detoxic

Buried But Not Dead:
A survey of occupational illness and injury incurred by
nurses in the Victorian health service industry


Author: Elizabeth Langford, RN, RM, BN, Grad. Dip. (Adv. Nsg.)

Australian Nursing Federation (Victorian Branch) Injured Nurses’ Support Group

In memory of Halina Zofia Testro, 1952-1997,
Member of the Injured Nurses’ Support Group

Copyright © 1997 Australian Nursing Federation (Victorian Branch).
(Reprinted by WING-USA with gracious permission)

Draft copy of the original publication 1997.  Revision in progress and to be posted soon.

 


TABLE OF CONTENTS

Page
 

1.0 ABSTRACT........................................................................................................................1

2.0 PILOT QUESTIONNAIRE..................................................................................................2

3.0 THE QUESTIONNAIRE......................................................................................................2

4.0 INTRODUCTION................................................................................................................ 3

5.0 SURVEY OBJECTIVES................................................................................................... 6

5.1 Specific aims..................................................................................................................... 6

6.0 DISCUSSION ................................................................................................................... 7

6.1 The disposable nurse....................................................................................................... 7

6.2 The financial costs............................................................................................................ 8

6.3 Profiles of injured nurses and work design.................................................................... 8

6.4 The treatment of the injured nurse in the workplace...................................................... 9

6.5 Types of injuries/illnesses sustained in the workplace................................................. 9

6.6 The ongoing effects of injuries/illnesses...................................................................... 10

6.7 Types of treatments used.............................................................................................. 10

6.8 The effect of injury on work and the financial costs..................................................... 10

6.9 Worker’s compensation and medical assessment.................................................... 11

6.10 The medical profession in worker’s compensation................................................. 12

6.11 Insurance agents......................................................................................................... 13

6.12 Rehabilitation............................................................................................................... 13

6.13 The future ..................................................................................................................... 14

7.0 CONCLUSIONS............................................................................................................ 15

8.0 RECOMMENDATIONS................................................................................................ 16

8.1 To the ANF (Victorian Branch).................................................................................... 16

8.2 Government................................................................................................................... 17

8.3 The WorkCover Authority............................................................................................ 18

8.4 Employers..................................................................................................................... 19

8.5 Nurses........................................................................................................................... 20

9.0 LIMITATIONS OF THE STUDY.................................................................................. 21

10.0 ACKNOWLEDGMENTS.......................................................................................... 22

11.0 REFERENCES......................................................................................................... 23

APPENDIX A PROFILE INFORMATION AND NURSES’ COMMENTS

 

 

 

 

 

 

 

1.0 ABSTRACT

This study was undertaken to identify the types of illnesses and injuries nurses sustain in the course of their work, and how they are dealt with by the various agencies they come into contact with once injured. These agencies include insurers and their medical examiners, rehabilitation providers, treatment providers, and the nurse’s employers. The study was also aimed at examining

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the effect of the injuries/illnesses on their long term health and how they perceived their futures in relation to work and receiving incomes. Also examined were the types of treatment for their injuries/illnesses and the effectiveness of these treatments.

A self-administered questionnaire was inserted into the middle pages of a Victorian only news section supplement to the Australian Nurses Journal in November 1996. With the invitation to any work injured/ill nurse to fill out the form and add comments if desired. The information was coded and presented in tables and graphs, and relevant comments presented. The most common reported injuries were back injuries (70%), with the lumbar/sacral region being the most affected (73%) part. The type of injury most often sustained in the lumbar/sacral region being intervertebral disc bulges and prolapses (61%). Of the nurses reporting work related illness 61% stated they had psychological stress type illnesses. The effect of the injuries/illness sustained by the nurses were long term with 92% still effected at the time of the report, and this had a detrimental effect on their abilities to sustain employment. Only 48% were working the same hours as prior to their injury/illness, and 46% stated they were receiving less in the form of wages.

The agencies injured/ill nurses came into contact with left a lot to be desired in the handling of the issues evolving from injuries and illnesses sustained. In particular the insurance agencies and employers need to reassess and reform the manner in which they deal with nurses. Forty seven percent of the respondents stated that they were unhappy with the insurers, and 34% thought the insurer’s examining doctors were not competent and professional and 21% experienced a mixture of satisfactory and unsatisfactory experiences. Thirty nine percent of the respondents thought they had been treated unfairly by their employers. A major overhaul of the whole health care industry system is needed to make the workplace for nurses a safe one. Nurses still have the greatest injury rate in the female work force. Along with the necessary occupational health and safety reforms, systems need to be implemented to deal with injured nurses in a humane and dignified manner.

2.0 PILOT QUESTIONNAIRE

The pilot questionnaire was presented to a meeting of 10 injured nurses who examined it and were satisfied with its structure. There was one amendment made prior to printing for distribution in the Australian Nurses Journal. This amendment was a section for information about union services to injured members. 3.0 THE QUESTIONNAIRE The survey form (Appendix­B) was sent out through the Australian Nursing Federation’s journal (“The ANJ”) in November, 1996. This journal contains a special insertion paper of news relevant to each state in Australia called “On the Record”. It was in this insertion (“On the Record”) that the questionnaire was presented. The form consisted of four pages which were situated in the centre of the insertion. The survey form included an invitation to any work injured/ill nurse to participate. An outline of why the survey was being performed was included. This consisted of an explanation that the ANF and the Injured Nurses Support Group were wanting the information to target areas of deficit in occupational health and safety in the workplace, rehabilitation, and compensation. Also included on the form was an optional section for the respondent to include their name, address, and phone number if they wanted to be contacted about the Injured Nurses Support Group (INSG). Phone numbers of the INSG information coordinators were also included if assistance was required.

The survey form had nine sections:

Section 1. Profile material (Age, gender, etc).

Section 2. Injury information (Injury year, reporting, etc).

Section 3. Condition (Type of injury, trigger, treatment).

Section 4. Impact on work.

Section 5. The union (ANF).

Section 6. Financial situation.

Section 7. Worker’s compensation system.

Section 8. Rehabilitation.

Section 9. The future.

The respondents were also invited to add any other information about their situation if they desired.

The completed survey forms were returned to a returning officer (occupational health and safety) at the Australian Nursing Federation, Victorian Branch.

4.0 INTRODUCTION

The Nurse: “She is a professional Rescuer who works in an institution that exploits her and pushes her to her physical limits. Initially her motivation to help others comes from caring, but caring soon becomes oppressive to her”. “Ironically, she ends up having to spend a lot of time in the hospital when she is older because of how she has been forced to exploit her body in the service of saving other people’s bodies. She may have injured her back saving a patient from a fall and consumed too many “uppers” to keep going during the day and too many “downers” and alcohol to cool out at night.” (Steiner, 1979).

When I used the above quote in a paper submitted as an undergraduate at a university it came back with the comment scrawled across it, that it was lazy American populist psychology. I was angered by this as the statistics at a local, national, and international level, certainly demonstrate Steiner’s point. The comment by the academic who marked my paper only served to highlight the denial in the health industry of the huge problems nurses face by exploitative institutional and government regimes.

Germain Greer (1972) stated “That nurses can be victimised by the essentialness of their work into accepting a shameful remuneration is an indictment of our society which is daring them to abandon the sick and dying, knowing they will not do it.” Nurses did have to strike for 60 days in Victoria in 1986, in order to obtain better wages and conditions. All sensible negotiations proved fruitless with governments of all political persuasions over the years so the extreme action had to be taken. The wage situation has improved slightly since Greer’s comments.

However the gains made to the physical conditions nurses work under has deteriorated since the strike with cutbacks in Victoria at both state and federal levels, forcing nurses to have to deal with heavier workloads and less staff. Early discharge of patients creates the situation whereby nurses are having to deal with a constantly high level of highly dependent patients requiring intense physical, intellectual, and emotional input, which is the breeding ground for work related illness, and injury in nurses.

The injury rates are extremely high in nursing. Unfortunately the dubious honour of nurses having the highest injury rate in the female work force, has remained unchanged since records were kept when WorkCare came into being in Victoria. The WorkCover Authorities statistics for the period of 1994/95 demonstrated that there were 1,028 new injuries accepted for compensation. For the period 1995/96 they demonstrated 1,060 new claims accepted for compensation. These are only the nurses who managed to obtain compensation, who are the “tip of the iceberg” as throughout this study a recurrent theme emerged that nurses were too afraid to claim worker’s compensation in case they lost their jobs, or would not be employed elsewhere.

Working as an information coordinator with the Injured Nurses Support Group with Australian Nursing Federation’s Victorian branch, I am aware of a constant stream of information regarding nurses with injuries and the problems they endure in relation to injury management, treatment, rehabilitation, medico-legal issues, and workplace return to work programs to name a few. It became apparent that the anecdotal information received about nurses injury issues needed to be examined in an in depth manner in order for them to be taken seriously, and programs implemented to bring about change in the health industry. The first part of this process therefore was a survey of work related injury/illness experiences. After the issues have been identified, it is then planned to address the problems with programs aimed at government, health institutes, universities, and insurers. These strategies will be nursing specific in relation to prevention, rehabilitation, injury management, and return to work programs which in their present form are proving to be very inadequate. The results of this survey are the first step in this direction.

The majority of nurses in this survey displayed regret at losing their careers, and the lack of support they received in finding appropriate work for which they had been educated. This problem occurred in all age groupings, however there was a disturbing number of young respondents in their twenties who stated they had just lost three years of their lives, have useless degrees, plus they are now injured for life. However injury rates peak in the forty year old age group. As was pointed out to me by a radio interviewer, in other career paths people in their forties are regarded to be at their peak and are justly rewarded for their valuable knowledge base. In nursing it seems the rewards may be injury.

High on the list of distressing phenomena injured nurses experience is loss of economic security and problems with the worker’s compensation system insurers, including insurer’s examining doctors. Clearly there is an urgent need to review these systems.

Nurses are an interesting group to study because not only do they have the highest rate of injuries in the female work force in Victoria, they also have a sophisticated knowledge of their medical conditions because of their education. They are also aware of what constitutes adequate care by the medical profession, which makes their observations of the insurer’s doctors behaviour towards them more acute. Nurses would normally be working alongside of some of the doctors which adds to the sense of betrayal some nurses experience when they are treated in an inhuman way by some in the worker’s compensation system. Other occupational groups when injured would not have the medical knowledge nurses had, and I was constantly made aware of the disadvantage other occupational groups would be enduring if nurses were being so negatively impacted upon. At least with the nurses level of education they would probably be better able to assist themselves through the maze of medico-legal jargon. However their distress is just as extreme and suicides have been reported.

The idea of this survey was to quantify statements often made by injured nurses, and often relegated as being “just anecdotal”, which often is another way of denying a problem exists. Respondents were also asked to make comments if they desired, this was very thought provoking. Some comments were included in the text of this report. There was so much information obtained that another study could be made at a later date. For the time being though this examination supplies enough information to start the reform processes so urgently needed in the workplace.

5.0 SURVEY OBJECTIVES

The survey’s primary objectives are to identify the types of injuries/illnesses nurses sustain in the course of their work, and how they are dealt with by the

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various agencies and the workplace after their injury. With this information it is then hoped that suitable programs can then be designed with the various involved bodies in the worker’s compensation system. These programs would address rehabilitation, injury management, accident prevention programs, and medico-legal issues.

5.1 Specific aims

1. To identify the groups of nurses most prone to injuries and illness; the areas of the industry which precipitate the injury/illness; the types of triggers which cause the injury/illness.

2. To ascertain the types of treatment for the injuries or illnesses these nurses had, and how effective the various forms of treatment were.

3. To find out how their injuries/illness affected their ability to work, and if they could return to the same type of work they were in prior to their injury/illness.

4. To find out how they were treated by the worker’s compensation system: including insurers, doctors, employers, supervisors, colleagues, and the union.

5. To assess their financial status after the injury or illness.

6. To find out the type of rehabilitation services they were offered/involved in and the effectiveness of these services.

7. To find out how these nurses saw their futures, including the status of their injuries/illness and how their recoveries could be assisted.

6.0 DISCUSSION

It is clear from this study and others from within Australia and overseas, that nursing whilst being a health profession is not healthy for the care givers themselves. There appears to be a huge dichotomy between good occupational health and safety conditions in nursing, and what is actually happening at the point of nursing service delivery.

There are many reasons for this, however the overriding issues are ones of attitude. The view that the health industry is automatically a healthy workplace leads to inaction in improving the design of hospitals, purchasing of equipment and work processes. This is exacerbated by poor staffing levels, and lack of funding to allow adequate staffing levels to patient numbers. The mechanical lifting and transfer machines will not be effective if (a)­there are not enough staff to use them, and (b)­the nurses themselves do not see the value of using them. Without these fundamental elements any other occupational health and safety (OH&S) program is doomed to failure.

In order for the necessary reforms to occur attitudes throughout governments, health institution administrations, nurses and their organisations, and the general community, have to be changed. The primary erroneous attitude to be changed is that high rates of injury are normal and acceptable. Once this attitude change has been adopted in a real way, then effective OH&S measures can be adopted.

6.1 The disposable nurse

Nurses at this point in time are still seen like disposable rubber gloves, that is expendable. It is more cost efficient to governments and institutions to dispose of injured nurses and replace them with the next batch of fresh, young, bodies until such time that they “clap out” too. Nurses take action for parity in wages, but ironically when it comes to OH&S issues, and in particular staffing levels they fall way behind. Maybe the community has to be warned that nursing is unhealthy to work in, so don't encourage your children to enter these university courses. Perhaps when the community is threatened with a shortage of nurses they may then pressure governments to really address the OH&S issues. Other care giving groups will also have to be warned of these problems, as now with governments trying to find ways of providing bedside services at cheaper costs than nurses, relatively untrained staff such as permanent care assistants are being used and incurring similar injuries.

6.2 The financial costs

Unfortunately the problem is not uniquely Australian, in a recent study undertaken in the United Kingdom of 4,000 nurses. It was found that one in four had suffered a back injury at work and required time off (Seccome and Ball,1992). A Royal College of Nursing study (1996) estimated that the loss of trained nurses due to back injury costs the National Health Service (NHS) an estimated £50 million per year.

No similar studies have been carried out in Victoria of the cost to the health industry, of the loss of registered nurses.

In Victoria in the 1995/1996 period the cost of claims in the health industry was $48.8 million dollars. Nurses account for 54% of all these claims (VWA, 1996). Of course these statistics do not factor in the physical, emotional, and social costs.

6.3 Profiles of injured nurses and work design

Of the 170 respondents in this survey the age group in which injuries peaked most was in the 40 year old group (34%). However the thirty and fifty year old age categories had significantly high injury rates. The final reporting of these injuries were in many cases probably the last event in a long line of stresses precipitating the current reported injury. Stubbs and colleagues (1984) were of the opinion that cumulative stresses particularly in the back,of lifting and other manual handling tasks over a long period of time predisposed the nurse to the final injury.

Perhaps it is time to look at how nurses should be expected to deliver high powered and heavy physical care. Issues of design of workplaces , equipment, and work processes need to be addressed. Restructuring the industry to allow nurses who have worked for long periods at the bedside to work in light work areas, or modifying bedside work should be an option To often the excuse that it is not economically viable is used to negate any change.

This would seem to be a ridiculous argument given the WorkCover Authorities statistics. Even when a nurse is injured, and a return to work (RTW) plan is devised for her/him, the pressures to return to the pre injury work are such that she/he is further injured or just gives up altogether. Nurses are valued only for their physical capacity not their intellectual labour and emotional support roles. These skills are ignored.

6.4 The treatment of the injured nurse in the workplace

The respondents in this survey illustrated the undervaluing by employers in this survey by the fact that 39% stated they had been unfairly treated by their employer, and 35% stating they were treated unfairly by their supervisors. The respondents reported that treatment by colleagues was better with 17% stating colleagues had treated them unfairly, however comments made would suggest their are real problems in this area too. An often made comment was that they felt colleagues resented the extra load they had to carry because of the presence of the injured worker. In the context of the workloads without extra staff being made available to cover for the work the injured worker could not do this would seem reasonable response. This harks back to the employer not making available resources to cover for injuries.

6.5 Types of injuries/illnesses sustained in the workplace

By far the most common forms of injuries reported by the respondents were back injuries. These accounted for 70% of the total, with the lumbar region being the most common area affected (73% of all back injuries). The most common type of back injuries were disc problems (bulges and prolapses) at 57%. This is at odds with the VWA statistics which state that sprains were the main type of back injury reported. The fact that the respondents are nurses with sophisticated medical knowledge helps to counter the VWA information.

A disc injury is likely to have more repercussions than a sprain (although sprains and muscle damage often lead to greater problems also). A disc injury can have serious neurological repercussions on nerve roots. It may also lead to spinal cord compression.

Of the 70% (127) of respondents, 15 required surgery. The type of spinal surgery required was fusion (33%), and laminectomy (17%).

Next on the injury list were shoulder/arm Injuries (9%). The type of injuries most common in this group were muscle and ligament damage. Many reporting rotator cuff problems which are very disabling and take a considerable time to heal. See graphs and tables for other injuries and discussions.

6.6 The ongoing effects of injuries/illnesses

Only a small proportion of the sample reported that they had occupational illnesses. Of the respondents who reported work related illness, 61% had stress type illness. In this group a constant theme came through of shortages of staff and work overload as a precipitator. Another causal factor in this group was poor management practices and workplace bullying.

Chemical exposure was the next precipitator of work related illness (11%). The main causal agent being glutaraldehyde. These illnesses were reported occurring in operating theatre settings. The types of chemical illness were respiratory and skin sensitivities.

Workplace acquired infections accounted for 11% of those in the illness categories. See tables and graphs for details.

Of the 170 respondents who had a workplace injury/illness 92% stated they where still affected at the time of the survey. This demonstrates the seriousness of the problems as some acquired the illness/injury as far back as the 1970's. Back injuries are particularly intractable to effective treatment. 45% of the respondents reported that their condition had improved since diagnosis; 22% stated they were the same; 33% reported deterioration in their condition.

6.7 Types of treatments used

The most frequently used treatment methods were physiotherapy (29%), medication (13%). However most respondents used a combination of various therapies.

6.8 The effect of injury on work and the financial costs

In this survey 96% of the sample required time off work. Of this percentage 41% required months, 36% weeks, and 11% had been off work for years. Only 48% were working the same hours on return to work, and only 46% were working in their pre injury work situation. This demonstrates the serious nature of the illness/injuries sustained.

This represents a financial and intellectual drain to the health institutions, but also to the nurses themselves. Only 25% stated they were financially unaffected by the injury. At the time of this survey 42% stated they were back at work on full . For 46% of nurses with injuries there had been long term financial detriment.. The fall in wages has serious repercussions on the material well being of the affected and their families. Some reporting relationship breakdowns and serious strains; bankruptcies; having to sell homes; buying from op shops and not being able to afford the basic necessities of life; serious despair and suicidal thoughts.

Worker's compensation in Victoria pays a proportion of pre injury average weekly earnings according to the category of the injury. It does not take into account any penalty rates or allowances. Therefore the true rate of pay for a person receiving benefits is a good deal below the proportion that the VWA states is being paid. For example someone who is receiving 60% of pre injury average weekly earnings would, in fact, be receiving more like 40% of their previous salary. The majority of respondents in this survey were on 60% of their pre injury average weekly earnings (piawe); (30% of the sample); whilst 20% were receiving 90% of piawe and 8% were receiving 95% piawe.

6.9 Workers’ Compensation and medical assessment

There have been major changes to the WorkCover system in Victoria which disadvantaged many people. If a worker does not have a serious injury, that is 30% whole person impairment (under the American Medical Associations guidelines 2nd edition), they do not qualify for benefits after two years.

The guidelines are not only unfair but they are also outdated by five editions, and they are not meant to be used in the manner the VWA uses them. They do not include pain as an impairment factor either, whereas later editions do. One could be cynical and suggest that the later volumes are not used because if pain was included in assessment more people would be eligible for ongoing benefits.

In December 1996 the government passed an amendment to the Act which changed the definition of “serious injury”. The adjustment was to delete the effects of so called ‘secondary psychological impairment’ when evaluating the injury. If an injured person becomes depressed on realising the full extent of the injury, this is discounted. It is a totally ridiculous situation when it is considered that one of nature’s protective mechanisms for injured people in shock is to be oblivious or to deny the true situation in order to concentrate on the immediate task of physical healing. The long term problems or effects are integral to the injury even though they may not be manifested until later.

To demonstrate how difficult it is to qualify for a “serious injury” classification one only has to look at amputations. A below the knee amputee with functional stump only qualifies for 28% whole person impairment. An intervertebral disc lesion disc lesion with residuals gives an impairment rating of only 5%. A worker with asbestosis, a crippling and potentially fatal disease, who can not walk 100 metres on the level without breathlessness, will only have a 25% physical impairment. The inevitable psychological impact of having a fatal disease can not be counted in deciding whether asbestosis is “serious”.

6.10 The medical profession in workers’ compensation

The following is an example of just how open to bias the WorkCover system of assessment is. The respondent had the following experience in 1993 during the changeover to WorkCover, and all people on benefits had to be reassessed to see if they would still qualify under the new guidelines for benefits. The respondent had previously been seen by the doctor working for an insurance company and had thought that although he had worked for the insurance company none the less he gave a reasonable report. When the respondent asked this doctor directly to undertake an assessment to present as evidence for her defence in the conciliation process, the doctor refused. When the respondent later discussed this with other doctors they stated “it would have been a conflict of interest” for the examining doctor. This seems to be a weak response, as if the doctor was reporting on purely clinical grounds he should have come to the same conclusion no matter who was paying for examination (i.e.­the insurer or the recipient)..

This exemplifies the adversarial nature of the section 112 medical examination process. One extremely disturbing phenomenon was the number of respondents to the survey who reported that their symptoms had been made worse or their injuries had been exacerbated by s112 examinations. This included one injured nurse who had been hospitalised.

Respondents in this survey were very critical of the WorkCover medical assessment system with only 46% stating the examining doctors behaving in a competent, caring, and professional way. Thirty six percent thought they were not competent and a further 21% had mixed experiences. Overall, 57 % of respondents had a problem with at least one of the examiners to whom they had been sent by insurers. The respondents were discerning, and even though some had undergone many examinations they could still say they were satisfied. They were not just malcontents, unhappy with the whole system, as in other parts of the assessments of employers etc some were satisfied. Obviously the medical profession needs to examine what is happening in the insurance medical assessment industry. The comments of the respondents about doctors included with the result section makes very interesting reading. It is particularly poignant when considering that nurses are colleagues of doctors in the health industry.

6.11 Insurance agents

The respondents were extremely critical of the insurance agents handling the WorkCover claims, with 60% of those who answered the question being unhappy with the treatment by the insurance companies.

This is particularly significant when it is recognised that the primary dissatisfaction level with all other players in the system is around 40%. Insurers were reported as treating workers unfairly far more often than employers, supervisors colleagues.

Employers 61%saw as fair 39% saw as unfair

Supervisors 64% saw as fair 35% saw as unfair

Colleagues 81% saw as fair 18% saw as unfair

Union 90% saw as fair 19% saw as unfair

Insurers 40% saw as fair 60% saw as unfair

The comments in this section also makes very interesting reading as they range from “so far continual harassment by insurer” to “totally disgusted with the whole problem”. Obviously a great deal of work is required to rectify the defects in the worker's compensation system.

6.12 Rehabilitation

Often nurses are not made aware that rehabilitation services are available. In this survey only 42% of the respondents stated that they had contact with an independent occupational rehabilitation provider despite long periods off work. A further 5% of our respondents sought rehabilitation but were refused, and 15% of those who received any rehabilitation had to initiate it themselves.

Of those who did access rehabilitation, 75% stated that they were satisfied with the service.

There is a problem with provision of rehabilitation services, in that the WorkCover authority is putting very little into resource for this service. The amount spent on rehabilitation for nurses in the health industry would average only $52 per nurse, despite the fact that many nurses require retraining as they will not be able to return to bedside nursing. It is little wonder then that the types of rehabilitation programs offered are often inadequate. See comments with graphs made by injured.

There was some evidence in this survey that some of the respondents were confused as to what type of service they were receiving. That is, was it independent of the health institution they were working in. Those who received "in house" rehabilitation services were often critical of the service, because those employed to assist the injured worker were “too close" to the administrators in the institution, and frequently felt confidentiality was not maintained, and that the respondent’s welfare was not the prime reason for the service.

6.13 The future

The majority of respondents were very unsure about their future. Only 11% thought their pre-injury/illness condition had been reinstated, whilst 5% thought they would reach their pre-injury/illness state. An overwhelming (63% thought that their injury/illness would improve, however they would always have a problem affecting their ability to work, 39% thought they would have to change their career due to their condition; and 14% thought they would not be able to work at all in the future.

The comments made by respondents exhibited a great deal of fear about their prospects for re employment and financial security. Many feared they would be sacked once their rehabilitation programs had ceased, or when the next round of redundancies were pronounced in their health institution. There was a great deal of disappointment expressed by many at losing their careers they had valued and enjoyed. Some of the younger respondents were very disappointed at having wasted so much time and money on university education only to lose it to injury/illness at the very beginning of their working lives.

Reading the comments, one cannot help wonder whether students should be advised that nursing is an unsafe occupation, and maybe their money and time would be better spent participating in another course. If this warning was given maybe the academics would take OH&S more seriously in their courses at the universities. They may also become more active in fighting for better staffing levels in the health services when their own jobs are threatened, because there are not enough students to fill their courses at the universities.

When several universities were contacted to see if they would contribute to the making of a OH&S film there was little response, and especially not financial offers, although some thought the proposal was a good idea. Often the films used in universities to teach students about OH&S issues are outdated, and they do not look at the broader structural issues which influence OH&S in the various health settings, such as the design of the facilities, equipment and work processes. These problems are exacerbated by lack of government funding and lack of staff.

7.0 CONCLUSIONS

It is clear from this study that very little has improved for nurses in relation to Injury rate & and occupational health and safety (OH&S) over the years. It is significant to note that despite the overall decreases in WorkCover claims and the reductions in nurses employed in the health industry, the claims in the health industry among nurses are rising. This suggests that the pressures in the health system are increasing the rates of injury among nurses.

Much "lip service” is given to improvements, however the core Issues of lack of adequate staffing are not dealt with. The old "window dressing” issues about correct lifting technique and manual handling aide are the prime focus in health institutions because they are the least expensive to provide. These items also focus on the nurse as the cause of the injury if she/he is not using the equipment or lifting technique. Never mind the fact that in many instances there is not enough staff to make use of such techniques or equipment practicable. The nurse is often used as the scapegoat for her injury. This allows the government and the employers to ignore the structural problems. It is necessary to address problems of funding and staffing levels, not just blame those who are injured in unsafe conditions.

This is not to absolve nurses from their responsibilities about their own OH&S issues. A change of attitude is needed on their part in order to force employers and governments to provide the prerequisites for good OH&S In the various workplaces. Unless these changes are brought about, the high injury rates and subsequent misery will continue, and under these conditions who would want to enter the nursing profession? How many can honestly say they want to see their offspring, relatives, and friends enter such an unsafe profession?

One only has to look at the statistics in this survey to show the misery incurred by the injured/ill and the long term effects. Not only do the injured/ill have the pain of the injury but also the ongoing problems with employers. Once a nurse is injured, employers, in many cases, cannot wait to get rid of him/her. They need healthy physical specimens to carry on in often exploitative working conditions.

The denigration of nurses to just units of work are compounded by the worker's compensation system, with its inappropriate and outdated medical assessment tool used in some cases by doctors with very biased political agendas. Assessments should be based on sound clinical observations and technique however, in many instances this is not the case. In turn this adds to the cost of the worker’s compensation because many more assessments are needed to resolve disputes between insurers and claimants.

The poverty which is imposed on injured workers, the antagonistic system which treats them as though they were criminals and the lack of suitable alternative duties make it clear that the worker’s compensation system in Victoria needs a major overhaul.

Rehabilitation services for injured nurses are also in desperate need of revision. They clearly do not serve nurses or the community well. Given the serious and chronic nature of the injuries nurses sustain and the need for long term rehabilitation programs that are not just about clerical retraining. It would be appropriate for the health industry to negotiate with nurses, rehabilitation providers, worker's compensation systems, and the government to develop a cohesive, integrated, and meaningful rehabilitation package which addresses the special issues faced by injured nurses including the fact that nurses are required to have a university level education.

Overwhelmingly in this survey the respondents were not optimistic about their return to full health or security about their future employment prospects. Sixty four percent thought they would improve but always have a problem affecting their ability to work. This obviously is not good enough, drastic changes have to be made.

Nurses in the future will not tolerate this, and this will flow through to the general community because there will not be enough nurses to service the communities health needs. General community education about the problems nurses experience will filter through and the intake rates to nursing courses will be depleted. It is therefore to everyone's benefit to bring about real and sustained change to OH&S practices and rehabilitation in nursing immediately.

8.0 RECOMMENDATIONS

8.1 To the ANF (Victorian Branch)

• That education programs about nurses rights to safe workplaces be stepped up. Including an emphasis on the roles employers need to play in providing safe work environments, sufficient well designed equipment and adequate staffing levels.

• That awareness is raised about the issues involved with injuries, rehabilitation return to work programs, and that the OH&S issues be as deserving of industrial action as wage conditions. Although the ANF (Victorian branch) has made large inroads to improving the situation in recent years, there is still a great deal of work to be done.

• That union members be made aware that ANF Top Up insurance is available if they are members. In this survey sample only 11% had received this benefit. At the time of the survey, it was a new entitlement of members which may not have been available to all respondents at the time of injury.

• The ANF work with the Health and Safety Division of the Victorian WorkCover Authority and health industry employers in the development of injury preventative strategies, and the development of centralised monitoring systems. Effective programs need to be put in place to decrease injury in workplaces with poor records.

It in ironic that although nurses have the highest injury rate in the female work force, there are no statewide television advertisements relating to the problems in nursing. There are television advertisements about machinery and building, and a few other occupational areas, but not nursing. Apparently there is a country regional advertisement, but nothing for the rest of the state. This is an area where the union could work directly with the WorkCover Authority in producing such a program.

• A program be undertaken to educate nurses to their rights and responsibilities about worker's compensation. Although the various compensating bodies are supposed to supply this information, rarely is it given freely to those needing it.

Nurses should be aware prior to injury so that they know how to go about managing the many issues that occur when injured and therefore decrease stress at the time of injury (if it occurs).

8.2 Government

• Adequate funding be made available to health service centres so as to develop and maintain safe workplaces, sufficient well designed equipment and work processes including sufficient patient/staff ratios. Not only for patient welfare, but that of nurses also.

• That systems of monitoring all health service delivery centres to make sure that these are maintained, and that injury rates are monitored and publicised to staff on a statewide basis (not just “in house”).

• A system of incentives and penalties be developed based on occupational health and safety conditions, not just claims performance. This information should be freely available throughout the heath industry, not just in the institutions concerned.

Self-regulation in most cases does not work. This is why a statewide system of annual reports advertising poor performers would assist the changes in work practices (the embarrassment factor).

• That statewide standards and monitoring are set with the full involvement of nurses, unions, government, and employers.

8.3 The WorkCover Authority

• The WorkCover system of benefits should be overhauled to provide sufficient

levels of payment to prevent people being forced into poverty.

• That the medical assessment system be reviewed the difference between serious injury and total incapacity (which occurs at 26 weeks) should be removed. The AMA Guides to the Evaluation of Permanent Impairment should not be the sole basis of. evaluation of incapacity for work.

• That a new method of obtaining examining doctors for the insurers should be devised. It should be less adversarial in nature than the current system of s 112 examiners. The medical profession should be provided with education programs in dealing with work related injuries, and not just insurance company "in house" education programs. Injured workers should be involved in developing the education programs.

• That an official complaints system be put in place so that insurers, medical practitioners and employers who are found to be treating injured/ill workers in a unprofessional way can be dealt with. This should be in the form of a WorkCover Ombudsman who has the authority deal with complaints. This role can not be played by the Victorian WorkCover Authority.

• That the WorkCover authority put into place rehabilitation programs for nurses that take into account the fact that nurses will often need lengthy re-education programs, not just short courses in clerical and office administration type programs. Nurses are now educated in university, and because of this they will often require re-education at this level so that they can be employed in a field of work equal to their previous level of education. This may take a year or two. The most common type of injury nurses sustain are back injuries which effect their whole body function, and often require a total change of work away from the heavy physical demands of bedside work, therefore appropriate tertiary education is often required (but seldom allowed under the current system).

• Although there is some evidence that some insurers are making efforts to improve attitudes and services to recipients of benefits, there continues to exist a large pool of insurers and their agents treating injured workers very unprofessionally. These providers are causing a great deal of distress to recipients, and the insurance industry needs a great deal more regulation by government agencies. There have been a number of suicides, and deteriorating health in injured/ill workers in all industries due to poor management practices by insurance companies.

Not only is this distressing to the workers involved, but in economic terms it can also be costly because often the disputes which arise when followed through conciliation processes, are found to be In the injured person's favour. The extra medical examinations etc. which could have been avoided with good management practices add to the employer’s costs.

• The WorkCover authority work with unions and nurses to develop injury/illness preventive programs.

8.4 Employers

• That a cultural attitude change be adopted by employers that high injury rates in their nursing staff is not acceptable.

• Reorganisation of work places, equipment and practices so that nurses are not forced into physically inappropriate work. Education about how cumulative injury occurs should be disseminated. It is recognised that cumulative injuries, usually due to manual handling under poor conditions, over long periods of time, are the usual precursor to serious injury. This being the case it would be sensible to reorganise working regimes, including matching jobs to age groups.

If an industry norm, or health and safety code of practice were in place, the acceptance by governments, health delivery centres, and nurses would probably be more easily accepted and accommodated for financially and socially. Therefore lessening injury/illness rates, and the subsequent costs to employers and distress to nurses.

• That employers be made aware of the true cost of their worker’s compensation bill. At present it is easy to forget the ongoing costs of claims because once WorkCover recipients have received benefits for three years they are no longer represented in the employer’s premiums. After the initial three years of increased premium to the employer an industry average applies. This allows a lack of accountability by employers because the costs are hidden in the usual industry average. That is employers can continue to deny that OH&S problems exist because they can “bury” the work injured/ill in a morass of fancy creative accounting. That is they can “bury the injured/ill, but these nurses are not dead”, they are lingering in “nowhere land”.

8.5 Nurses

• That a cultural change in attitude be made about accepting high injury rates. The change required is that it is not acceptable for nurses to be injured in the course of looking after others.

• That nurses accept that their health is as important as that of the people they care for, and that they are entitled to work in a safe environment. That they realise that just because they have a job and receive a wage does not give the employer the right to provide unsafe working conditions. This sounds so obvious, however it is surprising how many nurses do not realise this, and given the uncertain working conditions many are working in, some employers exploit the current economic climate to manipulate many into accepting intolerable working conditions.

• That nurses are made aware that they are not passive recipients of their conditions, that they have rights, and that they must make efforts to maintain safe systems of work practices for themselves, colleagues, and patients.

• That nurses avail themselves of all manual handling facilities available, and continue to educate themselves about safe work practices and use them.

• That nurses educate themselves about their rights and responsibilities when injured.

9.0 LIMITATIONS OF THE STUDY

• The survey was biased mostly towards nurses who were ANF union members. A small number of respondents were not union members.

• There appears to be some confusion in some respondents minds about whether they actually received WorkCover benefits, or if their employer paid from some other form of funding the medical costs for nurses. This is very apparent in the case of nurses who were on benefits for only short periods of time, or if they only required medical costs. The question regarding this should have had more detail to elicit a clearer picture.

• There appears to be some confusion regarding the various types of legal action that were being taken by some respondents. More explanation should have been supplied to clarify this for respondents.

• A clearer picture of the type of worker’s compensation system respondents were on at the time of injury could have been elicited if a specific question regarding this had been asked (e.g.­WorkCare, WorkCover etc.).

• A clearer picture of the types of work respondents had undertaken pre and post injury could have been obtained if the questions about this area had been framed differently.

• The survey form was placed in the middle pages of the Victoria paper supplement of the Australian Nursing Journal. Perhaps a higher response rate could have been obtained if the survey form had been a separate insertion.

• More injury information could have been obtained. For example the levels of impairment as assessed by doctors performing AMA permanent impairment checks, then comparing these with the self reports of respondents.

• Although the survey was about work related illness and injury, there were more reports about injury than illness. Perhaps there should have been more emphasis or explanation so that reports of illness were better documented.

10.0 ACKNOWLEDGMENTS

Anne Amourgis - Final report layout and word processing.

Yvonne Dann - Editing, general assistance.

Guinette Davies - Royal College of Nursing (RCN Brit.) Work Injured Nurses Group Advisor.

Judith Edwards - Information coordinator Injured Nurses Support Group (INSG). General support during research project.

Gwynnyth Evans - WorkCover Project Officer, Trades Hall Council Victoria.

Assistance with questionnaire and editing.

Melinda Goodyear - Research Assistant, who assisted with the statistics software and analysis.

Alec Mead (OAM) - Training and Information Officer, Victorian WorkCover Authority (VWCA). Assistance with WorkCover statistics.

Yvonne Kelley &

Rosemary Mullaly Media and Public Relations Officer ANF Victoria Branch

Belinda Morieson - Secretary Australian Nursing Federation Victorian Branch (ANF). Assistance with survey distribution and funding.

Cathie Rayner - Assistant Media and Public Relations Officer ANF Victoria branch. Layout of questionnaire and results

Jeanette Sdrinis Occupational Health and Safety Officer Australian

Nursing Federation Victorian Branch

Injured nurses - Who participated in the survey.

11.0 REFERENCES

1. American Medical Association's Guides to the Evaluation Permanent Impairment, 2nd Edition, Illinois, 1989.

2. Davies, G.M. Factors Helping or Hindering Nurses Returning to Work Following Injury or Illness/ London, October 1994.

3. Gray, D. Most Addicts at Clinics Are Nurses, The Age Newspaper, Melbourne, 10 November 1996.

4. Greer, G. The Female Eunuch, Paladin, Great Britain, 1972, pp. 128.

5. Royal College of Nursing Hazards of Nursing, Personal Injuries at Work, London, November 1996.

6. Sinclair, W. The Hazards of Hospital Work, Allen and Unwin Australia, 1988.

7. Seccombe, I. and Ball, J. Back Injured Nurses: A Profile of Manpower Studies, 1992.

8. Steiner, C. Scripts People Live, Transactional analysis of Life Scripts, Bantam Books, 1979, pp.222-224.

9. Stubbs, D, and Buckle, P. The Epidemiology of Back Pain in Nurses Nursing 1984; 32:935-38.