The consequences of hospital revitalisation on staff safety and wellness

1Ukwanda Centre for Rural Health & Division of Nursing, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa

2Department of Public Management, Faculty of Business, Cape Peninsula University of Technology, Cape Town, South Africa

 

Correspondence: Dr Guinevere Lourens, PO Box 19063, Tygerberg, 7505, South Africa. e-mail: guin@sun.ac.za

Abstract

Background: The proposed National Health Insurance strategy is driving health facility upgrades in South Africa. The impact of this on healthcare workers is largely unknown. The objective of this study was to describe the consequences of the Hospital Revitalisation Programme implementation at Paarl Hospital on staff. 

Methods: This was a descriptive qualitative study.  The occupational health register, meeting minutes, photographs of infrastructural construction activities, safety and security statistics, staff satisfaction surveys, and staff wellness programme reports were reviewed for the duration of the project implementation.  Twelve interviews with purposively sampled individuals and two focus groups with conveniently sampled health facility staff were conducted.

Results: Implementation plans and manuals lacked a comprehensive risk management strategy for application of occupational health and safety legislation. Results showed an increase in safety and security incidents as well as workplace physical injuries of hospital staff linked to construction activities. The data revealed lower staff morale and associated absenteeism.

Conclusion: Hospital revitalisation can give rise to mistakes at the cost of staff safety and wellness, and places staff at risk for low morale, workplace injuries and increased absenteeism. Establishment of a comprehensive occupational health and safety service in the planning stage of the revitalisation, with strong site management and an integrated staff wellness programme, is recommended.

 

Keywords: Risk management, occupational health and safety, employee assistance programme, staff wellness programme

Introduction

Hospital revitalisation, or the renovation of public health sector facilities, is set to increase as the establishment of a National Health Insurance (NHI) towards universal healthcare access coverage in South Africa gains momentum.1 Seen as a social investment, NHI will be characterised by huge capital investment in health infrastructure with continued efforts to expand service delivery towards the gradual realisation of the right to health within available resources.1 Health facilities are expected to remain fully operational during the implementation of the Department of National Health’s Hospital Revitalisation Programme (HRP);  this has the potential to impact on the wellbeing of staff.  The process of revitalisation immerses healthcare staff into rapid, unsettling change, and places them alongside construction-related infrastructural activities and health technology installations. For the proper functioning of NHI, a safe environment for healthcare workers is essential. This study explored the consequences of the HRP on staff of Paarl Hospital in the Western Cape Province of South Africa; risk management guidelines for staff safety and wellness during such renovations were consequently proposed. The findings have relevance for other health facility restoration, reconstruction and maintenance overhaul scenarios where staff might be affected. Patient risk was not considered in this study and deserves detailed attention in its own right.

 

Risk management

South African policies and Acts regarding staff safety include the Constitution of South Africa and its Bill of Rights, whereby “Everyone has the right to an environment that is not harmful to their health and wellbeing”; the Public Service Regulations: “Government will work towards the improvement of a working environment… to include employee health”; the Occupational Health and Safety Act (1993) which outlines the general duties of employees and employers; and the Compensation for Occupational Injuries and Diseases Act (COIDA).

With these legislative documents as a backdrop, the necessity for risk management during revitalisation is imperative. The role of thorough risk assessments in terms of staff, and technical quality issues to supply accurate and timely information about the hospital’s key risks during revitalisation to corporate governance stakeholders, cannot be overstated.2

There is a paucity of published work regarding hospital revitalisation and the effect on occupational health and safety or staff wellness in South Africa. However, in a local study in Hermanus in the Western Cape, the greatest challenge in the upgrading of an operational hospital was overcoming safety issues and performing structural work.3 In Australia, safety, design, logistics and communication problems were identified as key issues in the revitalisation of Bathurst hospital. The Bathurst report called for more technical and safety focus in order to bring the hospital building and equipment to a state of readiness for safe operational use, with adequate staff trained to function according to newly designed systems.4 During the building of a hospital in Trondheim, Norway, it was found that the need for control on the building site was underestimated and  that closer connection and better co-operation between all role-players, and  involvement of suppliers and subcontractors, would create more ownership of the process and share risk.5 An Italian hospital section had to institute an actively-engaged team approach with engineers, architects, doctors, specialists and the interdisciplinary team, to meet project objectives of safety and quality.6

Infection control resources and practices might be compromised during hospital revitalisation by the dirt and dust carrying bacterial or fungal micro-organisms. Compromised hand-washing facilities or water systems interruptions, as well as changes in air handling and staff traffic patterns, compound the risk to staff. Cases of Aspergillosis (fungus infection) may increase dramatically during hospital construction or renovation.7 Ground-disrupting activities can result in Aspergillus spores being dispersed into the air, which can cause respiratory and pulmonary infection in both staff and patients.  

 

Methods

Paarl Hospital in the Western Cape, a 311-bed regional secondary level public hospital with a staff complement of 737, was selected as a case study to evaluate the HRP implementation. A descriptive case study design with qualitative research methodology was utilised. This methodology focused the study on the circumstances, dynamics and complexity of the Paarl Hospital revitalisation as a single case.8   A multi-method approach to data collection was taken, and included two focus group discussions; 12 interviews [11 individuals and a 12th interview, consisting of two participants]; and a review of relevant project-related photographs and documents. Photographs were provided by the hospital administrative official responsible for the hospital newsletter, who kept a repository of photographs taken on the hospital camera by various staff members.

The study population comprised all staff, including management, of the Paarl Hospital HRP project employed in the period 1 January 2006 to 31 March 2012. The study participants consisted of purposively selected hospital and clinical managers, as well as a convenience sample of hospital staff.

Transcripts of the interviews were analysed using content analysis and thematic coding.  Documents reviewed included the occupational health register which recorded workplace injuries; the Health and Safety Committee meeting minutes; the monthly safety and security reports which reflected incidents of thefts and loss or damage of property; and a red flag incident register kept in the HRP site office, where near-misses were recorded. The quarterly reports from the staff wellness programme were evaluated for staff utilisation trends, as well as the annual staff satisfaction surveys which captured staff sentiments during the study period. The multiple sources of document review data allowed for triangulation with the themes that emerged from the interviews.

Ethical approval was obtained from the Cape Peninsula University of Technology (CPUT) Research Ethics Committee (FBREC0026) and the Western Cape Department of Health, for a student of the CPUT Business Faculty to conduct a public management doctoral study. 

 

Results

Staff reported that boundaries between building and hospital staff activities were not firm enough. Areas were demarcated but often without physical barriers between hospital staff and construction workers and their activities. The key challenges faced by staff during hospital revitalisation activities are highlighted in Figure 1; the results of the impact of HRP on staff circumstances are grouped into subheadings.

 

Decanting

Decanting involves moving clinical or service departments in an operational hospital into temporary accommodation during the revitalisation process of that specific department. Decanting emerged as the greatest challenge during most of the interviews and the focus groups.

Insufficient areas in which to decant; interruption of services such as electricity, water, sewage, medical gas and oxygen during decanting; overcrowding and unsatisfactory ergonomics in decanted areas; and high levels of conflict in decanting decis-ion making, were experienced. Weekly decanting meetings were eventually initiated between the clinical staff and contractors as an effective intervention.

 

Biological hazards

The construction activities had a challenging effect on hospital infection control operations in terms of dust, dirt, and debris which has the potential to carry bacteria and fungi. Work on roof structures, and ground-breaking and demolition, released spores and resulted in mould growth on walls of crucial clinical areas, raising awareness of the risk of Aspergillosis during hospital revitalisation. Infection prevention and control were also adversely affected by sewage explosions in strategic areas due to inadequate plumbing design, which had to be rectified.

Paarl Hospital is situated in a high incidence tuberculosis (TB) health sub-district. TB amongst staff was identified as a potential risk in the overcrowded, decanted situations. Shortcomings were identified in the engineering design of ventilation and air conditioning systems, to adequately address TB prevention in some new areas. The quality assurance initiatives of the HRP at Paarl Hospital included TB training and awareness sessions, as well as the development of an intervention strategy to enhance TB control strategies in the workplace.

Needle-stick injuries are an occupational risk for healthcare professionals and support staff in any health facility. During the revitalisation period, the decanted cramped work areas increased that risk. The reporting and follow up was streamlined by a new information leaflet with a form for staff, which was designed to track occupational health incidents.

 

Staff wellness  

The HRP implementation proved very trying for staff and tested their endurance. Staff quality was compromised in terms of the additional stress of a rapidly changing environment.

An outsourced staff wellness programme was available during HRP implementation, but was initially underutilised. The programme offered a wide range of services, including counselling, financial advice, management support, coaching, and group debriefing sessions. Issues raised about the staff wellness programme included uncertainty about confidentiality, delay in face-to-face referrals, and staff not being aware of services.

The staff wellness programme was marketed at staff training sessions, as well as change and strategic management workshops. It was eventually used more by individuals for psycho-social issues. Middle management sought assistance to deal with absenteeism and staff referrals.

 

Occupational health and safety

Another outcome of the HRP process was that the Health and Safety Committee requested a time slot during the Broad Management meeting, where middle and senior hospital management met every second week. They conveyed their concerns to management about various issues during construction, such as dust and pest control; omission of burglar bars; guidance on personal protective equipment in the new mortuary; mounting of sharps containers; safety and security issues; and emergency exit planning. The constant noise of construction activities prompted complaints from clinical staff.

Due to the dramatic expansion of the facilities, an entirely new fire safety system was implemented – a positive outcome of the project. However, incorrect/faulty fire equipment replacement was slow and the final fire safety consensus and sign-off by the relevant local and provincial fire chiefs and marshals took a number of years to conclude. Staff verbalised that they felt unsafe in this regard.

Comprehensive emergency and major incident planning was developed over time. A more detailed occupational health and safety inspection report checklist was developed during revitalisation by the occupational Health and Safety Committee.  The occupational health services developed over the project period with the culmination of the appointment of a full time occupational health nurse practitioner and the establishment of an occupational health clinic in the month of practical completion.

 

Workplace injuries

The interface between construction and staff activities impacted on safety. Demolition of the buildings saw incidents ranging from windows broken behind a clerk’s back while seated, to the release of asbestos lagging to which staff were exposed. Official workplace injuries recorded in the occupational health register included slips and falls in parking areas due to poor lighting or housekeeping during construction, or on uneven temporary walkways or access routes, as shown in Figures 2 and 3, resulting in strains and sprains. Hand and arm injuries occurred during decanting when staff assisted in moving furniture, resulting in an arm fracture and various hand injuries. The first, progress and final medical reports for these staff members were not accessed for this study, and the outcomes of these injuries are not documented in this study.

  The new neonatology unit was furnished with state-of-the-art service pendants which are rectangular metal service shafts that protrude from the ceiling, providing medical gases for neonatal care of pre-term babies. The low position of these pendants, due to limited ceiling space in a certain area, led to poor ergonomics. Numerous soft tissue injuries occurred when nursing and medical staff bumped their heads on pendants installed at the incorrect height.   This resulted in a costly and tedious process of decanting the neonatology unit and transporting the pendants to a factory in another Province, where they were shortened and service-adjusted. They were then re-installed and re-commissioned in the unit.

Problematic workmanship and design mismatch impacted on cost and increased risk. Roofing and air-conditioning issues aggravated matters and numerous near-misses of ceiling panels falling into clinical areas were reported, with one landing on a staff member’s head, resulting in a laceration and seven stitches. Isolated incidents of poor installations were reported, such as a new security gate and shelving which fell on staff members, causing contusions and abrasions. A breakdown, per hospital staff category, of the 41 workplace physical injuries related to construction activities, as recorded in the occupational health register, is depicted in Table 1.

 

Safety and security

It was generally accepted that the construction process increased technical risks in terms of safety and security, and resulted in many adverse incidents. The safety and security reports of staff were recorded quarterly around incidents such as theft and damage to personal property. Safety and security was compromised by multiple entrances, and unclear boundaries between construction and hospital areas on site. Staff also experienced theft of their personal belongings, including cars.

 

DISCUSSION

Hospital revitalisation results in huge benefits in terms of an improved work environment of the relevant hospital at the practical completion of the project, but staff are at risk during implementation. In this case study, the interface between the construction of an infrastructure revitalisation project and a fully operational hospital posed a particular challenge and tested the resilience of all categories of staff, including management. Decanting proved to be the greatest test for staff endurance.

 In the Bathurst study in Australia, a communication strategy was developed to deal with decanting, which included the names of management staff involved, timelines, benefits, information packs, details about planned changes, impact on existing services, and how information would be communicated to staff and the community.4 In the study reported in this paper, the weekly decanting meetings and ‘Project cast’ emailed weekly by the project manager’s team to all the staff, with information about lockouts and decanting, were deemed to be successful communication tools.

 The literature proposes creating supportive healthcare environments for staff. Studies by the Academy for Design and Health at the Karolinska Institute in Stockholm on the interaction between design, health, science and culture, guide design innovations to create restorative environments.

Hospital design can impact on staff stress.9 This was reflected during interviews with theatre staff and those in the resuscitation room in the emergency section, who felt positive about the fact that they could see trees and mountains from clinical areas. Guidelines for promoting positive staff feelings include comfortable staff break rooms to escape briefly from workplace demands and stressors, and easily adjustable work stations. In this study, the positive effect of the new stylish staff room (Figure 4) could not be underestimated. The new, more spacious wards with murals and furnishing designs introduced by the interior decorator assigned to the project, enhanced staff morale. Sadler et al. recommend the inclusion of evidence-based innovations such as social spaces, respite areas and staff gyms.10 The respite areas constructed at Paarl Hospital, such as an outdoor barbeque area, swimming pool and courtyard for staff, enhanced staff wellbeing.

The revitalisation process had a destabilising effect on staff. Pajak concluded that, despite uncertainty, staff were pressured to provide continuity of care as per their professional responsibility in the face of adversity brought about by revitalisation of a UK hospital.11 A structured change management process, with multidisciplinary teams, contains this destabilising uncertainty. Caring leadership and participative management emerged from the study and literature as a way to provide some support to assist staff in adjusting and stabilising during the constant cycle of change.

Construction and renovation projects pose special challenges for infection control personnel. Infection prevention aspects of construction and renovation projects require large amounts of time and hard work, and it is advisable for infection control clinicians to have a briefing or tailored training to prepare them for the impact of construction activities. Reducing staff stress with the use of ergonomic interventions, as well as careful consideration of air quality, noise reduction, and adequate light, can have a significant impact on staff health during revitalisation.12

Staff wellness or staff assistance programmes are usually linked to human resource management with a health promotion component, while occupational health and safety is managed separately in the realm of risk management, workplace injuries, rehabilitation, and disability management. A conundrum to consider is the combination of employee safety and wellness due to the critical connection between these programmes.13

This study focused on a single case and the limitations are acknowledged. Although the findings cannot be generalised to other settings, they can be used as a comparison for similar studies.  The validity of the results was ensured by a study supervisor being involved in all aspects of the study, multi-method data sources and collection, and triangulation during data analysis.8

 

RECOMMENDATIONS

Decanting emerged as the greatest challenge in this study. During decanting, poor working conditions, a cluttered environment and ergonomic challenges do not support the work of clinical staff.9 One of the recommendations to enhance communication is weekly information distribution and decanting meetings, with well-defined terms of reference.

The medical service pendants in the neonatology unit specifically, but also in theatre and high care, caused workflow problems and staff injuries due to positioning problems and technical complications. In the case of the pendants, close liaison between clinical specialists and nursing staff is recommended, as well as procuring the pendants on contract to ease the installation process.

Infection control personnel should be involved in all phases of these projects to avert outbreaks and to ensure that newly constructed or renovated areas allow staff to follow infection control practices. Investing in adequate infection control aspects of construction, before and during the projects, serves the wellness of healthcare workers. A daily construction survey sheet to ensure compliance with these measures is recommended.

The measures proposed in the literature to contain mould seem costly for the South African public sector context. Prevention should, however, be considered through processes such as sealing windows, keeping patient room doors closed, cleaning and dusting rooms daily, painting surfaces with an antifungal preparation, and considering the use of portable HEPA filter air purifier units.

Design for staff respite and comfort enhances staff morale, as does a structured change management process on such a project. An extensive occupational health and safety service with an integrated staff wellness programme, which encompasses health promotion, employee assistance, and disability management, would be of benefit.13

A key recommendation of this study is to do a thorough risk assessment of the entire revitalisation project. Risk management should be applied to mitigate risks of staff injury, low morale, inadequate infection control, and safety and security practices. This will supply accurate and timely information to corporate governance stakeholders about the hospital’s key risks during revitalisation.

 

CONCLUSION

Hospital revitalisation projects are increasingly being embarked upon in South Africa as part of the overhaul of health facilities in preparation for the NHI. In the context of an increasingly complex and technologically sophisticated economic system, tax payers, investors and stakeholders require that management takes the necessary steps to protect their interests in terms of healthcare facility investment and the health and safety of human resources for healthcare delivery.2

Staff are vulnerable to the chaos and change management requirements during revitalisation, which stretches staff morale and endurance. They are exposed to safety and security risks, and have occupational health risks to consider. Infection prevention and control is challenged by the inevitable dust and debris, and the overcrowding of decanting. Employers embarking upon hospital renovations should ensure that staff are protected from risks to their health and safety. Senior management should take all reasonable care to ensure staff wellness throughout the project. An effective change management process serves to avert some of the challenges experienced by staff during the Paarl Hospital HRP.

The light shed on issues around staff safety and security during revitalisation, in addition to a better understanding of staff perceptions, experiences, and insights, contributes to a customised risk management programme to address key risks in a systematic manner.  It is therefore important for the revitalisation of hospitals in the future, that government policy should define the range of risk management activities required in HRP implementation, as well as where or at what stage they might be appropriately applied. Deliberate consideration should be given to the integration of staff safety and wellness and the range of essential risk management interventions required from the conception of a new hospital revitalisation project through to practical completion and beyond.12

 

LESSONS LEARNED

1.  Robust infrastructure contract and site management, with thorough risk assessment, is required prior and during health facility renovations to contain infrastructure consultant- and contractor-related safety concerns

2.  Staff resillience needs to be nurtured throughout with a hospital revitalisation process through effective change management and encouraged utilisation of the staff wellbeing programme

3.  Establishment of a comprehensive occupational

     health and safety system is essential during the

     planning phase and throughout the hospital

     revitalisation programme

DECLARATION

The authors declare that there are no conflicts of interest.

 

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the financial support provided by DENOSA towards completing a doctoral degree; this paper is based on some of the results of the thesis. Ceridwyn Klopper is also acknowledged for manuscript review assistance.

 

REFERENCES

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4. Bathurst suspends surgery after safety concerns, February 18, 2008.   Available at: http://www.abc.net.au/news/2008-02-18/bathurst-hospital-suspends-surgery-after-safety/1046030 (accessed 5 May 2008).

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6. Fiorenza M. Construction of a centre for Oncologic X-Ray activity. Unpublished paper delivered at the Congress of the International Federation of Health Engineering. Cape Town; 2006.

7. Loo V, Bertrand C, Dixon C, Vityé D, De Salis B, McLean A, et al. Control of Construction – associated Nosocomial Aspergillosis in an antiquated Haematology Unit. Infection Control and Hospital Epidemiology. 1996; 17(6):360-364.

8. Bowling A. Research Methods in Health. Berkshire: Open University Press; 2009.

9. Rynor B. Beautifying hospitals: a tough sell. Can Med Assoc J. 2010; 182(13):E633-E634.

10. Sadler BL, Berry LL, Guenther R, Hamilton DK, Hessler FA, Merritt C, et al. Fable Hospital 2.0: The Business Case for Building Better Healthcare Facilities.  Hastings Centre Report. 2011; 41(1):13-23. 

11. Pajak S. A qualitative investigation of patient and staff experience across multiple clinical services: The case of a redevelopment programme at an English Acute Hospital NHS Trust. [Unpublished dissertation]. London: Brunel University; 2009.

12. Lourens G. Implementation Framework of the Hospital Revitalisation Programme in a regional secondary level hospital in Paarl, South Africa. [Unpublished dissertation]. Cape Town: Cape Peninsula University of Technology; 2015.

13. Ozer I. Safety and wellness: The Critical Connection. Occupational Health & Safety, September 1, 2013. Available at:  https://ohsonline.com/Articles/2013/09/01/Safety-and-Wellness-The-Critical-Connection.aspx  (accessed 5 May 2016)

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