthworkforce.

DadeSmithidentifiesthat“Whilethereisanundersupply(ofAboriginal&TorresStraitIslanderHealthWorkers),thisistheonlyhealthdisciplinewithfewretentionproblems.”However,thiswasnotthesituationidentifiedinprojectconsultation.

SomecliniciansandresearchersinterviewedduringprojectconsultationfeltstronglythatexpectingAboriginal&TorresStraitIslanderHealthWorkerstobethefirstclinicianon-callwasonlypushingsafetyissuesdown-stream.TheyidentifiedthatAboriginal&TorresStraitIslanderHealthWorkersalreadyhavesignificant,sometimesoverwhelmingdemandsplacedonthembymembersoftheircommunity,andthatfurtherpressurewouldresultinhigherratesofattrition.

Amanagerobservedthatinrecentdecades,manyAboriginal&TorresStraitIslanderHealthWorkershavebeentrained‘andyouhavetowonderwheretheyallarenow’.ItwasalsonotedthatsomeAboriginal&TorresStraitIslanderHealthWorkerswentontocompleteEnrolledNursetraining‘becausethemoneyandcareeropportunitiesaresomuchbetter’,whileotherswererecruitedintootherserviceoradministrationroles.

Otherthanbasicstatistics,theredoesn’tseemtobemucheasilyaccessibleinformationaboutAboriginal&TorresStraitIslanderHealthWorkersrecruitmentandattrition.WhilethisissuesitsoutsidethemandateoftheSafetyandSecurityproject,itremainsanissuewhichwillcontinuetoimpactonthewellbeingofremoteindigenouscommunities,andtheremotehealthworkforce.

4.3 SafetyofAboriginal&TorresStraitIslanderHealthWorkersOnlyalimitednumberofAboriginal&TorresStraitIslanderHealthWorkerswereinterviewedaspartoftheprojectorcompletedquestionnaires.Issuestheyidentifiedincluded:

SomeriskstoRANsandAboriginal&TorresStraitIslanderHealthWorkerswerethesame,butmanyweredifferent.Ifanangryordrugaffectedpersoncametotheclinicintendingtoharmstaff,everyonewouldbeatsimilarrisk.

Non-communitystaff–RNsandothers,wereatincreasedriskbecausetheyfrequentlydidnotknowthepersonalityorbackgroundofcommunityresidentsorvisitors.Theywerealsoatincreasedriskastheywereusuallylasttobeawareoftensionsinthecommunityandthelikelihoodofviolence.

Aboriginal&TorresStraitIslanderHealthWorkersweremoresusceptibletointernalfamilyandcommunityviolence–domesticviolence,punishment,orassaultbyotherstryingtoprojectblameontotheHealthWorker.Nodistinctionwasmadeaboutwherethecrossoverpointbetweenworkrelatedandnon-workrelatedviolencelay.

AnotherclinicianidentifiedthatRANsandotherswereattimesmoresusceptibletopropertydamageandviolencebecauseinvestigationandpunishmentfortheoffencewasaslow,unwieldyprocesswhichoftenremainedincomplete.Assaultorpropertydamagetoothercommunityresidentswasavoidedbysomeperpetratorsifithadpreviouslyresultedinrapidandpainfulretribution.

4.4 ProvidingservicesincommunitiesexperiencingsocialdisruptionClinicians,healthservicemanagersandothersnotedthatmanycommunitieshadlimitedcapacitytosupporthealthserviceprovidersasthecommunitiesthemselvesareexperiencingconsiderablesocialdisruption.Whetheritbefromlossofelders/leaders,substancemisuse,internaltensions,orlossofdirectionfrommultiplecauses,manyremotecommunitiesdonothaveacohesivepopulationabletoprovideafter-hourssupportforhealthservices.Blamingsmallcommunitiesisnotananswer.Asoneclinicianidentified,‘Communitiesarethesolution,nottheproblem’.

4.5 Dogbite/dogattackWhilenotidentifiedasasafetyissueinresearch,itislikelythatdogattackisthemostcommontypeofviolence/injurythattheremotehealthworkforcehastodealwith.DogattackstoodoutasthemostfrequentlyidentifiedworkrelatedriskraisedbyalmostallgroupsofRANswhendiscussionofsafetyissueswasinitiated.Numerouscliniciansidentifiedexamplesoftheirownexperiences,scarsandsuturelinesincluded.

Theycitedexamplesofcommunityresidentsandcommunityservicesstaffbeingattackedandneedingtreatmentonsite,orrequiringevacuationforsurgicalrepair.Pastreportsofthedeathofyoungandfrailagedresidentswereidentifiedtosubstantiatetheirconcerns.

Dogattackisasafetythreatthatalsoimpactsonprovisionofservices.Severalcliniciansandmanagersidentifiedpersonalorunofficialguidelinesrecommendingthatcliniciansshouldnotleavetheirvehiclewheninthecommunity.Stayingintheambulancedoeslimittheriskofdogattack,howeveritalsolimitsengagementwiththecommunity.

Learningabouttheroleofdogsinindigenouscommunities,andbehaviours–bothpersonalandorganisational-thatwillreducetheriskofattackwillimproveworkforceconfidenceandsafety.Senioretal32discussesDogsandPeopleinAboriginalCommunities,whilea2016videoproducedbyAMRRIC33providesaresourcethatisveryrelevanttotheday-to-daysafetyoftheremotehealthworkforce.

4.6 RemoteHealthWorkforcerecruitment,turnoverandchurnRecruitmentofclinicianstoremotehealthservicesisdifficult.Recruitmentplacesamajordrainontheresourcesofmanyhealthservices,withsomehavingturnedtotallytoRecruitmentAgenciestosourcestaff.TwoGovernmentsupportedstaffmobilisingagenciesalsosupportrecruitmenttoNTHealthServices.Thereareapproximately130NurseRecruitmentAgenciesoperatingthroughoutAustralia,althoughnotallappeartospecialiseintherecruitmentofstafftoremoteareas.

PrivateagenciesidentifiedthattheyfactorinWorkersCompensationcoverfortheirstaff,althoughthisislikelyalsopaidbyHealthServices–anapparentlyun-necessarycostduplication.AllAgenciesandmobilisingservicescontactedacknowledgedsomeresponsibilitytoensurethathealthservicesandnewrecruitsweremadeawareofreportedsafetyissuessuchasinsecureaccommodation,andrecentassaults.Theywerealsoamenabletoensuringthatstaffwereprovidedwithemployerworkplacesafetyguidelinesifthesewereavailable.

Whilesomeemployersseemtosuccessfullyachievereasonablestaffcontinuity,thereisageneraltrendforclinicianstoapproachremoteareaworkasalimiteddurationcommitment.Theyeitherlimittheirplannedremoteexperiencetooneplacementofafewmonthstotwoyears,orstartwithlongtermplans,onlytocommenceshorttermcontractsastheirtolerancetotheworkdiminishes.Manycliniciansagreedwiththeideathattheycouldcontinuetocopewithworkchange,butwerelessabletocopewithworkcontinuity.

WhilethetermFlyInFlyOut(FIFO)isannowacceptedtermforthisworkforce,thereareimplicationsspecifictoFIFORANs.ThegeneralFIFOworkforcehaslongtermcontractsidentifyinganannualsalary,withFIFOschedulesidentifiedaspartofthecontract.MostFIFORANsareonlypaidwhilethey’reworking,withcontractsdependentonavailabilityofacceptableplacements.Thisimpactsonsalaryandjobsecurity.

Whilethechurnofstaff–frequentmovementofstaffwithintheindustry–supportstheongoingavailabilityofclinicians,itisdetrimentaltostaffsafetyandserviceprovision.Shorttermstaffhavelittleopportunitytoestablishgoodcommunicationwithcommunityresidentsandotherstaff.Theirabilitytoidentifypotentiallyriskysituationsearly,andtheircapacitytoutiliseexistingrelationshipbondstodefusethreateningsituationsislimited.

4.7 RANfatigueChallengestostaffhealthandwellbeinghavebeenidentifiedinresearch,andthiswasfurtheridentifiedduringprojectconsultation.TheaverageageofRANs,whomakeupmosttheremotehealthworkforce,isincreasing,possiblynowbeingaround50years.Thisimpliesahighpercentageofskilledandexperiencedworkers;however,thismaynotbethecaseasmanyincomingRANsarealreadymatureaged–skilledintheirexistingclinicalroles,butnewtoremoteareawork.

Extremesoftemperature,humidityorariditytakeatollonthehealthandenergylevelsofeveryonewholivesinremoteAustralia.Thebaselinehealthstatusofanageingworkforcewillnotbeasgoodasitwillforayoungercohort.ManyRANsaremanagingtheirownchronicillnessesandstrugglingtomaintaintheirownwellbeing.SomehealthmanagersidentifiedRANexhaustionasapriorityconcern.Manycliniciansidentifiedaccesstofatigueleaveafterbeingon-callasessentialtotheirwellbeingandsafety.

4.8 RoadtravelinremoteareasAspreviouslyidentified,roadtravelinremoteareasinvolvesincreasedrisks,andrequiresdrivingandvehicleskillsnotgenerallyknowntourbanresidents.Mosthealthservicesstipulatethathavingamanualdriver’slicenseisamandatoryemploymentrequirement.However,fewerserviceshaveclearideasaboutwhatdrivingskillstheirstaffneed,andhowtheycouldgoaboutacquiringtheseskills.

Severalremoteworkforcememberswerequitescathingaboutthelackofpreparationofstaffforbushdriving.Itwasnotedthatevenbasic4WDcoursesdidnotprepareonefordrivinglongdistancesondirtroadsinvaryingweatherconditions,possiblywhilealsobeingtheprimarycliniciancaringforanacutelyillpatient.Roadsareoftenquitewide,andtravelat80-100kphormorenotuncommon.Asonecliniciannoted,‘Thesickerthepatient,thefastertheydrive,onesandyorboggysectionorroad,oramoment’slapseinconcentrationcanhavedisastrousconsequences,especiallyinalargevehiclewithahighcentreofgravity,cumbersomesteeringandsuspensionnotdesignedforhighspeedwork’.

Someserviceswhosestaffoftentravellongdistancesidentifiedthattheyhaveconsidered,orarealreadyusing,invehiclemonitoringsystems(IVMS)whileafewmoreuseGPSTrackingasasafetyandsecurityprecaution.Aswellasprovidingavehiclelocationsystem,IVMSsendsanalertifavehiclehashadaseriousaccidentorrollover.Reviewofthemonitoringsystemcanalsoidentifyifvehicleshavebeentravelingoverthespeedlimit,oriftheyhavebeensubjecttoharshaccelerationorbraking.

4.9 Actionandinactiontoprioritisesafety&securityThetraumaticeventsof2016havepromptedremotehealthstakeholderstoprioritiseworkforcesafetyandsecurity.Projectconsultationhasidentifiedthatpracticalinterventionsareoccurringatalllevels,althoughnotinalllocations,andwithvaryingcommitmenttocompliancewithexistingguidelines.EquipmentsuchastheSafeTCard–acombinedIDcardandmonitoredpersonalalarm-hasbeenusedbyanorganisationawarethattheirstaffworkingaloneinabuildingcanbeatsimilarimmediaterisktothoseworkinginremoteareas.GovernmentandNGOhealthservicemanagersidentifiedthattheleadtakenbyremotehealthservicesisalsobeingusedbyruralandsomeurbanagencieswhohavestaffworkingaloneinofficeandcommunitysettings.

Duringconsultation,projectstaffhaveobservedsafetycagesconstructedinhealthfacilities,man-downandotherpersonalalarms,increasedstaffingtofacilitate‘alwaysaccompanied’on-callstrategies,recruitmentofsecuritystaff,developmentofbestpracticeguidelinesbypeakagencies,andincreasedfocusbyclinicteamsandareamanagersontheconsistentimplementationofsafetyguidelines.Itisimportanttoacknowledgeeffortsmadetodate,andsupportcontinuationandwideruptakeoftheseinitiatives.

However,progresstodatehasnotbeenconsistent.Despiterecenthighprofileevents,someservicesandmanagersdonotunderstandthattheyhavearesponsibilitytodoeverythingreasonablypossibletoensurethesafetyandsecurityofservicestaff,believingthatcliniciansareprimarilyresponsibleforensuringtheirownsafety.Somemanagersidentifiedtheirprimarysafetyresponsibilitiesasensuringclinicianshaddemonstratedthecapacitytopracticeinasafemanner.

Similarly,somecliniciansareunderminingsafetyandsecuritysystemsbyinactionoraction.Personalalarmshangonahookintheofficeratherthanonabeltorlanyardaroundtheneckofthoseatwork.Manycliniciansidentifiedthattheyfeltbulliedintonotimplementingsafetyguidelinesbyotherstaffwhodidnotagreethatriskexists,orwhopreferredtoworkalonesotheirallegedlypoorclinicalpracticewasnotobservedbyothers.

4.10 Bullyingandharassment:down,up,andhorizontalManyparticipantsintheremotehealthindustryidentifiedconcernaboutthenatureandincidenceofbullying.Ratherthanactualbullying,someoftheeventsdescribedseemedmoretoreflecttheoverwhelmingemotionalstressexperiencedbybothmanagersandcliniciansworkinginremotehealthservices.However,otherexamplesdescribedepisodesofrepeatedunprofessionalbehaviourbyindividuals,bothmanagersandclinicians.SeveralcliniciansdetailedthebullyingbymanagementthathadresultedintheirnowonlyworkingthroughRecruitmentAgencies.

AfewRANsprovideddetailedevidenceofmanagersusingAHPRAnotificationsystemstomakecomplaints.Onlymonthslater,aftersignificantemotional,professionalandfinancialcost,didtherelevantBoarddeterminethattheclinicianconcernedhadnocasetoanswer.

InDecember2016,theSenateStandingCommitteesonCommunityAffairshasrecentlycompletedareviewofthemedicalcomplaintsprocessinAustralia.ThereviewspecificallynotedthatNursesandMidwiveswereincludedunderthetermmedical.TheCommittee’sreportidentifiedsixrecommendations:

Recommendation1Thecommitteerecommendsthatallpartieswithresponsibilityforaddressingbullyingandharassmentinthemedicalprofession,includinggovernments,hospitals,specialitycollegesanduniversities:•acknowledgethatbullyingandharassmentremainsprevalentwithintheprofession,tothedetrimentofindividualpractitionersandpatientsalike;•recognisethatworkingtogetherandaddressingtheseissuesinacollaborativewayistheonlysolution;and•committoongoingandsustainedactionandresourcestoeliminatethesebehaviours.

Recommendation2Thecommitteerecommendsthatalluniversitiesadoptacurriculumthatincorporatescompulsoryeducationonbullyingandharassment.

Recommendation3Thecommitteerecommendsthatalluniversitiesacceptresponsibilityfortheirstudentswhiletheyareonplacementandfurtheradoptaprocedurefordealingwithcomplaintsofbullyingandharassmentmadebytheirstudentswhileonplacement.Thisprocedureshouldbeclearlydefinedandawrittencopyprovidedtostudentspriortotheirplacementcommencing.

Recommendation4Thecommitteerecommendsthatallhospitalsreviewtheircodesofconducttoensurethattheycontainaprovisionthatspecificallystatesthatbullyingandharassmentintheworkplaceisstrictlynottoleratedtowardshospitalstaff,studentsandvolunteers.

Recommendation5Thecommitteerecommendsthatallspecialisttrainingcollegespubliclyreleaseanannualreportdetailinghowmanycomplaintsofbullyingandharassmenttheirmembersandtraineeshavebeensubjecttoandhowmanysanctionsthecollegehasimposedasaresultofthosecomplaints.

Recommendation6Thecommitteerecommendsthatanewinquirybeestablishedwithtermsofreferencetoaddressthefollowingmatters:•theimplementationofthecurrentcomplaintssystemundertheNationalLaw,includingroleofAHPRAandtheNationalBoards;•whethertheexistingregulatoryframework,establishedbytheNationalLaw,containsadequateprovisionforaddressingmedicalcomplaints;•therolesofAHPRA,theNationalBoardsandprofessionalorganisations–suchasthevariousColleges–inaddressingconcernswithinthemedicalprofessionwiththecomplaintsprocess;•theadequacyoftherelationshipsbetweenthosebodiesresponsibleforhandlingcomplaints;•whetheramendmentstotheNationalLawinrelationtothecomplaintshandlingprocessarerequired;and•otherimprovementsthatcouldassistinafairer,quickerandmoreeffectivemedicalcomplaintsprocess.

Recommendation6hasalreadybeenactioned,withthenewCommitteeestablished.Submissionscanbemadetill24/2/17,andthereportisdueon10/5/17.Informationisavailablethroughthefollowinglink:ComplaintsmechanismadministeredundertheHealthPractitionerRegulationNationalLaw

Managersidentifiedfewerexamplesofbullying.RANshavethreatenedtoresignifindividual(andsometimesunrealistic)requestswerenotapproved.Also,somemanagershavebeenplacedintheimpossiblepositionofbeingrequiredtoimproveservicessafetywhilemeetingKPIindicatorsthatinvolvebudgetefficiencies.

Horizontalviolence–thatperpetratedbycliniciansagainstpeers,usuallyworkinginthesameclinic,wasthetypeofbullyingmostfrequentlyidentifiedduringprojectconsultation.FIFOstaffreportedbullyingbypeersasthemostcommonreasonforthemtoavoidreturningtoaclinic.Theyalsoidentifiedthat‘goodstaff’atalocationwasoftenthemajorfactorintheirdecisiontoapplyfororacceptanofferedcontract.

Respondentsreportedthatsomepeoplewhochoosetoworkinremotelocationsappeartoprefertheirowncompany.Otherclinicianswereidentifiedaswarmandwelcoming.FIFOcliniciansprovidedmultipleexamplesofarrivingtodirtyaccommodation,withnofoodavailableandtheshopshut,onenotingthat‘thepersonIwasrelievinghadleftthebedunmadeandrottenfoodonthekitchenbench.Itwasdisgusting’.

Dirtyaccommodationisn’tnecessarilytheresponsibilityofotherremainingstaff,butnotprovidingevenbasicfoodrequirementstotideyournewteammemberovertillthenextdayisn’tagoodwaytocommenceanewworkingrelationship.

Individualorpeergroupunderminingofexistingsafetyguidelineswasaconcernidentifiedbymanystaff.MostFIFOclinicianswhohadworkedforayearortwoondifferentcontractsidentifiedthattheyhaveexperiencedthissituation,butthisisnottosaythatFIFOstaffwerenevercriticisedforsimilarbehaviour.

Thelessonfromthisfeedbackisthattheworkforceitselfhasacoreroleinpromotingorweakeningitssafetyandsecurity.Sometimesdifferencesofopinionwillbestberesolvedthroughusingclinicianinterpersonalcommunicationskills,whileatothertimes,despitethedifficultiesinstaffrecruitmentandretention,managementneedstointerveneanddirectitsstafftocooperatewithsafetyguidelines,orinitiateotheractionstoprotectthesafetyandsecurityofallstaff.

4.11 ChallengesofremotemanagementandsupervisionGoodclinicalservices,andgoodsafetysystems,requiregoodmanagementandsupervision.Respondentsexperiencesvaried,withcommentsfromdifferentindividuals,services,andlocationsidentifyingpositiveornegativeexperiencesrelatingtomanagementofissuesincluding:Administrativedemandskeepingcliniciansfromtheirclinicalrole;Noavailabilityofreliefstaffforholidaybreaks;Bullying(vertical&horizontal);Supportaftertraumaticevents;andpro-activeinterventiontoresolveproblemsbeforetheybecamecritical.

UseofInformationTechnologysystemsincludingTelecommunications,Electronicdatabases;andElectronictransferofdiagnosticinformation&resultswasacknowledgedbyrespondentsashavingimprovedinformationsharingopportunitiesforremotehealthservices.Concernsweremorefrequentlyraisedaboutinter-personalcommunicationandsupervisionofstaff.

Aspreviouslyidentified,difficultyrecruitingandretainingstaffisasignificantissueformostremotehealthservices.Thisappearstohaveresultedinsomeservicesavoidingproactivestaffsupervisionforfearoflosingstaff.ClinicianswhoseworkhistorywaspoorE.g.repeatedcomplaintsofbullyingorunprofessionalbehaviour,retainedemployment.Similarly,despitethephysicalandpsychologicalchallengesofremotehealthworkbeingacknowledgedinresearchliteratureandexperiencedonadaytodaybasisinhealthservices,manyserviceslefttheresponsibilityforwellbeingprimarilywiththeindividual–‘You’vegottotellusifyouneedhelp,orneedabreak’,ratherthansupervisorsinterveningtopromoteandmaintainstaff(andservice)wellbeing.

Projectconsultationidentifiedtwodifferenttypesofmanagementandsupervisionofremotehealthservices,onewascharacterisedbyfrequentlyreportedtensionanddistrustbetweenmanagersandclinicians,whileintheother,managersandstaffworkedasateam,notalwayshappyabouteachother,butfeelinggenerallysupported,acknowledgingtheirsharedgoalsandappreciatingindividualroles.

Clinicianswhofelttheywereheard,acknowledgedandsupportedbymanagersatclinicandregionallevelspokefarmorepositivelyabouttheirrole,andtheirintentiontoremainwithintheservicewhilepersonalandprofessionalconsiderationsallowed.Thoseclinicianswholackedtrustorrespectfortheirmanagersweremorelikelytousefrequentturnover(churn)asacopingmechanism.

Respondentsidentifiedthatthereweremanyremotehealthclinicianswhowereconsideredbytheirpeerstobeburnedoutorotherwiselessabletocontributepositivelyandsafelytotheirprofession.Thesestaffseemedtofindalocationwheretheycouldremain,largelyunsupervised,tothedetrimentofcommunities,otherclinicians,theiremployingservice,andprobablythemselves.

4.12 AsbestosAnumberofhealthstaffworkinginremotecommunitiesidentifiedAsbestosasapossiblehealthandsafetyhazard,citingexamplesofbuildingdamageandolddumpsofasbestoscontainingbuildingmaterials.Theuseofasbestosceasedinthelate1970’s.Priortothat,Asbestoswasusedextensivelyinbuildingmaterialssuchas:roofing;externalandinternalwalls/cladding;paint;andtileglue.Buildingsconstructedduringorafterthe1980’swillnothaveanyasbestosproducts.

Federal,StateandTerritorygovernmentsallhavemajorasbestosmanagementstrategies.Informationandlinkscanbefoundathttps://www.asbestossafety.gov.au

5 CLINICIANSURVEYWhilenotrequiredasapartoftheprojectconsultation,useofaquestionnairewasavaluablewayforclinicianstocontributetotheproject.Whenaskedaboutsafetyandsecurityissues,clinicianscurrentandpastwouldimmediatelyofferadescriptionoftheirmosttraumaticexperiences.Thequestionnaireprovidedastructuredopportunityforclinicianstoidentifyinformationaboutfactorsthatchallengedandpromotedsafetyandsecurity,aswellasidentifyingpositiveandnegativefactorsinfluencingtheuseofsafetyandsecurityequipmentandworkplacepractices.

GiventheincreasedeffortstoimprovesafetyandsecurityfollowingthemurderofGayleWoodford,questionnaireswereonlycollectedfromcurrentlypracticingclinicians,orthosewhohadworkedremotewithinthepastsixmonths.However,allclinicianscontactedduringtheprojectwereofferedcopiesofthequestionnaire,asitprovidedthosepreparingforremoteareaworkwithanopportunitytoconsidersafetyandsecurityissuestheycouldbelikelytoexperience.

AcopyofthequestionnaireisattachedasAppendix3

Thesurveyshouldbeconsideredasdatacollectedduringtheprojectratherthanaresearchproject.Thequestionnairewasdevelopedtofittheneedsoftheprojectratherthanansweraresearchquestion.Ethicsapprovalwasnotsoughtforthispartoftheproject.Resultsreflectinformationprovidedby90currentlyorrecentlypracticingRANs.Noteveryquestionwasrelevanttoallrespondents.Percentagesarebasedonthetotalnumberofrespondentstoeachquestion.Whilepercentagesareusedtomeasureresponserates,resultsshouldbeconsideredastrendsratherthanafiniteworkforceindicator.

Note:Surveyreliability.Resultsdocumentedhererefertorespondentanswers,anddonotnecessarilyreflectthelived&workedexperienceofeachremoteareaclinician.Inidentifying‘experiencedanddirectlyobservedevents’,morethanonerespondentcouldbereferringtothesameevent,oreventsmayhaveoccurredwithinthepasttwelvemonths,butpriortoarespondentarriving.Asaresult,thereisthepotentialofbothunderandoverreportingofresponses.Thisinformationisthereforeconsideredtorepresenttrendsratherthansolidreplicabledata.

5.1 QuestionnaireresultsanddiscussionThefirstpartofthequestionnairesoughtdemographicinformationtoenableresultstobeidentifiedaccordingtodifferentStatesandTerritories,ifthiswasconsideredwarranted,andtoenablefollow-upcontactbytheprojectiffurtherinformationwassoughtaboutindividualclinicianexperiences.Morethan90%ofrespondentswerehappytoprovidelocationinformation,afew(predominantlynon-nurses)decliningcitingidentificationandconfidentialityconcerns.

Question1.HowlonghaveyoubeenaRAN?Howlonghaveyoubeenemployedatyourcurrentormostrecentlocation?

Averagelengthofremoteareaexperienceofrespondentswasfiveyears,withtherangeofresponsesbeing1monthto20years.Timeatcurrentjobaveraged14months,therangebeing1monthto11years.

Resultswereskewedbyasmallnumberofrespondentswhowerepermanentremotetownresidents.AfewRANswhowerenearingretirementhadlivedandworkedinthesameremotetownformostoftheirlives.Excludingthe8-10%ofrespondentswhohaveworkedremoteforovertenyearswouldprovideamoreaccuratedescriptionofcharacteristicsofmosttheremotehealthworkforce.

ProjectconsultationidentifiedacommondescriptionofaRANcareercommencingwitha2-3yearcontract,thencomprisingshorterandshorterperiodsinanyonelocationuntiltheclinicianworkedonly1-2monthFIFOcontracts.Thisworkforce‘churn’isdisorientingforcommunities,cliniciansandhealthservices.However,extremechurndoesnotappeartobeanecessaryindustrycharacteristic.SomeServices/StatesandTerritoriesseemedtomaintainastable,longer-termworkforcethanothers.

Question2.AreyouemployeddirectlybyaHealthService,orthroughaNursingAgency?

62%ofstaffweredirectlyemployedbyaHealthServiceintheircurrentjob,with38%beingemployedbyRecruitmentAgencies.

ThisresponsewasskewedbyNorthernW.A.results,asfarmoreWArespondentsweredirectlyemployedbyGovernmentorAboriginalMedicalServices.Fortherestofthecohort,employmentwascloseto50:50HealthServiceandAgencyemployed.

Question3.IfyouhaveworkedthroughaNursingAgencyformorethansixmonths,whydoyoupreferthistodirectemployment?

Thereasonswhyclinicianspreferredagencyemploymentwere(byfrequencyofresponse):Flexibility;Variability;Asabuffertoavoidbullyingbymanagersandotherclinicians‘youcantestaplaceoutthendecidewhethertogoback’;ToavoidHealthServicepolitics;Betterpayandbettersupport–‘bettersupportifthingsareunsafe’;andtofitinwithfamilyprioritiesandothercareeropportunities.

Governmentemployersweregenerallyregardedasinflexibleaboutemployment‘workwithuspermanentfull-timeornotatall’.However,thismayhavebeentheapproachofmanagementratherthangovernmentrequirements,astherewereafewRANswhohadnegotiatedpart-timeE.g.0.7contractsthenworkedfull-timefor0.7oftheyear,buyingadditionalannualleaveiffamilycommitmentsrequiredmoretimeathome.Formanagerslookingtoreduceturnover,thisprovidesamuchmorestablestaffpresencethatrelyingonFIFOstaff.

Question4.HowmanyRANsandAboriginal&TorresStraitIslanderHealthWorkersareemployedatyourcurrent(recent)workplace?

ThenumberofRANsintheworkplacerangedfrom1-7.ThenumberofAboriginal&TorresStraitIslanderHealthWorkersrangedfrom0-6.Thesignificantinformationfromthisquestionisthat25%ofrespondentsworkinginIndigenouscommunitiesidentifiedthatnoAboriginal&TorresStraitIslanderHealthWorkerswereemployedintheHealthCentre.

RespondentsfrequentlyidentifiedthatworkingintheabsenceofAboriginal&TorresStraitIslanderHealthWorkersimpactednegativelyonprovidingculturallysafeservicesaswellascreatingsafetyandsecuritychallengesforRANsandnon-residentclinicians.

Question5.Doyouconsideryouraccommodationsafe&secure?(E.g.Gates/fences,insectscreens,firealarms,locksetc.)

25%ofrespondentsidentifiedthattheiraccommodationwasnotsafeandsecure.Lackoffirealarmswasaconcernforsome,howevermanyresponsesidentifiedproblemswithlackofsecurityscreens,brokenlocks,unsafedesign/construction,andinadequateperimeter(fence/gate)security.

Mostsignificantepisodesofviolencetoremotehealthstaffdocumentedoverthepasttwelvemonthshaveoccurredinandaroundstaffaccommodation.Highratesofinsecureaccommodationrepresentacontinuingthreattostaffwellbeing–AWHShazardthatcanusuallyberespondedtoeffectivelywithengineeringcontrols.

Question6.Hasyouraccommodationbeenbrokenintooverthepast12months?Ifyes,have‘weakpoints’beenadequatelyrepaired?

Approximately10%ofrespondentsidentifiedthattheiraccommodationhadbeenbrokenintoduringthepast12months.Severalrecentlyemployedclinicianswereunsureofthisinformation.

Thisinformationissignificant,asensuringaccommodationsecuritywouldappeartobetheprimaryresponserequiredtoreduceepisodesofsevereassaultandstafftrauma.

Question7.Doesyourworkplacejobdescriptionidentifyprioritisingstaffsafetyaspartofyourrole?

45%ofrespondentssaidyes,35%saidno,and20%wereunsure.

WhilenotarequirementthathealthservicesidentifyWHSstaffsafetyprioritiesinjobdescriptions,manyemployershaveusedthistodemonstratetheircommitmenttostaffsafetyandtoraiseawarenessamongstaffthattheyhavearesponsibilitytocontributetomaintainingtheirownsafetyaswellasthatofcommunityresidentsandotherpatients.

Question8.Doesyourworkplacehave‘NeverAlone’orsimilarsafetyguidelinesforbusinesshoursandon-callwork?

55%ofrespondentssaidyes,30%saidno,and15%wereunsureiftheirworkplacehadsafetyandsecurityguidelines.

Itisaconcernthat15%ofrespondentswereunsureoftheircurrentworkplacesafetyguidelines.AgencyrecruitedFIFOstaffwhodonotaccesspre-employmentorientationcomprisedmostofthisgroup.

Question9.Aresafety‘NeverAlone’guidelinessupportedandimplementedconsistently?

51%ofrespondentssaidyes,and49%saidno.

Question10.IfYesforQ9,What’scontributingtoensuretheguidelineswork?IfNoforQ9,What’scausingproblems?E.g.Nurses,Community,Management,Otherissues?

Factorsthatcontributetosafetyguidelinesbeingconsistentlyimplemented(notinrankedorder):LocalClinicmanagerand/orHealthServicemanagementpromotesafety;Adequatestaffing;Availabilityoflocallyemployedstaff;Clearsafetyguidelines;Supportive/cohesiveclinicteam;RegularCommunity–Healthserviceconsultation;Aconsistentscheduleofafter-hours/on-callworkers;andclearguidelinesthatstaffarenotallowedtogoouton-callifthereisevidenceofrisk.

Factorsthatcauseproblemswithconsistentimplementationofsafetyandsecurityguidelines:Managementnotsupportingorresourcingtheirownpolicies;Inadequatestaffing;NolocallyemployeddriverorAboriginal&TorresStraitIslanderHealthWorkers;RANsnotsupportingguidelinesoreachother;It’snotalwayspossibleorpractical;‘TwoRANsoncallmeanreducedclinichoursthenextday;andnothavingfatigueleaveputspressureonthefirston-calltonotwakeupthesecondoncall’.

Question11.Whatpersonaleffortsdidyoumaketofindoutaboutyouremployerandyourjoblocation/environmentpriortostartingwork?

Mostrespondentsusedoneormorestrategiestofindoutabouttheirjobbeforecommencing.Theseincluded:Directcontactwiththeemployer/recruitmentagency;Aninternetsearch;Socialmediaenquiry;anddirectcontactwithotherRANs.21%ofrespondentsidentifiedthattheymadenoefforttofindoutaboutthehealthserviceorcommunitybeforecommencingwork–thoughsome,especiallyclinicianswithlimitedornopreviousremoteareaexperience,notedthatinretrospect,theyshouldhave.

Morethan20%ofrespondentsidentifiedthattheymadenoefforttolearnabouttheirprospectiveworkenvironmentbeforesigningacontractandcommencingwork.SomeexperiencedRANsworkingshortFIFOcontractsfeltthatseekinginformationabouttheirnextjobwouldn’tchangetheirworkplans.Respondentsidentifiedthatsomehealthservices‘desperatetogetstaff’glossoverproblems,andtheopinionofRANswhohaveworkedinalocationpreviouslyvaries.Asaresult,theyprefertogotoaplaceforafewweeksandseeforthemselves–iftheyenjoytheserviceandplacement,they’llgoback.Ifnot,theyjustcrossthelocationofftheirlistoffutureacceptablecontracts.Significantly,whoyouworkedwith(localmanager,otherclinicians),seemedtobeamoresignificantfactorinconsideringasecondcontractthancommunitycharacteristics.

Question12.Didyouhaveanyorientationbeforecommencingemploymentwithyourcurrentemployer?Ifyes,howmanydays’duration?

50%ofrespondentsidentifiedthattheyattendedorientationbeforecommencingattheircurrentjob.Again,thisresponsewasboostedbyamorepositiveresultfromWArespondents.Orientationlastedbetween2hoursand3weeksandoccurredoffsite(priortodeployment)andoncetheyhadarrivedattheirnewworkplace.FIFOstaffmostfrequentlymissedoutonanyorientation,oraccessedonlyabrieflocalorientation–moreofahandoverthanacomprehensiveinductionandorientationprocess.

Severalclinicianswhoidentifiedthattheyaccessednoorientationnotedthat‘the(healthservice/clinic)wasincrisis,andIwasjustexpectedtohitthegroundrunning’.BothnewandexperiencedRANswereexposedtothissituation.Somealsoidentifiedthatemployersfeltthat‘ifyou’rebeenemployedinafewothercommunities,youcaneasilyfitinwithhowthingsworkhere’.

Anotherrespondentconcernwasthathealthservicesscheduledorientationevery3-6months,withparticipationbeingdependentonstaffbeingabletobefreedupfromtheirclinicalrole.Thismeantthatcliniciansmayhavebeenworkingforsixmonthsormorebeforetheycouldattendorientation.Thiswasseenashealthservices‘tickingboxes’ratherthanactuallypreparingcliniciansfortheirworkplacement.

Orientationiscostlyandrequiresstafftopresentcontentaswellasparticipants.Healthservicesnotedthatwhilethissituation(3-6/12scheduledorientationprogrammes)wasnotpreferred,theoptionwastodelayappointmentofstaffuntilorientationwasscheduled–whichcreatesanothersetofdifficulties.

Question13.Ifyoudidhaveorientation,diditfocusonhealthservicerequirements(IT,orderingRx&suppliesetc.),ordiditalsoinvolvesafety,security&staffwellbeinginformation?

Ofthosewhoaccessedorientation,50%identifiedthatitfocusedonservicerequirements,while50%identifiedthatorientationalsoidentifiedpersonalwellbeingandsafety.Onerespondentidentifiedthattheirthree-dayorientationcommencedwithahalf-dayfocusonsafetyandsecurityissues.

Pocketsofbestpracticeidentifythattheremotehealthindustrycanimproveoverallratesofcomprehensiveworkplaceorientation.Innovativestrategieswillbeneededtoimproveorientation&inductionofFIFOstaff.

Question14.Haveyoubeenprovidedformal(1-2day)4WDtraining,includingpracticaldrivingexperience,dailymaintenance,&hands-onflattyrechangeexperience?

33%ofrespondentsreportedbeingofferedgood4WDtraining,withmostidentifyingthattheyhadnotbeenofferedorrequiredtodemonstratecompetencyinbushdrivingskillsbeforecommencingworkinaremotehealthcentre.OneRANsaid‘Iflewintomeetwithmymanagerandcompletepayrollrequirements,thentheyjustgavemethekeysandtoldmetodriveouttotheclinic.’

Somerespondentssaidthattheyhadattendeda4WDtrainingsession‘yearsagowithanotheremployer’.Subsequentemployers,iftheyaskedaboutclinicianbushdrivingskills,regardedanypasttrainingorexperienceasacceptable.Onerespondentreportedbeingoffered4WDtraining‘aftertheroll-overaccident’.Afewrespondentswhoownedtheirown4WDshaddonecoursesindependently.Afewrespondentsquestionedthecontentofavailablecourses,notingthatdrivingondirtroadsinvaryingseasonalconditions,andwhenrespondingtoemergencies,wasthesignificanthazardforwhichtheremotehealthworkforceneededtraining–and4WDcoursesdidnotfocusondirtroaddrivingskills.

Question15.Isthemainhealthservicevehiclereliable&adequatelyserviced?IsitfittedwithGPStracking,SatellitePhoneorHighFrequencyradio?

85%ofrespondentsidentifiedthatthehealthservicevehiclewasreliableandadequatelyserviced.Only7%ofrespondentsidentifiedthatthevehiclehadGPStrackingequipmentfitted.Allvehicleshadafittedoraccessible(mobile)SatellitephoneoraHFtransceiver,andafewhadboth.AfewrespondentsreportedthatthecliniconlyhadonesharedSatellitephone,whichwasnotalwaysavailableforOn-Callstaff(leftintheclinic,orbeingusedinanothervehicle)ManyrespondentsidentifiedthatSatellitephonereceptionwasveryunreliable.

Aswithdrivingskills,afewcliniciansdidrealisetheimportanceofgoodknowledgeandtrainingonhowtouseemergencycommunicationsequipment.Theyhadfoundmanuals,readthemandpractisedwithequipmentpriortoneedingitinanemergency.Thisshowsinitiative,butintheeventofanythinggoingwrong,itwouldnotdiminishemployerresponsibilitytoprovideadequatetrainingforequipmentbeingused.

Question16.Haveyouhadtraining&practicalexperiencewithallavailablecommunicationequipment?

55%ofrespondentsidentifiedthattheyhadnothadtrainingandexperiencewithemergencycommunicationequipment.Ofthosethathad,mostidentifiedthattheyhadnotraininginequipmentuse,buthadlearnedonthejob.

Propertraininginequipmentuse,includingreceptiontroubleshooting,mayimprovethecapacityofstafftouseemergencycommunicationequipmenteffectively,andimprovecommunicationreliability.

Question17.Istheclinicbuildingsafe,lockable&secure?Isthereappropriatelighting?

75%ofrespondentsidentifiedthattheclinicwassecure.91%ofrespondentsidentifiedthatclinicinternalandsecuritylightingwasadequate.

Clinicsecurityisasignificantissue.Asriskfactorschange,HealthServicesarehavingtoimprovethesecurityofworkplacefacilities.SeriousconsiderationmustbemadeofbalancingsecurityandotherrequirementssuchasFireEscapes.Inputbylocalstaff,reuserequirementsneedstobebalancedwiththecontributionofarchitectsfamiliarwithconstructionregulationsandCrimePreventionThroughEnvironmentalDesign(CPTED).

Question18.Istherereliable24hrphoneand/orradiocontactwithotherhealth&communitystaff,yourmanager,andEmergencyServices?

90%ofrespondentsidentifiedthat24hrscontactwasreliable.Othersidentifiedthatitwas‘mostly’reliable.

Question19.Areclinicalarms,personalalarmsorpersonallocatorbeacons(PLBs)availableforstaffuse?Dostaffusethemeffectively?

NorespondentsidentifiedaccesstoPersonalLocatorBeacons(PLBs).17%ofrespondentsidentifiedavailabilityofpersonalalarms.75%ofrespondentsidentifiedthatclinicshadalarmsystems.

Therewasconsiderablecommentaboutclinicalarmreliabilityandeffectiveness.Severalrespondentsnotedthatthesystemhadbeentested,foundunserviceable,butnotrepairedinatimelymanner–stillunserviceableafterayear.Othersidentifiedthatthealarmwasmonitoredbyacommercialsecurityfirmbasedhundredsofkilometresfromtheclinic,sometimesinanotherstate.Whentriggered,therewasnothingtoindicatethatitwasworking.Thedelaysassociatedinmobilisingaresponseusingthissystemwouldnotprovideanyemergencyassistanceintheeventofanassault.

Therewasconsensusthataneffectivealarmsystemneededtosoundloudlyonsiteaswellasalertothersthatassistancewasneeded.Falsealarmswereidentifiedasaconcern,withcliniciansunabletoconstantlysupervisethepresenceofpatientsandrelatives(especiallychildren)inallareasofaclinic.

Question20wasdividedintosixsections.Itcommencedwithageneralframeworkforresponding:SinceAugust2015,haveyouexperiencedordirectlyobserved(E.g.involvingyourselforotherstaff)abuse,violence,bullyingorharassmentthatresultedin:

20.1Staffimmediatelyresigningandleavingthecommunity/healthservice?

30%ofrespondentsidentifiedthattheyhadexperiencedorobservedthis.

20.2Staffleavingthecommunityformedicaltreatment?

Somerespondentsaddednotesindicatingthatthattheyhadincludedstaffleavingforall/anymedicaltreatment,notjusttreatmentrequiredduetoviolenceortrauma.

20.3Staffrequiringreviewortreatmentonsitefollowingviolence?

20.4Thepsychologicalimpactofthreats,bullyingorassaultimpactingonthewellbeingofstaff,andtheirabilitytocontinueworking?

Thisisasignificantrateofresponsethatisconsistentwithresultsidentifiedinrecentresearchreferredtointheliteraturereview.Itappearslinkedtostaffturnover/churn,withrespondentcommentsattributingthisevenlyamongpeers,HealthServicemanagement,andpatients/relatives.

20.5Stafftemporarilyrestrictingserviceaccessorbeingevacuatedforsafetyreasons?

Respondentsidentifiedsomeambivalencewiththisaction.Therewasconcernthatclinicclosurecouldbeanexpressionofangerthatunfairlytargetsthosewhoneedhealthservices,ratherthanthosewhothreatenthewellbeingofhealthstaff.Respondentssupportedclosure/restrictingserviceaccesswhenhealthserviceshadpreviouslynegotiatedthiswiththecommunity,orwherestaffwereevacuatedfromaclinic/communityinresponsetothreatened/perpetratedviolence.

20.6Cumulativeepisodesofthreats,bullyingorharassmentbeingtheprimarycauseforstaffchoosingtoresign&leavethecommunity?

Thisquestionfocusedonbullyingandharassmentonly,distinguishingresponsesfromquestion20.4whichalsoincludedviolence.77%ofrespondentsidentifiedthattheyhadexperiencedorwitnessedthis.

Respondentcommentsaddedtothisresponseidentifiedthattheperpetratorsofweremostcommonlyhealthservicemanagersorpeers,withbothgroupsbeingidentifiedequally.

Question21.Wouldyoubewillingtobecontactedpersonallytoprovidefurtherinformationaboutanyofyouranswers?

67%ofrespondentsagreedtofurthercontactifthiswasneededbytheproject.Manywhodeclinedstatedthattheydidsobecausetheydidn’tfeeltheyhadanyfurtherinformationtocontribute.Afewdeclinedtoprotecttheirconfidentiality.

Question22.Howwouldyourateyourskills&confidenceaboutde-escalatinginter-personalconfrontation?Responseoptionswere:1.VeryCompetent;2.Confident;3.Requiresdevelopment

Thisquestionwasaddedmidsurveyinresponsetode-escalationbeingidentifiedinresearchasrequiredtraining,andasbullying&harassmentwasfrequentlybeingraiseasanissuebecliniciansandmanagers.

Feedbacktodatehasbeenprovidedby35respondents.22%ratedthemselvesveryconfident,60%ratedthemselvesconfident,and18%ratedthemselvesasrequiringdevelopment.

Anumberfromtheconfidentresponsegroupnotedthatalthoughconfident,de-escalationskillsbenefitedfromongoingtraining,asdidallclinicalskills.

Thisquestionwasincludedtoidentifyclinicianconfidencewithrespondingtoallinter-personalconfrontation,includingthreatsofviolenceintheworkplace.However,fromcommentprovided,itappearsthatsomerespondentsinterpretedthequestionasrelatingonlytointer-personalconfrontationwithotherstaffandmanagement.Asaresult,theresultsshouldnotbeinterpretedasaccuratelyreflectingworkforceself-measuredcapacitytorespondeffectivelytothreatsofviolenceintheworkplace.

6 SUMMARYOFCONSULTATIONANDSURVEYRESULTSTwenty-fivepercentofIndigenouscommunitiesservicedbyquestionnaireparticipantswerereportedtohavenoAboriginal&TorresStraitIslanderHealthWorkers.TheabsenceofIndigenousclinicalstaffimpactsnegativelyonboththeculturalsafetyofservicesavailabletocommunities,andthesafetyofRANsandothermembersoftheremotehealthworkforce.

Aboriginal&TorresStraitIslanderHealthWorkersidentifiedthatsomeriskstoRANsandAboriginal&TorresStraitIslanderHealthWorkerswerethesame,butmanyweredifferent.Ifanangryordrugaffectedpersoncametotheclinicintendingtoharmstaff,everyonewouldbeatsimilarrisk.Indigenoushealthstaffweremoresusceptibletointernalfamilyandcommunityviolence–domesticviolence,punishment,orassaultbyotherstryingtoprojectblameontohealthstaff.RANsandothers,wereatincreasedriskbecausetheyfrequentlydidnotknowthepersonalityorbackgroundofcommunityresidentsorvisitors.Theywerealsoatincreasedriskattimes,astheywereusuallylasttobeawareoftensionsinthecommunityandthelikelihoodofviolence.Externalstaffwereattimesmoresusceptibletopropertydamageandviolencebecauseinvestigationandpunishmentfortheoffencewasaslow,unwieldyprocesswhichoftenremainedincomplete.

Severalrespondentsnotedthatmanycommunitiesthemselvesareexperiencingconsiderablesocialdisruption.Blamingsmallcommunitiesisnotananswer.Asoneclinicianstated,‘Communitieshavetobethesolution,nottheproblem’.

AlmostallgroupsofRANsidentifieddogattackasthehazardtheyexperiencedmostfrequently.Dogattackisasafetythreatthatalsoimpactsonprovisionofservices,asitkeepscliniciansfromengagingeasilywithcommunitymembers.

Alongwithdirectrecruitmentbyhealthservices,twogovernmentsupportedstaffmobilisingagenciesandapproximately130NurseRecruitmentAgenciesoperatethroughoutAustralia.AllAgenciesandmobilisingservicescontactedacknowledgedsomeresponsibilitytoensurethathealthservicesandnewrecruitsweremadeawareofreportedsafetyissuessuchasinsecureaccommodation&recentassaults.Theywerealsoamenabletoensuringthatstaffwereprovidedwithworkplacesafetyguidelinesifthiswasidentifiedasindustrybestpractice.

Thereisacleartrendforclinicianstoapproachremotehealthworkasalimiteddurationinterest.Theyeitherlimittheirplannedremoteexperiencetooneplacementofafewmonthstotwoyears,orstartwithlongtermplans,onlytocommencecontractworkastheirtolerancetotheworkplacediminishes.Manycliniciansagreedwiththeideathattheycouldcontinuetocopewithfrequentworkplacechange,butwerelessabletocopewithworkcontinuity.

Mosthealthservicesstipulatethathavingamanualdriver’slicenseisamandatoryemploymentrequirement.However,fewerserviceshaveclearideasaboutwhatdrivingskillstheirstaffneeded,andhowtheycouldgoaboutacquiringtheseskills.Itwasnotedthatevenbasic4WDcoursesdidnotprepareonefordrivinglongdistancesondirtroadsinvaryingweatherconditions.

Thetraumaticeventsof2016havemotivatedremotehealthstakeholderstoprioritiseworkforcesafetyandsecurity.Projectconsultationhasidentifiedthatpracticalinterventionsareoccurringatalllevels,althoughnotinalllocations.Itisimportanttoacknowledgeeffortsmadetodate,andsupportcontinuationandwideruptakeoftheseinitiatives.

Someservicesandmanagersdonotseemtounderstandtheirlegislatedresponsibilitytodoeverythingreasonablypossibletoensurethesafetyandsecurityofservicestaff,stillbelievingthatcliniciansareprimarilyresponsibleforensuringtheirownsafety.Similarly,somecliniciansareunderminingsafetyandsecuritysystemsbyinactionoraction.Manycliniciansidentifiedthattheyfeltbulliedintonotimplementingsafetyguidelinesbystaffwhodidnotagreethatriskexists,orwhoallegedlypreferredtoworkalonesotheirpoorclinicalpracticewasnotobservedbyothers.

Itisalarmingtohearsomanyparticipantsintheremotehealthindustryidentifyconcernaboutthenatureandincidenceofbullying.Whilesomeexamplesseemtoreflectthefraughtemotionalstateofmanymanagersandclinicians,otherexampleshighlightedexamplesofhighlyunprofessionalbehaviour.

Horizontalviolence–thatperpetratedbycliniciansagainstpeers,wasthetypeofbullyingmostfrequentlyidentifiedduringprojectconsultation.FIFOstaffreportedbullyingbypeersasthemostcommonreasonforthemtoavoidreturningtoaclinicorhealthservice.Theyalsoidentifiedthathaving‘goodstaff’atalocationwasasignificantmotivatorforthemtoapplyfororacceptanofferedcontract.

Thelessonfromthisfeedbackisthattheworkforceitselfhasacoreroleincontributingtoorweakeningitssafetyandsecurity.Sometimesdifferencesofopinionwillbestberesolvedthroughusingclinicianinterpersonalcommunicationskills,whileatothertimes,proactivemanagementinterventionsarerequiredtoprotectthesafetyandsecurityofallstaff.

Inadequatestaffsupport&supervisionallowsproblemissuestobecomeacceptedandentrenchedinsomelocations.

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PARTC:CONCLUSION

7 CONCLUSIONPartAofthisdocument,theLiteratureReview,builtonthe2012WorkingSafeinRuralandRemoteAustraliaProjectreport,andnotedtheconclusionsofadditionalavailableresearchpublishedfrom2011onwards.NationalModelWorkplaceHealthandSafetyguidelinespromptedre-considerationofsomepre-2010researchfindingandrecommendations.Analysisofviolent/traumaeventsinvolvingtheremotehealthworkforceoverthepast12monthsresultedinre-evaluationofwhatwaspreviouslyacceptedasthemajorhazardsandrisksaffectingstaff.

PartBofthisdocumentcollatedinformationprovidedduringindustryandcommunityconsultation.Italsoreportsonfindingsfromthequestionnairecompletedby90currentlyorrecentlypracticingmembersoftheremotehealthworkforce.Thisinformationreinforcedmanyofthepriorityissuesidentifiedintheliteraturereview.Consultationalsoidentifiedsignificantsafetyandsecurityissuesnotprioritisedinresearch,andprovideduptodateinformationabouttheopinionsandmotivationofFly-InFly-OutRANs,anincreasinglysignificantcomponentofthetotalremotehealthworkforce.

Inpreparingthisreport,theprojecthasgatheredcomprehensiveinformationaboutissuesinfluencingremotehealthworkforcesafetyandsecurity.Thisprovidesasoberingaccountofthechallengesfacedbycliniciansandmanagers.

Manyoftheidentifiedissuescanberespondedtopositivelywithlimitedcostimplications,althoughthecontributionofindustrystakeholdersisrequiredtoprogresschange.However,otherinitiativesinvolveconsiderablecosts.Procurement,repairandmaintenanceoffacilities,accommodationandequipmentwillrequirethecontributionoffundingagencies.

Usingtheinformationcompiledfromtheliteraturereviewandindustryconsultation,theprojectisnowwellplacedtoprogresswiththecompletionofotheroutputs.Thesewillsupportremotehealthstakeholderstopromoteworkforcesafetythroughtheeffectiveuseofworkplaceguidelines,riskassessmenttools,training,andindustryresources.Otherstrategies,suchaseducationofincomingcliniciansaboutsafetyandsecurityissues,cliniciancommunicationandde-escalationtraining,andorientationoptionsforFly-InFly-Outstaffwillrequirefutureinputsbyemployersandprofessionalorganisations.

7.1 PriorityIssuesandRecommendationsInthecourseofindustryconsultation,itwasapparentthatAustralia’sremotehealthsectoriscommittedtoengageintheirroleandcontributefurthertothehealthofthecommunity.However,thetraumaticeventsoccurringthrough2016havechallengedtheircapacitytodothis.Athree-prongedresponserequires:

1. Reducingtheriskofseriousassault2. Improvingworkforceknowledgeandskillsinactivitiesthatsupportsafeimplementationoftheir

clinicalrole3. Reducingbullyingandpromotingpersonalwellbeingacrosstheindustrythroughpeereducationand

supportivesupervisionbymanagementActivitiesbasedaroundthisapproachwillimprovethecapacityofstafftoenter,practice,andremainsafelyintheremotehealthworkforce.

Thefollowingsummaryofissuesandrecommendationsprovidesaguideforward:

Issue Recommendations

1 Workforceinjuryanddeath

Analysisofknownsevereepisodesofinjuryanddeathoftheremotehealthworkforceoverthepasttwelvemonthsindicatesthatbeingfemale,inyouraccommodation,andafterhours’timeswereriskfactors.Assaultsarecommonlyperpetratedwithcriminalintent.

• Securityofaccommodationneedstobebasedoncrimeprotectionthroughenvironmentaldesign,qualityconstructiontechniques,andtimelymaintenance.

• Allfacilitiestobeauditedannuallyforcompliancewithsafety&securityguidelines.

• Incomingstaffneedtobeinformedofriskissuesandeducatedaroundeffectiveandconsistentuseofsafetyguidelinesbeforecommencingwork.

• Allepisodesofassaultorinjurytobereportedbytheworkforceandcollatedbyemployersthroughaformalisedreportingprocess.

2 StaffassaultedduringBusinessHours&On-Call

Pastresearchandprojectconsultationhasidentifiedunacceptablelevelsofviolenceandaggressiontowardsstaff.

• WorkplacesafetyguidelinesshouldidentifythatRANsarealwaysaccompaniedon-callandatotherworktimeswhenriskissuesareidentified

• Allcall-outsshouldbeexternallymonitoredandidentifytime,natureofcall-out,patient/callerIDandsafecompletionoftheepisodeofcare.

• Allremotehealthservicesshoulddevelop,resource,implementandreviewworkplacesafetyguidelines.

• Priortocommencingwork,stafforientationshouldidentifysafetyissues&safeworkguidelines.

3 Respondingtocriticalevents

Researchreportsthatstafffeelunderskilledinassessment,communication,&de-escalationofcriticalevents.

• TrainingshouldbedevelopedandrolledoutfortheremotehealthworkforcewithcontentincludingRiskAssessment,Communication,andDe-escalationskills.

4 LocatingandassistingstaffwhensomethinggoeswrongTheremoteandisolatedhealthworkforcelacksconsistent&effectiveearlyresponseandlocatorprocess.

• Clinic,accommodation,andifrequired,personalalarmsystemsshouldbeassessed&asnecessaryupgradedtoemitaloudlocalalarmaswellasalertoff-sitemonitoringservices.

• RemotehealthvehiclesshouldbefittedwithaGPStrackingdevice.Dependingonworklocation&use,anEpirb(locatorbeacon)andmorecomplexrealtimevehiclemonitoringsystemsshouldbeconsidered.

• Personalalarmsshouldbeconsideredforlargerandmorecomplexhealthcentresandservices.

5 Workforcedrivingskills,MVAs

Staffreportedinadequatepreparationforhazardsresultingfromdriving4WDvehiclesinvaryingclimateconditionsonremotedirtroads.

• Staffwhohaveformalfirstrespondent(Ambulance)responsibilitiesshouldbeeducatedandresourcedas‘emergencyserviceworkers’inaccordancewiththejurisdictionsfirstrespondentprocesses.

• Trainingandexperienceisrequiredinsafeandeffectivebasicmaintenance,trouble-shootingandchangingaflattyre.

• Trainingandexperienceinbasic4WDskills.

• Trainingandexperienceonlongdistancedrivinginremoteareasondirtroadsinvaryingweatherconditions.

6 Workforceemergencycommunicationequipment

Manystaffareuntrainedandlackexperienceineffectiveuseofemergencycommunicationequipment.Staffreportedthatsatellitephonecommunicationwasoftenunreliable

• AllremotehealthvehiclesshouldbeequippedwithaSatellitephone.

• TrainingandpracticeinSatellitephoneset-up,useandtroubleshootingofreceptionissuesshouldbecompletedpriortostaffworkingon-call.

• Whereinuse,training&practicewithHFradiotransceiversshouldbecompletedpriortostaffworkingon-call.

• Annualcommunicationequipmentmaintenanceshouldbeincludedwiththehealthvehiclemaintenanceschedule.

7 WorkforceFatigue

Environment,workload&wellbeingpressuresresultinfatigue,reducingstaffcapacitytoworkeffectivelyandrespondrapidlytocriticalevents.Staffareexpectedtoself-monitorwellbeingratherthanthisbeingasharedemployer&employeeresponsibility.

• Employersshouldactivelymanagefatiguethroughafatiguemanagementprogram/process.Includingmonitoringofrosters,on-callhoursworked,timelyuseofleave,andsupportivestaffsupervisiontoidentifyandrespondtofatigueandchallengestowellbeing.

• Professional/Clinicalsupervisionshouldbeavailableforandrequiredofallremotehealthcliniciansandmanagers.

8 StaffretentionStaffattrition,turnoverandchurnchallengescapacitytoconsistentlyimplementsafetyandsecurityguidelines.Thetransientworkforcehaslimitedopportunitytoengagewithcommunitiesinwhichtheywork.

• ManagershavetheprimaryresponsibilityofproactivelymonitoringtheworkplaceenvironmentandinterveningwhererequiredtofulfillWHSobligations.

• FurtherrolloutoftheCRANAplusBullyingAppandotherresourcesisrequiredtosupportindividualcliniciansandengagetheworkforceinhowtomanageworkplacebullying.

9 Violenceandtraumadata

Thereislimitedstatisticalinformationavailableonwhichtoidentifyandanalysetheincidenceandcharacteristicsofviolentandtraumaticeventsinvolvingtheremotehealthworkforce.

• AregisterofRemoteHealthWorkforceAssaultandTraumashouldbemaintainedtomonitorincidenceandnatureofeventstobetterinformpreventiveactions.Theregistershouldbecross-jurisdictionalanduseastandardiseddataset.

• Researchshouldbeundertakenabouttheincidenceandcharacteristicsofworkplaceviolenceperpetratedagainstremoteareaclinicians,andeffectivepreventiveandresponsestrategies.