Physical Work Environment

Working in healthcare involves uncomfortable working positions and moving heavy individuals. The risks can be reduced with knowledge of transfer techniques (ergonomics) and various aids. Equally important is to work with stress, the interaction between employees and the maintenance of the premises.

From a working environment perspective, there should be 80 cm free path around all places where work with heavy lifting may be required. An area where it has taken time for many healthcare activities and they find it difficult to live up to the requirements in toilets and in bathrooms. The requirements have been the same for decades. The patience of the Work Environment Authority is running out and healthcare providers are forced to rebuild nursing homes that do not meet the work environment requirements.

According to the Work Environment Authority, 30% of those who reported occupational injury reported strain, i.e. poor working positions and heavy lifting. Almost as many (28 percent) cited organizational and social factors and chemical and biological factors (28 percent) as the cause of illness. Among chemical and biological causes there are infections, but also complaints due to problems that can be related to the building. Threats and violence are a risk factor for employees.

The employer is obliged to follow regulations on systematic work environment work, which among other things means assessing the risks that may exist in the business. The employer must ensure that managers and leaders have knowledge of how to prevent an unhealthy workload and how to prevent and manage offensive special treatment. The employer must have goals for the organizational and social work environment. The goals should promote health and counteract ill health.

Employees should have the opportunity to participate in the work of developing the goals. Workload and difficulty should be balanced with sufficient resources. The employer must take measures to counteract tasks that are strongly mentally stressful and that can lead to ill health (Swedish Work Environment Authority, AFS 2015:4). Training employees in ergonomics, ie. transfer technique and working positions is a necessary effort.

Psychosocial work environment

There are workplaces where employees avoid writing deviations in order not to be exposed to criticism or reprisals. It is extra dangerous when it is the management that spreads the culture. Reports often come from the school world and the academic world. Occasionally, there is a repressive leadership in nursing homes. A functioning quality work starts from looking for system errors. Looking for scapegoats and working with punishments of various kinds counteracts it.

There are workplaces where there is a culture in the team where the person who questions the way of working and the treatment becomes ostracized. Often, new employees disappear quickly as they cannot stand the culture. During visits, the culture is seen by observing that the unit is unpleasant. There is no one who does that little extra to make it homely for the residents.

There have been reports in the media where healthcare workers violate those who are dependent on their care. Threats and reprisals occur against the residents. Since no one raises the alarm, there must be something holding them back.

When the media knock on the door, managers and leaders look as if the shortcomings had come like a bolt from the blue. By being out in the business and having conversations with employees who quit, you as a manager can get valuable information. Listen for relatives' views. They often see other sides of the business than the boss. All stakeholders in healthcare have an obligation to ensure that there is a high ceiling and that signals of shortcomings are properly investigated.

Another way is to measure the safety culture. SKR has an excellent questionnaire that in a simple way measures the willingness to report deviations and the employees' experience of how the management handles safety issues.

Other signs of a poor psychosocial work environment may be high short-term absence, high staff turnover or simply that employees do not seem to care about their workplace.

Work environment and patient safety are linked

The relationship between work environment and patient safety is strong and there are many risks in the work environment. A healthcare injury is "suffering, discomfort physical or mental injury, illness or death caused by healthcare that could have been avoided". Many healthcare injuries are related to stress, poor lighting, poor logistics for handling materials and more. Working systematically to evaluate risks in the work environment and care environment on a daily basis can be a way to create good conditions for safe and secure care.

Ignorance and unclear routines for systematic work environment work make it difficult for employees to participate and have influence, this applies at all levels. Risk analysis should take place regularly as part of the systematic work environment work. Without risk analysis, the risk increases that the business is without competent employees and/or essential equipment. It can be about housing that poses a risk from various aspects.

Deficiencies in work environment work are often linked to lack of compliance with routines otherwise. Often measures are described without follow-up and control of effects, for example, measures against stress or high workload are not followed up to see if they provide sustainable effects.
Sometimes the problems are higher up in the organization. It could be that the manager has weak support from the employer to manage his leadership. Turnover of nurses and nursing assistants is often a sign of a poor work environment. An administratively unreasonable workload and a management responsibility over too many employees are common management problems.

Employees who make mistakes and mistakes

It happens that employees make mistakes. The background to mistakes being made varies. Someone has problems at home and has difficulty concentrating. Another may have misunderstood an instruction or lacks information. In further other cases, it may be about omission or neglect.

Giving someone a warning can be sad, but necessary. A manager should be clear about what applies. Through conversation, getting the employee to understand a mistake has been made and it must not be repeated is a fundamental part of working with continuous improvements.

Healthcare operations are often cautious about using labor law measures. There are a number of ways to handle or support the person who makes mistakes or mistakes in the business. It is always the employer who leads and distributes the work. There are cultural problems in some workplaces that cannot be blamed on the individual employee.

The manager is always obliged to point out phenomena that are not acceptable. There are a number of laws that regulate the labor law area. Examples are MBL (co-determination law) and the Employment Protection Act. Often there are rules in the collective agreements to take into account. The ultimate consequence of misconduct is always dismissal or termination. There are a number of milder measures.

In all handling of individual cases, it applies to the manager to act promptly to clarify the conditions, converse to get clarity, speak plainly - be clear, document and give a reminder or warning if required.
• The first step is to have a conversation about what happened. The conversation is documented and the manager requests a written statement. It may be a misunderstanding and not misconduct.
• If it is a serious event, it can be supplemented with a verbal or written reminder.
• If there is a lack of knowledge, the employer can offer competence development.
• In serious shortcomings, the employer can decide to take the employee out of service. Suspension is a temporary measure while investigation is ongoing. The employee almost always retains the salary during the investigation period in anticipation of more long-term measures. What prompts a suspension can, for example, be suspicion of drug abuse or committed crimes.
• If it appears that the mistake was made as a result of ill health, the employee needs to be offered contact with occupational health care.
• If an event is repeated, the employer can call for a corrective conversation. Then often more people from the employer participate and the employee can bring support from, for example, a union representative. All conversations are documented and stored in the personnel file.
• Relocation can be a measure. It must not be used as punishment or with the intention of getting an employee to quit. In a care unit, it may become relevant if there is someone living there who harbors special resentment towards the employee or if the work group does not function.
• Warning or written warning is a way to indicate that the employer takes the event seriously. Repeated warnings can be grounds for dismissal. Salary deductions may be an option.
• Crimes should always be reported to the police.

Misconduct can be about work refusal, recurring late arrival, unauthorized absence, drunkenness in service, cooperation difficulties, poor work performance, criminal acts, disloyal action such as supporting competing activities, consequences following from illness or abuse.

Reasonable grounds for dismissal can be personal circumstances such as unauthorized absence, work refusal, misconduct or similar. It also applies to misconduct due to drug abuse, such as coming to work under the influence of drugs or not completely recovered. On the other hand, illness is usually not a valid ground for dismissal. Doctors determine whether drug abuse is considered a disease. If the disease leads to the employee neglecting his work and no longer performing work of any significance, there may still be a valid reason.

The employer has a far-reaching responsibility to adapt the work, provide the opportunity for rehabilitation and to try the possibility of relocation. For employees with a probationary period, the employment can be terminated at short notice.

The Patient Safety Act stipulates that if a healthcare provider believes there is reasonable reason to fear that a person, who is licensed for a profession in healthcare and who is active or has been active with the healthcare provider, may pose a danger to patient safety, it must be reported as soon as possible to IVO.
IVO investigates licensed healthcare personnel whose professional practice can be questioned from a patient safety perspective or from a confidence perspective. The reasons for the review may be incompetence, unsuitability, criminality, illness or abuse of alcohol, narcotics or other drugs.

Reflection - work environment
Care staff:
• Do you find yourself in situations where you are forced to uncomfortable working positions?
• Do you find yourself in situations that are mentally stressful?
• Do you have an open climate in your work group?
• Is there a dialogue about the work environment for example at workplace meetings?
• Is there a balance between responsibility and authority?
• Is there a clear leadership that corrects shortcomings in work methods and operations?
• Do you have good routines that make it "easy to do right"?

Manager, nurse, occupational therapist and physiotherapist:
• Do you have regular reviews of the work environment?
• Have you done a risk analysis of the work environment?
• Have all employees undergone training in transfer technology?
• How is the mental and psychosocial work environment?
• Do you have a way of working that highlights shortcomings in values and treatment?
• Do you have a good dialogue about the work environment issues?
• Do you get support from your management when it comes to developing a good work environment?
• Is there a balance between responsibility and authority?
• Do you have good tools for measuring how the work environment work develops over time?
• Is it clearly stated who has work environment responsibility?
• Do you have a consensus on how different deviations should be handled?

Residents and relatives:
• Do the employees have a good work environment?
• Are the nursing assistants in your unit safe and engaged?
• Does the accommodation seem to have a good working environment?
• Have you seen phenomena that you perceive as misconduct from an employee?
• Have you brought it up with the manager of the operation?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day