Embedding ergonomics in hospital culture: top-down and bottom-up strategies
Introduction
Nottingham City Hospital is a specialist teaching hospital, associated with the Universities of Nottingham and Derby, employing approximately 5000 staff. It provides a wide range of general services (medicine, surgery, gynaecology, paediatrics, care of the elderly, rehabilitation and obstetrics) to the local population and specialist services including heart and lung transplant surgery, cystic fibrosis service, breast screening, and regional renal, burns, head injury and oncology centres. Additionally, there are extensive laboratories for genetics, haematology, clinical chemistry, microbiology, histopathology (including a mortuary) which are used for both research and diagnostic testing. Non-clinical support facilities include a hospital laundry, on-site kitchens (for all food preparation and distribution), a steam-generating boiler house, and administration and clerical staff.
The strategy for the ergonomic approach at Nottingham City Hospital was based on the findings of a two-year research project (Hignett, 1999; Hignett and Richardson, 1995) which explored the role of ergonomics in manual handling operations in nursing. The research project included a review of over 80 published studies from three decades (Hignett, 1996a). One of the findings of this review was that although there had been considerable research done on training in lifting and handling techniques, the traditional approach to manual handling problems in health care, this alone had shown little or no long-term benefits. An exploratory study (Hignett and Richardson, 1995) was carried out resulting in the extension of the four-point risk assessment model of the Manual Handling Operations Regulations (1992, 1998) from task, load, environment and individual capacity to include organisational factors with the task at the centre rather than the risk.
This model has been used at Nottingham City Hospital to inform the hospital strategy on Moving, Handling and Back Care (Nottingham City Hospital, 1992, 1996, 1999) and to set out the scope of ergonomic practice, including both `top down’ (macro, policy and support) and `bottom up’ (micro, operational) strategies.
This type of top-down approach has been called `macroergonomics’ by Hendrick (1995), where the organisational context is recognised as affecting the appropriateness of change or design measures. The top-down process looks at the overall structure of the work system and related processes, while the bottom-up process is concerned with implementation.
The concept of organisational culture tends to include the beliefs, values, norms and patterns of action that characterise social relationships and are reflected in the structures and processes within an organisation (Giddens, 1993; Mullins, 1993; Helmreich and Merritt, 1998; Ranade, 1997). Helmreich and Merritt (1998) discuss two distinct layers of culture, using a similar model to French and Bell (1990). The surface, or overt, layer of culture includes observable behaviours and recognisable physical manifestations such as written procedures, members uniforms, symbols and logos, and organisational routines and rituals. The deeper, or covert layer, consists of the values, the beliefs and informal interactions that underlie this surface.
Mullins (1993) suggests that there is no consensus on the meaning or application of the concept of culture to work organisations. Helmreich and Merritt (1998) describe the concept of organisational culture, in the following quote, as used in four academic disciplines. “Business schools tend to define organisational culture as a phenomenon that can be managed and manipulated, where as sociologists and anthropologists adopt a more ethnographic approach stressing that each organisation is a unique, historically derived, subjective phenomenon beyond simple manipulation, and organisational psychologists, with an empirical background, seek to reduce the phenomenon to its sub-components.”
The title of this paper `embedding ergonomics in hospital culture: top-down and bottom-up strategies’ takes the position that ergonomics has a socially situated practice. When ergonomics is embedded, it becomes part of the organisational culture. Many of the underlying principles of ergonomics, from various definitions (Wilson and Corlett, 1995), become part of both the formal and informal processes and thus are no longer uniquely the domain of the ergonomics expert.
The National Health Service (NHS) is the biggest civilian employer in Europe, employing more than 1 million people, 5% of the UK working population. It is the largest employer of women, with approximately 75% female workers, with nurses accounting for 50% of all staff (Rose, 1994; Walby et al., 1994; Halford et al., 1997; Ranade, 1997; Dargie, 1999; Tanner et al., 1999).
Hospitals are characterised by a heterogeneous mix of professional and non-professional staff who may share only the most abstracted aims, such as that of improving the health of their patients (Green and Thorogood, 1998). Klein (1982) suggests that the influences which shape the environment of the health-care industry are: occupational complexity; heterogeneity in the range of services provided and the technologies employed; uncertainty in the relationship between the input of health care and output of improved health; ambiguity of goals and objectives; and provider dominance. So the health-care industry does not simply respond to consumer demands, it also creates them through the clinical decisions and recommendations of the professional providers about what consumers ought to have.
A particular aspect that differentiates hospital work from most other industries is the “hands on care”. Nursing work is often physically heavy (involving lifting weights which would be unacceptable in male-dominated industries); physically dirty (involving tasks such as washing soiled bodies); and highly repetitive (Lee-Treweek, 1997). Lawler (1998) describes how nurses `must overcome their own sociological background and adjust to a particular professional subculture and its established methods that permits handling other people's bodies. They must also conform to the symbolism of certain parts of the body, in particular parts which have sexual significance and they must find ways to manage social interaction during those times when they break taken-for-granted rules about the body'.
Fox (1989) gives an emotive description of a hospital as “a highly symbolic world, intimately and powerfully connected to the `hardest surfaces’ of social and cultural life and to its most `deep lying’ dimensions”. She goes on to say that a hospital is “where suffering and pain of all sorts — physical and psychic, moral and spiritual — are concentrated; where anxiety, sadness, anguish, bewilderment, anger and fear are pervasive, where care and caring abide. Comfort, hope, trust and faith exist too, and healing, recovery and even cure occur. Hospitals are also places where every form of human aloneness, woundedness, disorientation and misery is assembled and laid bare along with the ravages of human violence. In the hospital the comedy and tragedy of human existence, its nobility and its ignominy, lie close to the surface, are juxtaposed and intermingle”.
This gives a social context for the description of the following ergonomic programme and starts to explore the differences of organisational culture in a hospital with the informal level being highly overlaid by the emotional nature of the service provision.
The ergonomic strategy for risk management of manual handling risks is part of the organisational health and safety policy. The framework for the strategy was developed from the model (Fig. 1). Most of the sections of the model are discussed (with the appropriate section number indicated in Fig. 1), with one exception. Hospital initiatives to reduce stress and fatigue are not included in this paper as they are co-ordinated by the Human Resources Department.
The strategy gives an organisational structure for authority and accountability for the operational management of manual handling risks. The departmental or ward manager has the day-to-day responsibility for managing health and safety risks and is, therefore, pivotal in the successful implementation of the programme. Every department/ward is visited annually for an audit of their performance. This includes a review of known risk assessments; an update of new staff working practices and equipment; a check to ensure that documentation is up-to-date; and two spot checks for (a) a designated manual handling task, by interviewing a member of staff, (b) a completed risk action to ensure that the risk is still managed. The audit enables specific issues to be identified, this might be as simple as providing information about a piece of equipment, or as complex as setting up an exploratory study to investigate a problem in more detail (Hignett, 1996b).
This annual visit has gradually become part of the hospital processes, part of the formal culture. Initially, there was some concern, and even reluctance, by the managers but over the years they have come to see this visit as a benefit, with some even contacting the ergonomics department to book an early annual audit.
This paper only describes the use of ergonomics for manual handling problems rather than all health and safety risks. This is due to the organisational structure of the hospital where non-musculoskeletal health and safety risks are managed in a separate department. There is close collaboration but different priorities have been established, for example there is no centrally co-ordinated annual audit for other health and safety risks.
Section snippets
Management
The `top-down’ input was set up to support cross-professional, organisational-wide intervention in the form of an Injury Prevention Team with members from the Trust Board (Director of Nursing and Director of Operational Services), Divisional Co-ordinators of Rehabilitation and Surgery as well as the Ergonomist, Occupational Health, and Health and Safety personnel. This team has functioned both as a steering group and to facilitate the implementation of change at the highest levels in the
Building
Another failure, which has seen very limited ergonomic input, has been building design for refurbishment and new work. Moran et al. (1990) made the comment that “few, if any other industries, have been subjected to so much piecemeal and uncoordinated regulation. Hardly any aspect of hospital operations — from the width of the corridors to the number of fire extinguishers to the method of cost funding and accountancy and the overtime payment of the orderly — escapes the scrutiny of some public
Professionalism
Personal and professional factors affect the well-being and safety of staff. The guidance from professional bodies (Royal College of Midwifery, 1997; Royal College of Nursing, 1998; Chartered Society of Physiotherapy, 1998) as well as from government bodies (HSAC, 1998) and unions provide useful sources of information on manual handling operations in health care. At Nottingham City Hospital there has been an effort to make health and safety issues an integral part of the management structure,
Patient (physical, emotional and mental needs)
One of the major differences in practising ergonomics in a hospital, compared with other industries, is the patient. For manual handling this means the `load’ is animate, unpredictable and often offers its own opinion.
At Nottingham City Hospital a patient-focused approach is taken to try to facilitate the staff/patient interface. A `Mobility And Communication System’ (MACS) is used to ensure that information about patients with special mobility needs (e.g. currently using a walking aid) is
Incident reports, sickness absence and completed risk assessments
Over the five-year period three measures have been monitored to look at any trends following the introduction of the ergonomic strategy, these are: manual handling incident reports; musculoskeletal sickness absence; and completed manual handling risk assessments.
As in any large organisation there have been initiatives to reduce sickness absence. In particular, there has been a programme to reduce the duration of long-term sickness absence with supported return-to-work and improved management of
Conclusion
This paper does not seek to report a research project, simply to share the experience of trying to tackle the manual handling risks by taking an ergonomic approach. After five years the completed risk assessments suggest that the working environment has become safer, and the trend for manual handling incidents and days lost from musculoskeletal-related sickness absence is downwards.
Taking a top-down (macro) and bottom-up (micro) approach is not unusual (Drury et al., 1999), but there are few
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