Environmental and Occupational Health

Environmental health (WHO, 2017)

• Aspects of human health, including quality of life, determined by physical, chemical, biological, social, and psychosocial factors in the environment.

• The theory and practice of assessing, correcting, controlling, and preventing environmental factors that can adversely affect health of present and future generations.

Examples of each type of environmental factor

• Physical: noise, heat, radiation, housing.

• Chemical: toxins, pollutants, heavy metals.

• Biological: bacteria, viruses, mold, vectors.

• Social/psychosocial: income, stress, social support.

Planetary health

• A newer term, broader than environmental health.

• Reduces health system climate impact (GHG), protects the natural environment through reduced resource use, keeps services running through climate shocks, supports sustainable community development.

Why should nurses care about GHG?

In Canada, health care produces more than 4.5% of greenhouse gas emissions, about equal to aviation.

Nursing and environmental health (Larsson and Butterfield)

• Nurses have restored health through environmental interventions since Nightingale (light, fresh air, cleanliness).

• Involvement diminished as care focused on medical treatments

• current findings require nurses to recapture expertise in environmental health principles.

Environmental health as an 'appendage'

Despite a large share of disease being environmental, it is often viewed as an add-on of occupational health nursing rather than central to nursing's vision of health.

Proximal environmental influences

• Close to the person

• home, neighbourhood and community, and the ambient (immediate surrounding) environment.

Proximal environmental influences: home

• physical conditions and surroundings in your home that directly affect your health.

  • indoor air quality

  • household chemicals

  • waste disposal

  • noise

  • sanitation

Proximal environmental influences: neighborhood

• road safety

• crime and violence

• child labour

• drug abuse

• food security and safety

• nutrition and diet

• drinking water

Proximal environmental influences: ambient

• radiation

• hazardous chemicals

• surface water quality

• air quality

• insect-borne diseases

• waste

Co-benefit (CNA)

People and the environment both benefit from healthy interactions (e.g., being active outdoors).

Global environmental influences: direct pathways

Heat-related illness, extreme temperatures, extreme weather (floods, drought, storms).

Global environmental influences: indirect pathways

Water quality, air pollution, land use change, ecological changes.

Climate change: health outcomes

• Loss of livelihoods

• mental illness

• food- and water-borne infections

• vector-borne diseases

• respiratory and cardiovascular disease

• undernutrition

Combined with social factors (age, gender, health status, income, public health infrastructure, mobility, conflict).

Who is hit hardest by climate change?

• People in low- and middle-income countries

• young children, older people, women

• people with existing conditions or disabilities

• poor and marginalised communities

• Indigenous peoples (less resilience, resources, ability to adapt).

Mitigation vs. adaptation

• Mitigation = reducing or preventing GHG emissions.

• Adaptation = reducing vulnerability to the harmful effects.

How climate change has affected Canadians

• Soil and coastline erosion, ozone depletion, warmer seasons

• longer vector-borne disease seasons (West Nile, Lyme)

• more water-borne disease from rain

• stronger thunderstorms, floods, heat waves.

Effects: heat stress, water/vector-borne disease, mental health problems, heart and lung disorders, death.

Precautionary principle (Rio Declaration, Principle 15)

• Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason to postpone cost-effective measures to prevent environmental degradation.

• Nurses can apply it through advocacy, health promotion, education, and working with industry, occupational safety, and urban planning.

Precautionary principle example

Banning a food additive shown to cause cancer in lab rats even though it hasn't been tested in humans.

European Commission: 3 conditions to invoke the principle

1) Identification of potentially harmful effects

2) evaluation of the scientific data available

3) extent of scientific uncertainty

= We identify the possible harm, examine the evidence, and determine how much uncertainty remains before deciding whether precautionary action is needed. We don't necessarily have to wait for complete scientific certainty to act.

European Commission: risk management principles

• Proportionality

• non-discriminatory application

• consistency with similar measures

• examination of benefits and costs of action or inaction

• measures subject to review

Weighting of public health vs. economy (EC)

Evaluation of risks and benefits must give public health a greater weighting than the economy.

Why nurses are uniquely qualified to advise on environmental health

• Assessment skills to identify hazards

• scientific background to inform interventions

• communication skills to explain exposures and risk reduction

• valuable contributors to interdisciplinary research.

Other reasons nurses should know environmental health

• Emergency planning (disasters increasing in frequency/intensity)

• commitment to social justice (CNA Code of Ethics).

CNA (2017) roles: assessing and educating

• Assess and communicate risks of environmental hazards to individuals, families, communities

• educate people and communities about environmental health issues.

CNA (2017) roles: leadership and collaboration

Show personal leadership in practices that reduce harm to the environment; collaborate with interdisciplinary colleagues to identify and reduce environmental risks in practice settings.

CNA (2017) roles: advocacy, research, environments

• Advocate for policies that prevent exposure and promote sustainability

• produce nursing science and interdisciplinary research

• promote natural and built environments that support health.

ICN (2018) role: waste and committees

• Advocate for effective waste management policies (reduce healthcare waste, correct handling)

• actively engage in environmental health committees and policy-making (worker safety, regulation of the healthcare environment).

ICN (2018) role: empower lifestyle changes

• Empower individuals, families, communities to make healthy lifestyle choices and reduce GHG:

  • active transportation (biking), green energy, plant-based diet, sustainable anti-consumerist lifestyle.

ICN (2018) role: other sectors and resilience

• Engage with other sectors to lower GHG (urban redesign, public transit, cookstoves).

• Work with communities to build resilience, going beyond reactivity to address underlying vulnerabilities.

Resilience strategies (ICN)

1. Assess — Who is vulnerable?

2. Prepare — What could happen?

3. Include — Whose voices are missing?

4. Expand — What has worked that we can scale up?

5. Evaluate — Did it work, and how can we improve?

Environmental impacts on health

• Smog leads to cardiovascular/respiratory disease

• children's lead exposure from paint reduces IQ

• prenatal exposures include secondhand smoke

• heat waves are risky for elderly people.

Environmental impacts on health for women with new born

• may choose to bottle feed due to contaminants in breast milk

  • mercury in fish; indoor air quality and asthma; viruses, respiratory disease.

Why are children at higher risk from environmental exposures?

• Higher needs for oxygen and nutrients

  • They may take in more of a harmful substance relative to their size.

• they don't control their own exposures before and after birth (CNA reading).

  • exposed to harmful substances through the pregnant person's body

Canadian environmental legislation: Health Canada

• Hazardous Products Act

• Food and Drugs Act

• Pest Control Products Act.

Canadian Environmental Protection Act, 1999 (CEPA)

• Prevents pollution and protects the environment and human health

• sets rules for preventing and regulating toxic substances and managing pollution

• includes impact assessments for environment and human health.

Who is responsible for environmental health legislation?

Many federal and provincial government agencies share responsibility.

WorkSafeBC right 1: right to know about hazards

The hazards on the job (safe work procedures), how they can affect you, and how they are controlled or risk minimized.

WorkSafeBC right 2: right to participate in health and safety

• Receive orientation and special training

• ask questions

• take part in safety activities

• report unsafe conditions without losing your job or getting in trouble

• join the health and safety committee.

WorkSafeBC right 3: right to refuse unsafe work

• If you have reasonable cause to believe a job or task puts you or someone else at undue risk, you must not perform it.

• You must follow the proper process.

Right to refuse: the process

1) Inform supervisor, who must investigate and resolve.

2) If unresolved, supervisor investigates again with you and a joint committee member (or another worker).

3) Still unresolved: you and your employer notify WorkSafeBC.

4) Prevention Officer investigates and decides.

Silent right: not to be discriminated against (prohibited action)

• Any act/omission by an employer, union, or person that negatively affects employment:

  • suspension, lay-off, dismissal, demotion, loss of promotion, transfer, reduced wages or hours, coercion/intimidation, discipline, job elimination.

Worker responsibilities (WorkSafeBC)

• Take reasonable care for your own and others' health and safety

• follow safe work procedures

• no horseplay or impairment

• wear PPE

• report unsafe acts/conditions

• report injuries to supervisor and first aid attendant; be proactive and set a good example.

Employer responsibilities (WorkSafeBC)

• Ensure health and safety of own and other workers

• establish policies/procedures, inspect, investigate

• correct unsafe acts and conditions

• provide and maintain equipment

• provide information, instruction, training, supervision

• cooperate with the joint committee and the Board.

Key compliance issue for employers

Lack of supervision.

Hazard vs. risk

• Hazard = a thing or condition that may expose a person to a risk of injury or occupational disease.

• Risk = a chance of injury or disease.

Health care injuries by cause (BC)

• Overexertion 45%

• slips, trips, and falls 14%

• acts of violence or force 12%

• infectious diseases 6%

• others 23%

Hazard type: overexertion (MSI)

• 50% of RN injuries

• Highest risk with patient handling: transferring, repositioning, bathing, toileting, dressing.

• Controls: risk assessment, mechanical lifting equipment, training, evaluation, consult joint committee.

Hazard type: slips, trips, and falls

14% of health care injuries.

Hazard type: violence

12% of RN injuries; 63% of violence claims are in health care. Employer must do a risk assessment, set policies/procedures/arrangements, and instruct workers.

Hazard type: infectious disease / biological agents

• About 8% of RN claims

• Norovirus/influenza, hepatitis B/C, TB, superbugs, surgical plume

• Controls: hand hygiene, vaccination, aseptic technique, safety-engineered sharps, exposure control plans, PPE.

Workplace violence (WorkSafeBC)

• Attempted or actual exercise by a person, other than a worker, of any physical force to cause injury to a worker

• includes threatening statements or behaviour that give a worker reasonable cause to believe they are at risk of injury.

What else does WorkSafeBC count as violence?

Aggression, resistive/reactive behaviour, acting out, sundowning.

WorkSafeBC: 3 areas

Prevention, Compensation (and rehabilitation), Assessments.

WorkSafeBC: prevention

Educate, enforce and consult with employers, workers, owners and suppliers to prevent injuries from occurring.

WorkSafeBC: compensation

• settle claims

• compensate and rehabilitate workers with occupational disease and injury

• assist injured or disabled workers and their dependants.

WorkSafeBC: financial assessments

The financial assessment determines how much employers pay WorkSafeBC in premiums, based partly on industry risk and past injury claims.

Workers Compensation system

• Historic compromise: workers and employers agreed to a trade-off.

• All workers covered: Workers who fall under the system's coverage can receive benefits for eligible workplace injuries.

• Employers fund it: Employers pay premiums to support the system.

• Employers must register: Employers required to have coverage must register with WorkSafeBC.

• No wage deductions: Employers cannot take their WorkSafeBC premiums out of your paycheque.

Legislation: the Act and the Regulation

• Workers Compensation Act = general duties, incident investigations, joint committee

• Occupational Health and Safety Regulation = orientation/training, PPE, specific requirements.

• WorkSafeBC administers the Act for the BC Ministry of Labour.

Prevention Officers (safety and hygiene officers)

• Top priority: prevent injuries/disease.

• Enforce through worksite inspections and orders

• Educate

  • young workers, JHSC, supervisor training

• Consult

Who is responsible for health and safety? (3 roles)

The employer, the supervisor and the worker all share responsibility; the three roles are interdependent.

Supervisor (WorkSafeBC)

A person who instructs, directs and controls workers in the performance of their duties (not only someone with the title). You may soon have PNs/HCAs reporting to you.

Supervisor's responsibilities

• Know the hazards in their area

• ensure the health and safety of their workers

• make sure workers are aware of hazards

• investigate and take corrective action when workers report unsafe conditions or acts

• know the Act and Regulation.

New worker (WorkSafeBC)

Anyone who is new to the workplace, returning to a workplace where hazards changed during their absence, or relocated to a workplace with different hazards.

Young worker (WorkSafeBC)

Any worker under 25 years of age (ages 15 to 24 in BC).

Why are new/young workers more at risk?

• Lack experience

• eager to please

• assigned tasks they aren't trained for

• 'it won't happen to me'

• tired

• unaware of rights and responsibilities

• afraid to speak up

= More than half of serious injuries happen in the first 6 months of employment.

Workplace characteristics that raise young worker risk

• insufficient training

• insufficient resources (over-represented in small firms)

• perceived work overload (feeling rushed).

New law for young workers (Jan 1, 2023)

• Minimum age 16: construction, silviculture, forest firefighting, work at heights needing fall protection.

• Minimum age 18: tree falling/logging or chainsaw, confined space/underground, work needing a respirator, asbestos/silica exposure, mills, foundries, metal processing, refinery or smelter.

Are nursing students 'workers' under the Act?

• Yes, even if not paid.

• Students must get the same site orientation as other workers before starting

• coverage for students at approved institutions.

• The school provides basic rights/responsibilities knowledge

• the workplace employer provides specific training and supervision.

Young or new worker orientation (Reg 3.23)

• Employer must give workplace-specific health and safety orientation and training BEFORE the worker starts

  • supervisor's name and contact, rights and responsibilities under the Act and Regulation (reporting unsafe conditions, right to refuse), and more.

Safe work procedures

• Directions on how work is to be carried out safely

• identify hazards and what must be done to eliminate or minimize risk.

• Following them is a legal responsibility: If unsafe, tell your supervisor.

When are written safe work procedures needed?

• Hazardous tasks

• complicated tasks

• frequently performed tasks

• less routine tasks where workers need reminders about hazards and controls.

Right to refuse: a second worker

• If a supervisor wants to assign another worker while the refusal is under investigation, they must give written notice: another worker refused; the reason; why the employer believes the work is not an undue hazard; and the new worker's right to refuse.

Who can you call about safety?

WorkSafeBC: Lower Mainland or toll-free 1.888.621.SAFE. A Prevention Officer will take steps to address the concern.

Bullying and harassment (WorkSafeBC)

• An action or comment toward a worker that a person ought to have known would cause the worker to feel humiliated or intimidated.

• Excludes reasonable performance/direction.

• Employer, supervisor and workers need a policy

• procedures to report and investigate. If no investigation, contact WorkSafeBC.

If injured at work: the 4 steps

1) Report to the first aid attendant

2) Report to your supervisor

3) Seek medical attention (tell the doctor it's work-related; employer pays transport)

4) Start a claim with WorkSafeBC (Teleclaim). The employer investigates.

Joint health and safety committee (JHSC)

group of workers and employer representatives who work together to make the workplace safer.

Overexertion: ergonomic risk factors

• Forceful exertion, awkward posture (bending, reaching, twisting), static postures (e.g., charting on a computer, bed making).

• Injuries are cumulative.

• Safe maximum lift for health care workers under ideal conditions is about 16 kg (35 lbs).

Patient handling: factors related to injury

• Frequency, force and postures of the task

• design/layout of the care environment

• availability and use of appropriate equipment

• patient characteristics.

MSI risk assessment and control for client handling

• Risk assessment before any transfer or repositioning

• risk control (eliminate or minimize)

• education and training; evaluation of effectiveness of controls

• consult with the JHSC and workers with signs/symptoms of MSI.

Patient handling is a process and a skill: mobility assessment

• Point-of-care mobility assessment: cognition, cooperation, physical ability; selection of equipment (including slings)

• use of equipment.

Controls for patient handling

• Mechanical lifting equipment is the only known way to reduce risk when someone needs physical support (hierarchy of controls).

• No evidence that teaching body mechanics reduces injuries.

• If mechanical devices aren't practicable and the person can bear most weight: slider sheet, transfer board, bed ladder, grab bar, triangle trapeze.

Violence: where are injuries most likely?

• Providing care (bathing, toileting, dressing) and transferring/repositioning (e.g., clients with dementia, mental illness, brain injury).

• Be willing to STOP, back off and re-plan.

Violence: employer must instruct workers on

• Recognizing the potential for violence

• procedures, policies and work environment arrangements to minimize risk

• appropriate response, how to obtain assistance, reporting, investigating and documenting incidents

• inform workers of persons with a known history of violent behaviour before they start work and of risk assessment results.

Infection prevention for workers

• Hand washing

• vaccination

• aseptic technique

• stay home when sick/isolation

• cough/sneeze etiquette

Surgical plume (biological/chemical hazard)

• Smoke from lasers/cautery that vaporizes tissue

  • contains airborne contaminants (viruses, bacteria, harmful chemicals).

• Workers may not see or smell it.

• Effects: headaches, nausea, eye and upper respiratory irritation.

• Control: local exhaust ventilation (plume scavenging system) and an exposure control plan (ECP).

Biological agents controls

• Mandatory safety-engineered sharps (SED) unless not clinically appropriate or not commercially available

  • self-sheathing needles, retractable syringes, needleless systems, safety scalpels.

• exposure control plans

• PPE

• sharps containers removed from service when three-quarters full.

Prevention Officer inspections in health care focus on

• MSI prevention, violence prevention, infectious disease/controls, and the Internal Responsibility System

• they check documentation, communication and controls.

WorkSafeBC top 5 takeaways

1) Expect training

2) You have rights including refusing unsafe work without being punished

3) Anyone can get hurt: know hazards and how to work safely

4) If something doesn't feel safe, tell your supervisor

5) Ask a question or report a concern to WorkSafeBC

Examples of environmental impacts on health

• Smog leads to cardiovascular/respiratory disease

• children's lead exposure in paint reduces IQ

• prenatal secondhand smoke; heat waves and elderly people

• women choosing to bottle feed due to breast milk contaminants

• mercury in fish

• indoor air quality and asthma

• viruses (avian flu, COVID-19) and respiratory disease.

CANE: mission and membership

• Canadian Association of Nurses for the Environment

• promote planetary health among nurses and people in Canada and globally through advocacy, education, research, practice and policy.

• Student membership $15 annually

• benefits: educational webinars, networking, getting involved, governance/voting, advancing nursing practice.

CNA role list

• Assessing and communicating risks

• educating people and communities

• showing personal leadership

• interdisciplinary collaboration

• advocating for policies

• interdisciplinary research

• promoting natural and built environments that support health.

Why can't we just move to another planet?

'We can't move into another body if we ruin our own, and we can't move to another planet if we ruin this one': protecting our own health and the planet's health go together.