LEGISLATIVE FRAMEWORK ON OCCUPATIONAL HEALTH AND SAFETY:LOCAL AND GLOBAL PERSPECTIVES

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CHAPTER 3 THEORETICAL FRAMEWORK

INTRODUCTION

This chapter outlines the theoretical framework, the World Health Organization Healthy Workplace Framework and Model, underpinning this study (WHOHWFM) (Burton 2010:82). The chapter also defines a healthy workplace and describes the avenues of influence for a healthy workplace and the core principles of the model. The WHOHWFM serves as a global guide that employers and employees can use as a practical yardstick to promote healthy and safe workplaces. The WHOHWFM is embracive of the various types and nature of workplaces. It provides a grounding for both the development of data collection tools and practical guidelines, which are the primary outputs of the study.

THEORETICAL FRAMEWORK OF THE CURRENT STUDY

The WHO’s Healthy Workplace Framework and Model is a document designed to guide occupational health professionals and provide them with a scientific basis towards structuring healthier workplaces (Burton 2010:1). The term ‘framework’ in the WHOWFM, refers to a description of key aspects (avenues of influence; and core principles) and provides an interpretation of the model for healthy workplaces. In addition, the term ‘model’ refers to the abstraction of the concept ‘healthy workplace’ in relation to its structure, content and process components (Burton 2010:1), as depicted in figure 3.1.

Definitionn of a healthy workplace

The World Health Organization defines a healthy workplace within the context of the WHOHWFM as:
“A place where everyone works together to achieve an agreed vision for the health and well-being of workers and the surrounding community (Burton 2010:15). The WHOHWFM provides all members of the workforce with physical, psychological, social and organizational conditions that protect and promote health and safety. Furthermore, it enables managers and workers to increase control over their own health and to improve it, and to become more energetic, positive and contented” (Burton 2010:15).
The WHOHWFM is the foundation for the current study due to its relevance and role in advocating for occupational health and safety. In particular, it promotes OHS for workers globally and across all sectors. It identifies workplace hazards and the management in an attempt to establish a safe and healthy workplace. The WHOHWFM identifies factors within the physical and psychosocial work environments, which hamper a good and safe work life within workplaces.
As a result, the current study seeks to unpack the occupational health and safety challenges that affect health care workers. The study includes the physical, psychological and social issues that pose as health challenges among HCWs and hopes to suggest ways in to enhance health and safety promotion. The ultimate aim is to foster a good quality of life among health care workers. The framework and model thus provides a relevant base from which to investigate challenges experiences by the HCWs at the Tshwane District Public Hospitals, as they face similar hazards inherent within the South African and global healthcare environment.

Components of the WHO Healthy Workplace Framework and Model (WHOHWFM)

The WHOHWFM comprises of three components, which are: (i) the content, also referred to as the avenues of influence for a healthy workplace; (ii) the process; and (iii) the core principles around which the model is centred (Burton 2010:98). The content component and core principles of the WHOHWFM are the focus of discussion for the current study.

Avenues of influence for a healthy workplace: the content component

The content component of the WHOHWFM comprises of (i) the physical work environment; (ii) psychosocial work environment; (iii) personal health resources in the workplace; and (iv) the enterprise community involvement, which are collectively called the avenues of influence (Burton 2010:83). The avenues of influence for a healthy workplace, as described in the WHOHWFM in Burton (2010:83), are strategies through which organisations and workers should influence the achievement of health and safety for workers and organisations, thus ensuring protection and promotion of the physical and psychosocial wellness of workers (Burton 2010:83). Figure 3.2 is a modification of the four avenues of influence identified in the WHO Healthy Workplace Framework and Model (WHOHWFM).
While the WHOHWFM consists of four avenues of influence for a healthy workplace, only three of the four avenues are relevant for this study, and these (the physical work environment, psychosocial work environment and personal health resources) are included in this discussion. The three avenues of influence are relevant to the study and appropriate the context within which the study investigates challenges of health care workers (HCWs) in the Tshwane Healthcare District’s public hospitals. The avenues of influence for a healthy workplace, as described in the WHO Healthy Workplace Framework and Model (WHOHWFM), are interrelated and some occupational health issues spill over from one to the other avenue, as described hereunder:

The physical work environment

The WHOHWFM defines the physical work environment as the physical space where workers are exposed to products, machinery, polluted air, chemicals, biological agents and work processes, and including the structure of the workplace (Burton 2010:83). Clarke and Brooks (2010:302) refer to the physical work environment context as “the work setting wherein nurses practice and the impression of the work environment on the nurses’ lives”. Factors within the physical work environment may have a negative influence on the health of the workers and give rise to physical and psychosocial health and safety problems (Burton 2010:83). Berninger, Webber, Weakley, Gustave, Zeig-Owens, Lee, Al-Othman, Cohen, Kelly and Prezant (2010:1474) note that the physical work environment encompasses various hazards, including biological hazards, which result in physical ill health of HCWs, manifesting as occupational diseases. Occupational injuries, such as back injuries and sprains, among HCWs emanate from physical and ergonomic hazards, which prevail within the physical work environment (Grobler 2013:210).
The physical work environment may, however, be influenced positively. This positive influence includes collaborative effort towards hazards and risk reduction, and an improvement of the work environment to yield beneficial health results for workers (Burton 2010:96) as well as reduce occupational mishaps. Burton (2010:84) reiterates that the physical aspects of the work environment have a bearing on worker wellness, thus either lowering or promoting the quality of life experienced at work.
The WHOHWFM highlights examples of hazards in the physical work environment and proposes hierarchies of control to curb the hazards (Burton 2010:84), as described below:
(i) Common hazards within the physical work environment
The WHOHWFM, in Burton (2010:84), describes the physical work environment as consisting of the physical, chemical, mechanical, ergonomic, safety, violence at work and biological hazards as outlined below:
Physical hazards
Physical hazards are non-biological hazards emanating from the physical work environment, which have the potential to cause injuries and diseases (Ndejjo et al 2015:[3]). The WHOHWFM encompasses aspects such as exposure to radiation and extreme temperatures within the work environment and these pose dangers to workers’ physical health (Burton 2010:84). Health care workplaces, the setting for the current study, harbour radioactive material, which may be present in liquid biomedical waste (Biswal 2013:100).
Chemical hazards
Chemical hazards result from exposure to chemical agents such as solvents, solutions, pesticides and insecticides as noted by the WHOHWFM (Burton 2010:84). HCWs are exposed, in health care settings, to chemicals such as disinfectants, antimicrobials, solutions and latex powder from the use of rubber gloves, with the likelihood of causing allergic reactions (Nagendran, et al 2009:270). Toxic drugs and liquid biomedical waste, such as mercury, are further examples of chemical hazards prevalent among HCWs that put the lives of HCWs in danger (Biswal 2013:100).
Mechanical hazards
Mechanical hazards, as described by the WHOHWFM in Burton (2010:84), pertain to the interface between workers, machinery and equipment, and the effects of faulty machinery on the health of the workers. In the case of health settings, the use of machinery or equipment may be of danger to HCWs if there is improper usage resulting from poor or lack of training (Tullar et al 2010:200). The WHOHWFM proposes that mechanical hazards may be enhanced by continuous exposure to machinery (Burton 2010:84), whereas Wachter and Yorio (2013:118) support the notion by suggesting less or no exposure of the worker to dangerous machinery to minimise harm.
Ergonomic hazards
The WHOHWFM describes ergonomic hazards as dangers involving the use of excessive force, awkward posture when performing certain tasks, and performance of repetitive work (Burton 2010:84). Examples of ergonomic hazards at health care workplaces include cases where HCWs engage in activities that are labour intensive or involve manual material handling such as turning, lifting heavy patients whilst adopting awkward positions, prolonged standing, repetitive movements and working long hours (D’Arcy et al 2011:837; Schoenfisch & Lipscomb 2009:117).
Safety hazards
Burton (2010:84) describes safety hazards in the WHOHWFM as those related to electrical sparks resulting in electrocution, and the slips, trips and falls (STF) resulting in musculoskeletal disorders (MSDs). In the case of health care workplaces, the STF occur due to liquid spills, stock piles, and loose lying electric cords which may result in injuries (McDiarmid 2014:316; Chernovsky, et al 2010:5). Operating rooms have been found to have frequent electrical hazards. As a result, Chernovsky, et al (2010:19) suggest that static electricity and flame producing hazards, such as flammable anaesthesia, need to be reduced in the operating rooms (Chernovsky et al 2010:19).
Violence
The WHOHWFM cites violence and lack of safety in workplaces as examples of the hazards commonly found in the physical work environment (Burton (2010:84). Easton and Van Laar (2012:17) highlight that the physical work environment should provide safe working conditions and resources that promote the safety of the environment (Jayakumar & Kalaiselvi 2012:146). Other studies also argued that the emergence of violence in the physical work environment is an occupational health hazard which renders the healthcare workplace unsafe (Kowalenko, Cunningham, Sachs, Gore, Barata, Gates, Hargarten, Josephson, Kamat, Kerr & McClain 2012:523; Chen, Huang, Hwang & Chen 2010:1156). Kowalenko et al (2012:523) further advocate for the prevention and eradication of violence in the health sector through policy development and feasible practical approaches.
Biological hazards
The WHOHWFM also describes biological hazards as disease-causing agents, which exist within the physical work environment (Burton 2010:83). Berninger et al (2010:1474), in concurrence with the previous statement, describe biological hazards as causing occupational diseases that lead to physical ill-health. The biological hazards include hepatitis B, HIV, pandemic threats, hepatitis C, and circumstances, such as lack of toilet and hygiene facilities, which lead to the existence and sustenance of biological hazards. In addition, and relevant to the context of the current study, Knoeller, Mazurek, and Moorman (2012:776) state that occupational disease characteristics among HCWs arising from hazardous biological agents (HBAs), cause breakdowns in the physical functionality of the workers due to ill-health. This is corroborated in studies on occupational tuberculosis among health care workers and occupationally acquired blood-borne conditions, such as hepatitis and AIDS, respectively, which all attest to HCWs’ poor physical functionality due to ill-health resulting from HBAs (Zungu & Malotle 2011:17; Dény & Zoulim 2010:246; Abuelhassan 2012:94). Finally, Berninger, et al (2010:1474) show the link between respiratory ailments, such as asthma and chronic cough, and HBAs existing in the physical work environment.
(ii) Hazard control within the physical work environment
Burton (2010:84) states that the physical work environment safety and an eradication of risk to health are achievable through the institution of various measures that minimise exposure to hazards, which result in occupational injuries and diseases. A number of measures, which include: (i) hazard identification; (ii) an assessment of hazards (type and magnitude); and (iv) the control of hazards (hierarchy of controls), can influence and render the physical work environment healthy and safe (Burton 2010:84). The WHOHWFM describes the hierarchies of control, as measures that include substitution or elimination of hazard causing phenomena; engineering controls; administrative controls; and the use of personal protective equipment (Burton 2010:84), as discussed below:
Elimination or substitution
Elimination or substitution involves the complete removal of a hazardous agent and its replacement with one that is less or not toxic (Burton 2010:84). An example for HCWs would be the removal latex gloves and replacing them with powder-free gloves for those HCWs experiencing latex allergy (Burton (2010:84).
Engineering controls
Engineering controls refer to altering existing systems, processes or machinery to minimise the occurrence of injuries or diseases (Burton 2010:84). The replacement of ventilation systems that remove air filled with air-borne hazardous agents with clean ventilated air to minimise the spread of tuberculosis (TB) and the use of safety engineered needle systems are prime examples of such measures (Burton 2010:84).
Administrative controls
Administrative controls that maintain good housekeeping result in the promotion of a safe and healthy physical work environment. Cleanliness within the environment promotes hygiene and minimises the spread of diseases, whilst tidying up of the environment ensures well-packed equipment and stock as well as avoid injuries (Burton 2010:84). Good housekeeping involves worker training on procedures and systems and machine maintenance (Burton 2010:84). The rotation of workers is also a housekeeping measure that can reduce workers’ exposure to hazardous environments for a longer period (Burton 2010:85).
Personal protective equipment (PPE)
The WHOHWFM proposes the use of PPE as one of the intervention measures that protect workers against contamination from pathogenic material (Burton 2010:85). Similarly, the South African legislation obligates employers to provide PPE by to their employees, through the Occupational Health and Safety Act, 1993 (Act No. 85 of 1993) as amended (OHS Act, 1993:8). In the current study, hazardous pathogens in the health care physical work environment are inherent in the daily duties of HCWs, and warrant the use of PPE. PPE use, in conjunction with other hazard control measures, such as elimination, substitution, engineering and administrative controls, is the last line of defence against exposure to workplace hazards (Lunt, et al 2011:311). Finally, it is important that provision of personal protective equipment (PPE) should consider the make and size of the protective gear for both genders when procuring the PPE (Burton 2010:85).

The psychosocial work environment

The WHO Healthy Workplace Framework and Model outlines beliefs, values, work practices, the culture of the organisation and work organisation as some stressors within the psychosocial work environment that impact on the psychosocial and physical health and safety of workers as well as give rise to various types of mental or emotional strain (Burton 2010:85). The hazards found within the psychosocial work environment are discussed below:
(i) Hazards within the psychosocial work environment
The WHOHWFM cites the examples of hazards in the psychosocial work environment.
The salient features highlighted in this regard are:
Organisational culture
Burton (2010:85) suggests that, based on the WHOHWFM, there are few or no policies that specifically target the promotion of respect and dignity of workers; condemn violence-related acts; and support healthy lifestyles. The culture of the organisation needs to foster practices that ensure the respect of workers. Acts of violence, such as harassment and bullying, should be addressed through policy formulation and implementation to protect vulnerable workers. Finally, policies that protect workers against discrimination based on their gender and other personal orientations should exist (Burton 2010:85).
Shift work
The WHOHWFM proposes that shift work is associated with psychological stress among HCWs and contributes to changes in sleeping patterns (Burton 2010:85; Kleiner & Pavalko 2010:1464), and physical health problems, such as fatigue and sleepiness (McClelland et al 2013:60; Knutson & Bøggild 2010:87). Shift work related-stress is exacerbated by workplace violence, which is noted as taking place more during the night shift than during the day (Nabe-Nielsen, Tüchsen, Christensen, Garde & Diderichsen 2009:52). Relevant to the current study is the fact that HCWs in the participating hospitals work on a shift basis and are most likely to experience shift work-related challenges identified in the WHOHWFM.
Lack of support from management
Burton (2010:85) proposes, basing on the WHOHWFM that, lack of support from management towards workers, and failure to protect workers’ rights regarding hours of work, and occupational health and safety rights, may contribute towards psychological hazards. Lack of support for the occupational rights of workers over long hours of work (Burton 2010:85; Al-Qutop & Harrim 2011:197) and the denial of the right to be medically assessed, and to work in a safe and healthy work environment as stipulated in OHS legislation is a source of psychological stress (Burton 2010:85). HCWs workers also lack support in the quest for work-life balance (Burton 2010:85).
Type of management style
The WHOHWFM states that management style that does not promote consultations with the workers and is not open to two-way communication between management and workers stands as a major occupational stressor (Burton 2010:85). Leaders should take a lead in fostering good relations in the workplace (Spence-Laschinger 2010:875; Davey, Cummings, Newburn-Cook & Lo 2009:322). The current study investigated the impact of management practices on the promotion of occupational health and safety among HCWs in the Tshwane Healthcare District’s public hospitals, and suggested ways to curb the existing poor managerial practices.
(ii) Hazard control within the psychosocial work environment
The WHOHWFM proposes that the handling of psychosocial work stressors should follow some of the generic hierarchies of control, elimination, substitution and administrative controls, and apply them in the physical work environment (Burton 2010:85). Workplaces can use surveys and interviews as an alternate to physical inspections during attempts at hazard identification (Burton 2010:85). The training of workers on coping skills and the handling of conflict situations may also help alleviate occupational stress and empowers workers with skills in how to cope with stressful situations in the future (Burton 2010:86).

Personal health resources in the workplace

Personal health services in the workplace, as proposed in the WHOHWFM, refer to the provision of health resources, opportunities, information and other personal resources in order to create supportive environments (Burton 201:86). The services motivate workers to improve and maintain healthier lifestyles, as lifestyle modification is dependent on knowledge and information provision (Burton 2010:86). Workers employed at organisations that have no information may find themselves in difficulties regarding the making of healthier lifestyle choices (Burton 2010:86). This domain of the WHOHWFM supports the current study, which explored whether HCWs working in public hospitals in the Tshwane Healthcare District were provided with the necessary personal health services and information to support their well-being at work.
(i) Hazards within the personal health resources domain
The WHOHWFM identifies some of the hazards, in a commentary on personal health issues in the workplace, in Burton (2010:86) as:
• Poor sleep quality and quantity due to occupational stress, long hours of work, shift work and increased workloads (Burton 2010:86). Other studies highlight, in support that, altered patterns of sleep can be as a result of heavy workloads and long hours of work, respectively (Bolge, Doan, Kannan & Baran 2009:415; Caruso & Hitchcock 2010:192). The current study investigated the occurrence of long hours of work and increased workloads among HCWs and their impact on their physical and psychological health.
• Lack of accessibility to health care resulting in undiagnosed and untreated medical conditions (Burton 2010:86). In the present study, the researcher investigated accessibility and provision of personal health resources such as family planning and reproductive health assessments for HCWs.
(ii) Hazard control within the personal health resources domain
The promotion of health, as suggested by Burton (2010:87) in the WHOHWFM, requires the application of hierarchies of control in the psychosocial work environment. This will result in a positive influence towards the organisations’ provision of personal health resources (Burton 2010:87). Hazard control in this domain is mainly administrative and includes:
Provision of health services and facilities
The WHOHWFM suggests that worker counselling services assist in alleviating occupational and personal stress levels (Burton 2010:87). It also suggests the provision of efficient medical assessments for workers as mandated by OHS legislation for the prevention, early detection and early treatment of occupational diseases (Burton 2010:87). Finally, encourages the establishment of food services that provide healthier options to prevent obesity or poor nutrition, and that of facilities such as gym and fitness improvement initiatives in the workplace are required to inspire workers to engage in active physical and healthy practices (Burton 2010:87).
Enforcement of rest periods
Fatigue and burnout may occur among HCWs as a result of extended hours of work, thus creating further physical health problems such as poor sleep patterns and heart conditions (Stimpfel et al 2012:2501; Knutson & Bøggild 2010:87). The WHOHWFM proposes that workers should have physical and mental rest (Burton 2010:87). Proper tea and lunch breaks should be enforced during break times, and workers should be encouraged to exercise so that they can re-vitalise themselves (Burton 2010:87).
Training and information
The provision of training and information regarding management of finances, good eating habits and cessation of smoking can help workers to make informed personal choices. Worker support in the form of training, dissemination of appropriate information and invitation of health lifestyle experts to address workers is also necessary (Burton 2010:87). Finally, the provision of information regarding counselling, abuse of alcohol and drugs in the workplace is requisite (Burton 2010:87).
Provision of options to suit personal needs
The WHOHWFM identifies work schedules as one of the hazards affecting the personal health needs and choices of workers (Burton 2010:86). The WHOHWFM proposes that workers be afforded a reasonable extent to make personal choices regarding flexible work and be allowed a preference in the choice of shifts, all of which are enabled through the development of healthy shift work policies that promote flexitime (Burton 2010:87). This resonates with the current study as it explored HCWs’ concerns regarding the structuring of working hours and shifts, and the way these influenced their occupational and social well-being. The provision of personal options for flexi hours to suit the HCWs’ personal needs and lifestyles reflects work environment social structures that strive to alleviate personal stress and foster a supportive environment (Burton 2010:86; Lautizi, et al 2009:447; Padayatchi et al 2010:964).
Creation of supportive work environments
Burton (2010:87) suggests the creation of supportive work environments that enable workers to access personal health facilities such as family planning services, and cancer diagnostic services such as PAP-smears and mammograms, over and above those provided in the general medical surveillance. This endeavour may prevent psychological stressors resulting from lack of personal health information and services. The availability of family planning services on site would be advantageous and provide a measure of security for HCWs that their personal health needs can be met within their workplaces, without having to seek help outside of their workplace (Burton 2010:87). Based on the WHOHWFM, as the theoretical underpinning the current study, the researcher sought to investigate whether the personal health needs of HCWs were supported through the provision of required health resources to foster their well-being in the workplace. Burton (2010:86) underscores that personal health resources pertain to the support that the institution gives to its workers in the form of information, health services and any enhancement to assist workers to maintain healthy personal life practices with a view to promote their health and safety at work.

TABLE OF CONTENTS
CHAPTER 1  ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITIONS OF KEY CONCEPTS AND OPERATIONAL DEFINITIONS
1.7 FOUNDATION OF THE STUDY
1.8 RESEARCH DESIGN
1.9 RESEARCH METHODOLOGY
1.10 SCOPE AND LIMITATIONS OF THE STUDY
1.11 STRUCTURE OF THE THESIS
1.12 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 METHODS
2.3 LEGISLATIVE FRAMEWORK ON OCCUPATIONAL HEALTH AND SAFETY:LOCAL AND GLOBAL PERSPECTIVES
2.4 OVERVIEW OF COMMON OCCUPATIONAL HAZARDS IN HEALTH CARE AMONG HCWs
2.5 OCCUPATIONAL HEALTH AND SAFETY INTERVENTIONS TO PREVENT OCCUPATIONAL HAZARDS
2.6 CONCLUSION
CHAPTER 3 THEORETICAL FRAMEWORK
3.1 INTRODUCTION
3.2 THEORETICAL FRAMEWORK OF THE CURRENT STUDY
3.3 CONCLUSION
CHAPTER 4 RESEARCH METHODOLOGY
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 RESEARCH METHOD
4.4 INTERNAL AND EXTERNAL VALIDITY OF THE STUDY
4.5 CONCLUSION
CHAPTER 5 ANALYSIS, PRESENTATION AND DISCUSSION OF THE RESEARCH FINDINGS
5.1 INTRODUCTION
5.2 RESEARCH RESULTS LAYOUT
5.3 RESULTS ON DATA FROM QUESTIONNAIRES
5.4 PRESENTATION OF PARTICIPANTS’ OPEN-ENDED RESPONSES (SELF ADMINISTERED QUESTIONNAIRE)
5.5 RESULTS ON INSPECTION REGARDING THE AVAILABILITY OF AND COMPLIANCE WITH THE OHS POLICY (PART A)
5.6 PRESENTATION OF DATA FROM INSPECTION CONDUCTED TO ASSESS THE EXISTENCE AND COMPLIANCE WITH THE OHS POLICY (PART A)
5.7 DESCRIPTION OF OHS INJURIES AND DISEASES DATA FROM REVIEWED HOSPITAL RECORDS (PART B)
5.8 DISCUSSION ON FINDINGS
5.9 CONCLUSION
CHAPTER 6 SUMMARY, CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS OF THE STUDY 194
6.1 INTRODUCTION
6.2 SUMMARY
6.3 RECOMMENDATIONS
6.4 CONTRIBUTIONS OF THE STUDY
6.5 LIMITATIONS OF THE STUDY
6.6 CONCLUDING REMARKS
CHAPTER 7  DEVELOPMENT OF GUIDELINES TO PROMOTE THE HEALTH AND SAFETY OF HEALTH CARE WORKERS IN PUBLIC HOSPITALS IN THE TSHWANE HEALTHCARE DISTRICT OF GAUTENG, SOUTH AFRICA
7.1 INTRODUCTION
7.2 THE PURPOSE OF THE GUIDELINES
7.3 SCOPE OF THE GUIDELINES
7.4 THE GUIDELINES’ DEVELOPMENT AND ALIGNMENT PROCESS
7.5 IMPLEMENTATION PLAN FOR THE DEVELOPED GUIDELINES
7.6 EVALUATION OF THE GUIDELINES
7.7 IMPLICATIONS FOR HOSPITAL MANAGEMENT
7.8 IMPLICATIONS FOR THE GOVERNMENT
7.9 DISSEMINATION OF THE GUIDELINES
7.10 CONCLUSION
LIST OF REFERENCES
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