remote health workforce safety & security report january 2017 · remote health workforce safety...
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cairns office PO Box 7410, Cairns QLD 4870 Phone: (07) 4047 6400 Fax: (07) 4041 2661
[email protected] www.crana.org.au abn 31 601 433 502
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
© CRANAplus
Thisworkiscopyright.Itmaybereproducedinwholeorpartfortrainingpurposessubjecttotheinclusionofanacknowledgementoftheauthorandsource,andnocommercialusageorsale.Reproductionforpurposesotherthanforthoseindicated,requiresthewrittenpermissionoftheCRANAplus.RequestsandenquiriesconcerningreproductionandrightsshouldbeaddressedtotheChiefExecutiveOfficer,CRANAplus,POBox7410,Cairns,QLD4870.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 2
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
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 3
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
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 4
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
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 5
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 6
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 7
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 8
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 9
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 10
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.
__________________________
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 11
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 12
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.
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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.
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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.
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PartA:LITERATUREREVIEW
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 16
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.
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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.
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TheresearchdoesnotsuggestthatthestudygroupfulfilsPTSDdiagnosticcriteria.However,PTSD-likesymptomscaninclude:feelingemotionallyoverwhelmed;diminishedcapacitytomanagechallengingsituations;poorsleep;reducedmotivationandcapacitytomanageself-care;lowenergy;irritability;andasenseofdis-empowermentandinabilitytomakechange.Significantly,itisthispopulationofRANswhoareexpectedtoprovideon-sitementoringandorientationtonewandincomingshorttermstaff.
WorkplaceHealthandSafetylegislation®ulationsinallStatesandTerritoriesofAustraliaprioritisethesafetyofworkersabovetheirworkresponsibilities.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:
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“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.
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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 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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 21
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 22
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 23
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
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 25
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.
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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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 27
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.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 28
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.
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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’.
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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
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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.
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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.
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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.
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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.
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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.
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20.2Staffleavingthecommunityformedicaltreatment?
33%ofrespondentsidentifiedthattheyhadexperiencedorobservedthis.
Somerespondentsaddednotesindicatingthatthattheyhadincludedstaffleavingforall/anymedicaltreatment,notjusttreatmentrequiredduetoviolenceortrauma.
20.3Staffrequiringreviewortreatmentonsitefollowingviolence?
24%ofrespondentsidentifiedthattheyhadexperiencedorobservedthis.
20.4Thepsychologicalimpactofthreats,bullyingorassaultimpactingonthewellbeingofstaff,andtheirabilitytocontinueworking?
48%ofrespondentsidentifiedthattheyhadexperiencedorobservedthis.
Thisisasignificantrateofresponsethatisconsistentwithresultsidentifiedinrecentresearchreferredtointheliteraturereview.Itappearslinkedtostaffturnover/churn,withrespondentcommentsattributingthisevenlyamongpeers,HealthServicemanagement,andpatients/relatives.
20.5Stafftemporarilyrestrictingserviceaccessorbeingevacuatedforsafetyreasons?
38%ofrespondentsidentifiedthattheyhadexperiencedorobservedthis.
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.
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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.
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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
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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:
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 41
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.
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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.
10 ReducednumberofAboriginal&TorresStraitIslanderHealthWorkersinmanyindigenouscommunitiesThelackofAHWsinmanyhealthcentresincreasesworkforcesafetyrisksanddiminishesthecapacityofservicestoprovideculturallysafehealthcare.
• Relevantorganisationsshouldbesupportedtoundertakefurtherworkaboutthisworkforceshortage.
11 DogattackDogattack/dogbiteisafrequentlyoccurringformofinjuryexperiencedbytheremotehealthworkforce.
• Educationresourcese.g.AMRRICvideostobeamandatorycomponentofremotehealthworkforceorientation.
• HealthServicesandprofessionalorganisationstoinitiatecontactwithanimalmanagementservicestopromoteworkingsafelyarounddogs.
12 Workforcesafety&securitynotadequatelypromotedLackofnationalsafety&securitystandardscontributestovaryingqualityof,andcompliancewithemployersafetyguidelines.
• NationalremotehealthworkforcesafetyandsecuritystandardsarerequiredtoprovidecompliancebenchmarksforhealthserviceSafety&Qualityprograms
• Sharinginformationaboutsuccessfulinterventionsthroughindustrypresentations&othercommunicationsmotivatesmanagersandclinicianstotakecontrolofimplementingeffectiveworkforcesafetyinitiatives.
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8 REFERENCES
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18McCullough,K.Williams,ALenthall,S.2012.Voicesfromthebush:remoteareanursesprioritisehazardsthatcontributetoviolenceintheirworkplace.RuralandRemoteHealth12:1972.(online)Available:http//:www.rrh.org.au
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23CRANAplus2016.CRANAplusSingleClinicianpostpositionpaper.Retrieved12/11/16from:https://crana.org.au/uploads/pdfs/Position-Paper_Single-Nurse-Clinician-Post_-14-Jan-2014.pdf
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33AnimalManagementinRural&RemoteIndigenousCommunities(2016)StayingSafeAroundDogs–Aguidetoworkingwithremotecommunitydogs.Retrieved12/11/16fromhttp://www.amrric.org/our-work/staying-safe-around-dogs-0
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Appendix1.ExecutiveSummary,RDAAWorkingSafeinRuralandRemoteAustraliaprojectreport
INTRODUCTION
TheWorking safe in ruraland remoteAustraliaproject aims to seek solutions to theproblemofworkplaceviolenceforhealthworkers,policeandteachersinruralandremoteAustraliabypromotingandfacilitatingawhole of community approach. The project is a collaborative effort of the Rural Doctors Association ofAustralia (RDAA), the Australian College of Rural and Remote Medicine (ACRRM), the Australian NursingFederation (ANF)plus. A Project Steering Committee comprised of representatives from each of the abovementionedorganisationsisoverseeingtheproject,whichisfundedbytheDepartmentofHealthandAgeing(DoHA).
UrbishasbeencommissionedbytheRDAA,onbehalfoftheProjectSteeringCommittee,toundertakeStage1oftheWorkingsafeinruralandremoteAustraliaproject.Stage1seekstolaythefoundationforpreventingviolenceandbuildingsaferworkplacesinruralandremoteAustraliaby:
1. increasingourunderstandingofcurrentinitiatives/strategiesandtheireffectiveness;and
2. developinganationalframeworkforactionforawhole-ofcommunityresponsetoworkingsafely.
Thisreportaddressesthefirstpointabove.Itidentifiescurrentstrategiesandinitiativestopreventworkplaceviolenceand,totheextentpossible,commentsontheireffectiveness.Itsummariseswhathasbeenlearnedinthecourseofundertakingaliteraturereviewaswellasprimaryresearchcomprisingkeyinformantinterviewsandasurveyofhealthprofessionals, teachers,andpolicewithexperienceof livingandworking inruralandremoteAustralia.
METHODOLOGY
Urbis used amulti-pronged approach to identify and collect publications and documents for the literaturereview.WefocusedonAustralian,andtoalesserextent,internationalliteratureproducedinthelast10years.In total, approximately 80 pieces of themost relevant literature and documentswere reviewed, including:academic articles; government policies and guidelines; and industry guidelines, education kits and positionstatements.
Inaddition,weinterviewed13keyinformantswhorepresentedanumberofpeakbodiesorsupportagencies.Theseinterviewswereconductedearlyintheprojectandhelpedinformthedevelopmentofanonlinesurveywhich was distributed through a convenience sample to police, teachers and health workers in rural andremoteAustralia.Over600responseswerereceived,withoverhalfofthesefromhealthworkers.Thesurveyresponses were analysed using analytic software, with the open-ended question responses coded andanalysedseparately.
PARTA:LITERATUREANDDOCUMENTATIONREVIEW
Thefirstpartof thereportsummarisestheavailable literatureontheprevalence,risk factorsand impactofworkplace violence in rural and remote Australia. It also identifies the strategies that exist to improveworkplacesafetyandreduceworkplaceviolence.ThekeyfindingsfromPartAareoutlinedbelow.
PREVALENCEOFWORKPLACEVIOLENCE
Whileworkplaceviolenceisrecognisedasaseriousproblem,itisdifficulttoascertainitsprevalence.Thiscanbeattributedto:
• theabsenceofamechanismtocollectsolid,uniformdataonworkplaceviolenceinAustralia• under-reportingofworkplaceviolence • ambiguitysurroundingthedefinitionof‘workplaceviolence’.
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There isnouniversallyaccepteddefinitionof ‘workplaceviolence’.The terms ‘violence’and ‘workplace’areboth marked by disagreement concerning what does and does not constitute violence, and where theboundariesoftheworkplacebeginandcease.
Adefinitionof‘workplaceviolence’frequentlycited,andadoptedbytheEuropeanCommission,is:
Incidentswherepersonsareabused,threatenedorassaultedincircumstancesrelatedtotheir
work,involvinganexplicitorimplicitchallengetotheirsafety,well-beingorhealth.
(Hoeletaln.d:4citingWynneetal1997)
There appears to be some consensus in the literature that workplace violence can be both physical andpsychological,andcancomefromanumberofperpetrators,suchascustomers,clients,students,co-workersand supervisors. Workplace violence can range from verbal abuse, threats and behaviour that creates anenvironment of fear, to physical violence, sexual harassment and homicide (Mayhew and Chappell 2005;Mayhew2000;Leinoetal2011).
A number of researchers have developed typologies to classify workplace violence to assist in developingviolencepreventionprograms.MayhewandChappell (2003),whohaveundertakensignificant research intoworkplaceviolence,separateworkplaceviolenceintothefollowingthreecategories:
• Category1:Externalviolence:perpetratedbypeopleoutsidetheorganisation
• Category2:Client-initiatedviolence:inflictedonworkersbycustomersorclients
• Category3:Internalviolence:betweenco-workersandsupervisor/employers.
ThisreportfocusesonCategory2;thatis,strategiestopreventviolenceperpetratedagainsthealthworkers,teachersandpolicebycustomers,clients,students,orothermembersofthepublic.However,acategoriesofworkplaceviolence,andthedifferentstrategiesthatarerequiredtorespondtoeachone(Chappelln.d:25).
DespitethedifficultiesinaccuratelymeasuringtheprevalenceofworkplaceviolenceinAustralia,anumberofstudies have been undertaken which provide some insight into the prevalence of workplace violence,particularly in the health sector. The health studies vary in sample size andmethodology but indicate thatviolenceagainsthealthprofessionalsisaseriousproblemwithkeystudiesfindingaround65percentofhealthprofessionalsreportedaviolentincidentintheprevious12months;somestudiesreportedsignificantlyhigherincidencesofviolence.
The literature search undertaken for this project identified significantly less literature on the prevalence ofviolenceagainstteachersandpoliceinAustralia.Theliteratureidentifiedsuggestsassaultsagainstpolicearerelatively common, perhaps 10 per cent of officers each year (Mayhew 2001), and violence directed atteachersbystudentsisincreasinginatleastsomepartsofAustralia(Williams2009).
A few studies have attempted to gaugewhetherworkplace violence ismoreprevalent in rural and remotelocations,asopposedtourbanlocations.SomestudieshaveconcludedthathealthprofessionalsinsomepartsofruralandremoteAustraliareporthigherlevelsofviolencethantheirurbancounterparts(Maginetal2010a;Fisher et al 1996). However, no firm conclusions can be drawn from these studies, nor can the results begeneralisedgiventhecompositionandchallengesfacingruralandremotecommunitiesvarysignificantly.
WORKPLACESAFETYRISKS
Intheruralandremotesetting,riskfactorsassociatedwithworkplaceviolenceinclude:
• lack of anonymity: in rural and remote communities, health workers, teachers and police have aprominentrole,andexpectationsassociatedwiththerole(egbeingoncall24hoursadaysevendaysa week) can be difficult to meet. In a rural and remote community, it can be harder for healthprofessionals, teachersandpolice to remove themselves fromapersonwithagrievanceandotherthreateningsituations.
• cultural issues: cultural issues in rural and remote communities are complex and multi-faceted;ignoranceofculturalnormscanresultinunintendedbreachesofcommunityprotocols.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 47
• distancemanagementandsupport:insomecases,managementandco-workerscanbelocatedsomedistance fromtheircolleagues in ruralandremoteAustralia; thiscan impacton thecapacityof theworkplace to be a safe environment and on the support that can be provided following a violentincident.
• mandatory reporting requirements: there can be practical difficulties surrounding mandatoryreportingof suspectedchildabuse in ruralandremotecommunities,where theremaybea lackofanonymityfortheprofessionalandacommunitypreferencetoresolveissuesinternally.
STRATEGIESTOIMPROVEWORKPLACESAFETYANDREDUCEWORKPLACEVIOLENCE
Strategies to identify, prevent and respond to workplace violence exist at the government, industry,communityandworkplacelevels.SomeofthestrategiesarerelevantspecificallytoruralandremoteAustralia,butmostaregeneralandcanbeadaptedtoworkplacesinalllocations.
It iswithin theWork,HealthandSafety (WHS) legislative framework thatmost violencepreventionpoliciesand initiatives aredevelopedand implemented.Under this legislation, employers are required toprovide asafeplacefortheiremployeestowork,includingthosewhoworkoff-site.WHSlegislationisimplementedatastate/territorylevel inAustralia,howeverjurisdictionsarecurrently intheprocessofharmonisingtheirWHSlegislation.
A largenumberofpolicydocumentsandguidelinesexistonpreventingandminimisingworkplaceviolence.Thesedocumentsexistatthestate/territory,nationalandinternational levels.Theyhavebeengeneratedbygovernments, industrybodies,tradeunionsandemployergroups.Whilethecontentofthedocumentsvary,theytendtooffergeneralistadvicethatenablesmanagerstodevelopworkplaceviolencepoliciesthataddressprevention,responseandrecovery,asopposedtoprovidingprescriptiveviolencepreventionprogramsperse(Perrone1999:74).
The types of strategies mentioned in these policy documents and guidelines, and implemented at theworkplacelevel,include:
• CrimePreventionThroughEnvironmentalDesign(CPTED):enhancingthedesignofbuildingswiththehelpofarchitects,engineers,buildersandlandscapegardenerstodiscouragecriminalactivity
• Educationandtraining:onissuessuchasrecognisinganddiffusingviolentandaggressivebehaviour,self-defencetechniques,communicationskills,andculturalsensitivity
• Communicationprocedureswhenworkingoff-site:suchasasystemtorecordtheaddressoftheplacevisitedandtimeofdepartureandreturn,andscheduledtelephonecalls
• Supportpost-incident:suchasgivingthevictimaccesstomedicalcare,collectingevidenceabouttheincidentandcompletinganincidentreport,holdingapost-incidentde-brief,andensuringthevictimisfullyinformedofallactionstakeninresponsetoaviolentincident(Mayhew2000;Perrone1999)
• Employee Assistance Programs: an early intervention strategy, which involves assisting employeeswithpersonalandworkproblems,throughconfidentialcounselling,educationalmaterial,referralstoself-helpgroupsandspecialistservices(2003)
• Mentoringprograms:whichallowforpeernetworkingandinformalsourcesofadviceandsupport.
Specificviolencepreventionstrategiesrelevanttothehealthsectorinclude:
• recognisingandde-escalatingviolentbehaviour
• zerotolerancepolicies
• flaggingthefilesofclientswithahistoryofviolentoraggressivebehaviour
• acceptablebehaviourcontracts
• refusetotreatdirectives
• interventionorders.
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Intheeducationsector,specificstrategiesforcombattingviolenceagainstteachersincludeprogramstocreatestrong relationships between teachers and students, and controlling student behaviour through policies onbullying,schooldressandlanguage,andprohibitionofweapons,drugs,andalcoholonschoolpremises.Inthepolicesector,specificstrategiesincludewearingofbodyarmour,andtheabolitionofsinglepersonpatrolsandsinglepersonposts.
Some researchershave sought to identifywhat individual strategies shouldbe included in a comprehensiveWorking safe in rural and remote Australia project seeks to develop a whole of community approach topreventingworkplaceviolenceagainsthealthprofessionals,teachersandpoliceinruralandremotelocations.Awholeofcommunityapproachneedstorecogniseandrespondtothediversityofruralandremotelocationsinsocial,culturalandeconomicterms.Itmustalsoseektoengagethecommunityandinvolvekeyplayersinthedevelopmentofstrategiesandinitiatives.
PARTB:CONSULTATIONS
Part B of this document reports the findings of an online survey completed by 624 health professionals,educationprofessionalsandpoliceinruralandremoteAustralia.Thesurveyaskedrespondentsaboutissuessurrounding workplace safety, including any exposure to workplace violence, and effective strategies torespondtoandmanageworkplaceviolence.Duetothelackofasampleframe(iealistofpolice,healthandeducationworkersinruralandremotecommunities)asampleofconveniencewasundertaken.Whilethisisalegitimateapproachtoquantitativesamplingforhard-to-reachaudiences,thesampleisnotrandominnatureandasaresult,itisnotpossibletoextrapolatethefindingsfromthisreporttothepopulationasawhole.
Thekeyfindingsofthissurveyareoutlinedbelow.
CONCERNSANDEXPERIENCESOFWORKPLACEVIOLENCE
Generally, respondents concerns for workplace violence were not excessively high, with the majority ofrespondentsacrossthethreesectorsreportingtheyfeltsafemostofthetimewhileatwork.Thereappearstobesomeacceptancethatthereisalevelofriskwhichcomesfromworkinginthesejobsorintheselocations.That said, the main safety concerns for respondents focused on physical violence or verbal abuse fromcommunitymembers,while respondentswere least concerned about experiencing sexual abuse or assault,andbullyingandharassmentbycolleagues.
Environmentalfactors,suchasworking longandunsociablehoursandworkingalonewerealso identifiedascontributingtofeelingsofbeingunsafeintheirworkplace.Isolationandworkingaloneappeartocontributetoconcernsabouttheriskofviolence.
Oftherespondentsthatexpressedseriousorsomeconcernaboutworkplaceviolence,generallylessthanhalfreportedactuallyexperiencingan incident in thepast12months. Somekey informantsalso suggested thatperceivedriskwasgreaterthanactualrisk.Thedifferentskillsetsrequiredtowork inthethreesectorswasalsotosomeextentreflectedinthedifferentconcernsforsafetyandexperiencesofworkplaceviolence.Forexample,policeweremuchlessconcernedaboutdrivingonruralroads,butexpressedconcernforconductinghomevisits,workingontheirown,andworking longand/orunsociablehours.Notably,healthprofessionalswere much more concerned about bullying and harassment from colleagues, than either police or healthprofessionals. This could suggest that the issue of colleague- initiated workplace violence requires furtherconsiderationwithinthehealthsector.
Despitethedifferencesamongstthesectorsintheirconcernsforworkplacesafety,negativeimpactsresultingfromtheseconcernswerestillfeltbyallrespondents,andincreasedstressandanxietywerereportedasthebiggestimpacts.Addressingissueswhichcausestressandanxiety,aswellasotherworkplacesafetyconcerns,maybeonewayinwhichworkplacescanhelptheirstaffremainlongerintheirroles,andfeelsaferworkinginaruralorremotelocation.
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SUPPORTTOPREVENTWORKPLACEVIOLENCE
Overall, respondents generally indicated theyhad received some levelofworkplace trainingandeducation.The most commonly reported education and training received by respondents included professionaldevelopment,firstaidtraining,andculturalcompetencyandawarenesstraining.Respondentsfromthehealthsector reported receiving themost training and education. Not surprising, the types of training commonlyreceivedreflectsthedifferentjobrequirementsforeachsector.Forexample,healthprofessionalsweremorelikelytohavereceivedtraininginviolencepreventionandaggressivebehaviourmanagement,butleastlikelytohave received first aid training. Police andeducationprofessionals on theotherhand reported receivingmoretrainingindrivinginruralandremoteAustraliaandinfirstaidtraining.
Overall, respondents generally felt the policies theirworkplace had in place to preventworkplace violencewereadequate.Notwithstandingthis,thenumberofrespondentswhoreportedusingstrategiesandsupportsidentifiedintheliteraturesuchasCPTED,scheduledtelephonecallsoracceptablebehaviouragreementswaslow.
Suggestions on how workplaces could be improved to prevent workplace violence generally related toimproved training (particularly inmanagingviolentandaggressivebehaviour),enforcingexistingpolicies (egzerotolerancepolicies)andimprovingworkpractices(egjointpatrols).Implementingsuchsuggestionsislikelyto require funding and staff time. However, both lack of funding and lack of staff were identified byrespondentsasthetwobiggestfactorsaffectingtheabilityofemployerstorespondtoworkplaceviolence.
COOPERATIONTOREDUCEWORKPLACEVIOLENCE
Overall, the findings from the survey did not present a consistent picture of whether and how the threesectorswerecooperatingtoreduceworkplaceviolence.Whilesomerespondentsdidreporttherewereformalmechanismsinplace,othersreportedlowlevelsofcooperationacrosssectors.
The role of police in providing support in emergency situationswasmost commonly reported as a specificexample of sector cooperation, although this is in fact part of the job rather than an example of sectorcooperation. Information sharing, communicationandnetworkingopportunitieswerealsoexamplesofhowcooperationwasoccurringbetweensectorprofessionals.
Themost commonly reported suggestions for improving sector cooperation related to better information-sharingandcommunicationthroughmulti-agencymeetings,betternetworkingandsupportacrossthethreesectors,andbettereducationandtraining.
In developing options for improved cooperation, however, consideration must be given to the barriers tointer-agencycooperation identifiedbyrespondents.These include lackofstaff, lackoftime, lackof funding,andthedifferentinterestsandprioritiesacrossthethreesectors.
PARTC:CONCLUSIONS
PartCof this report concludesbydrawing together the findingsofPartsAandB, andmakes the followingpoints.
• There isaneedtodevelopreliablemechanismsfor recordingworkplaceviolence, ineachsectoraswellasacrossdifferentlocationsinAustralia.
• Generally,surveyrespondentsreportedfeelingsafemostofthetime.
• Levelsofconcernregardingworkplaceviolenceappeartobehigherthanactualviolentincidents.
• Anystrategy to improve inter-agencycooperationneeds tobe flexible tobuildonexisting levelsofcooperation.
• Thereisaneedforevaluationofviolencepreventionstrategiesandinitiatives,todiscoverwhatworksbestinparticularenvironmentsandsituations.
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 50
Appendix2.CRANAplus2016Membersurveyresults
Lotsofreallyusefuldatahasbeencollected,andasyoucanseefromthesummarysomereallyclearresultscamein!Forexample,ifyou’reanemployer,thenyouneedtoensurethatyourstaffhavegoodinternetaccessintheiraccommodationotherwiseyou’repotentiallygoingtomissoutonattractingabout90%oftheworkforcewhothinkthisisimportanttotheirsustainability.
With70%ofourworkforcepushing50yearsorolder,and20%oftheworkforcenotexpectingtobeworkingremotewithinthenext2years,wehavesomeseriousworkforceshortageissuesthatwemusturgentlyaddressasanindustry.Someotherunexpectedresultsincluded:
• 5%ofrespondentsstatedthatpoorpersonalsafetyandsecurityimpactedonthem,with34%sayingitdidn’timpactonthematall
• 95%ofrespondentsfeltthatdrugandalcoholusagewasnotasignificantimpactor
• Theburdenofon-callwasanimportantworkplaceconditionfor85%ofrespondents,withthedaytodayworkloadandfatiguemanagementsystemsbeinganevenhigherpriorityat98%
• WeareprettyITsavvywithavastmajoritykeenfora‘remotehealthapp’,althoughabout50%ofrespondentswerenotfussedaboutFacebookorsocialmedia
Note:MembershipsurveyresultsmaydiffertothosefromtheSafety&Securityconsultationprocess,asthetwoactivitieshaddifferentgoals,anduseddifferentquestions,andsurveymethodologies.Comparisonbetweenthetwoactivitiesisnotincludedaspartofthisreport.
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Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 51
Appendix3.CRANAplusNationalSafety&SecurityProjectQuestionnaire
ThegoaloftheSafety&SecurityProjectistodevelopandshareresourceswhichuseapositive,supportiveapproachtopromoteremotehealthworkforcesafety,andindoingso,tofacilitateavailabilityofqualityhealthservicestoremotepopulations.Yourassistanceincontributingtoprojectinformationcollectionisappreciated.Participationisvoluntary.Pleasenotethatrespondentname&contactinformationisrequestedtoassistfollowupandfurthercommunication,itisnotmandatory.ConfidentialityofClinicianandHealthServiceinformationisaCRANApluspriority.Projectreportsandresourceswillnotidentifyanyspecificindividuals,servicesorlocations. Name
Whatisyourcurrentworklocation?
1 HowlonghaveyoubeenaRAN?
Howlonghaveyoubeenemployedatyour
currentormostrecentlocation?
TotalRANexperience:Timeatcurrentjob:
2 AreyouemployeddirectlybyaHealthService,
orthroughaNursingAgency?
3 IfyouhaveworkedthroughaNursingAgency
formorethansixmonths,whydoyouprefer
thistodirectemployment?
4 HowmanyRANsandAHWs/AHPsare
employedatyourcurrent(recent)workplace?
RANs:AHWs/AHPs:
5 Doyouconsideryouraccommodationsafe&
secure?(E.g.Gates/fences,insectscreens,fire
alarms,locksetc.)
6 Hasyouraccommodationbeenbrokeninto
overthepast12months?Ifyes,have‘weak
points’beenadequatelyrepaired?
7 Doesyourworkplacejobdescriptionidentify
prioritisingstaffsafetyaspartofyourrole?
8 Doesyourworkplacehave‘NeverAlone’or
similarsafetyguidelinesforbusinesshoursand
on-callwork?
9 Aresafety‘NeverAlone’guidelinessupported
andimplementedconsistently?
10 IfYesforQ9,What’scontributingtoensurethe
guidelineswork?
IfNoforQ9,What’scausingproblems?E.g.
Nurses,Community,Management,Other
issues?
11 Whatpersonaleffortsdidyoumaketofindoutaboutyouremployerandyourjoblocation/environmentpriortostartingwork?
Remote Area Health Workforce Safety and Security Report CRANAplus, January 2017 52
12 Didyouhaveanyorientationbeforecommencingemploymentwithyourcurrentemployer?Ifyes,howmanydays’duration?
13 Ifyoudidhaveorientation,diditfocusonhealthservicerequirements(IT,orderingRx&suppliesetc.),ordiditalsoinvolvesafety,security&staffwellbeinginformation?
14 Haveyoubeenprovidedformal(1-2day)4WDtraining,includingpracticaldrivingexperience,dailymaintenance,&hands-onflattyrechangeexperience?
15 Isthemainhealthservicevehiclereliable&adequatelyserviced?IsitfittedwithGPStracking,SatPhoneorHFradio?
Reliable:GPStracking:SatPhone:HFRadio:
16 Haveyouhadtraining&practicalexperiencewithallavailablecommunicationequipment?
17 Istheclinicbuildingsafe,lockable&secure?Isthereappropriatelighting?
Building:Lights:
18 Istherereliable24hrphoneand/orradiocontactwithotherhealth&communitystaff,yourmanager,andEmergencyServices?
19 Areclinicalarms,personalalarmsorpersonallocatorbeacons(PLBs)availableforstaffuse?Dostaffusethemeffectively?
Clinicalarms:Personalalarm:
PersonalLocatorBeacons:20 SinceAugust2015,haveyouexperiencedorobserved(E.g.involvingyourselforotherstaff)abuse,violence,
bullyingorharassmentthatresultedin:20.1 Staffimmediatelyresigningandleavingthe
community/healthservice?
20.2 Staffleavingthecommunityformedicaltreatment?
20.3 Staffrequiringreviewortreatmentonsitefollowingviolence?
20.4 Thepsychologicalimpactofthreats,bullyingorassaultimpactingonthewellbeingofstaff,andtheirabilitytocontinueworking?
20.5 Stafftemporarilyrestrictingserviceaccessorbeingevacuatedforsafetyreasons?
20.6 Cumulativeepisodesofthreats,bullyingorharassmentbeingtheprimarycauseforstaffchoosingtoresign&leavethecommunity?
21 Wouldyoubewillingtobecontactedpersonallytoprovidefurtherinformationaboutanyofyouranswers?
22 Howwouldyourateyourskills&confidenceaboutde-escalatinginter-personalconfrontation?
1.VeryCompetent2.Confident3.Requiresdevelopment
Ifyouhavenotbeenabletocompletethequestionnaire,orifyouaresharingitwithotherremoteareastaff,pleasescanyourresponseoranswerthequestionsbynumberinanemailandsendto:[email protected],andWorkSafe!