Risk assessment for midwives in the choosing

Transkrypt

HEALTH AND WELLNESS 4/2014
WELLNESS AND SOCIETY
CHAPTER IX
Institute of Obstetric Propaedeuties Chair of Woman’s Health
Health Care Department Medical University of Silesia in Katowice
Zakład Propedeutyki Położnictwa Katedry Zdrowia Kobiety
Wydziału Nauk o Zdrowiu
Śląskiego Uniwersytetu Medycznego w Katowicach
1
Chair of Woman’s Health, Health Care Department
Medical University of Silesia in Katowice
Zakład Profilaktyki Chorób Kobiecych i Seksuologii
Katedry Zdrowia Kobiety Wydziału Nauk o Zdrowiu
2
3
Institute of Nursing and Social Medical Issues
Chair of Nursing Health Care Department
Zakład Pielęgniarstwa i Społecznych Problemów Medycznych
Katedry Pielęgniarstwa Wydziału Nauk o Zdrowiu
4
Department of Health Promotion and Community Nursing
Chair of Nursing Health Care Department
Zakład Promocji Zdrowia i Pielęgniarstwa Środowiskowego
Katedry Pielęgniarstwa Wydziału Nauk o Zdrowiu
MARTA MAJCHRZAK1, BARBARA KOTLARZ 2,
MARIOLA CZAJKOWSKA1, KATARZYNA STAWICKA2,
CELINA GOGOLA2, MONIKA MAZUREK1, IZABELA MĘŻYK2,
MARIOLA BARTUSEK3, KATARZYNA LESZCZYŃSKA4
Risk assessment for midwives in the choosing place of work
Ocena ryzyka zawodowego na wybranym stanowisku pracy położnej
Wellness and society
Key words: midwife, risk assessment, occupational hazards, occupational risk factors, working environment midwife.
Słowa kluczowe: położna, ocena ryzyka zawodowego, zgrożenia zawodowe, czynniki ryzyka zawodowego, środowisko pracy położnej.
INTRODUCTION AND AIM OF THIS STUDY
Work in each of our lives is not only an important element of human activity, but
often it is also an additional factor motivating and encourage others to take action
[2]. The amount of time spent at work support the conclusion that it is, generally
speaking, half of human activity during the period of his best mental and physical
development [13]. For this reason, to provide safe working conditions became a
priority for social action and the law was grounded in the Polish legislation. The
duties of the employer is therefore create a safe working environment, monitoring
and informing the employee of the results of the evaluation [21].
But not only the employer is obligated to conduct a job in terms of its safety for
the employee. The vast part of the responsibility for health and safety in the workplace rests with the employee. Labor laws give special attention precisely on the
principles of safety, defining this requirement as the primary duty of the employee.
Hiring staff is also associated with the partial transfer of responsibility for company
functions. That the employee could find themselves in a given situation, must have
the necessary knowledge about the scope, area and level of delegated his powers and
duties [13]. Nothing but top-down regulations will not affect strongly on improving
working conditions, if the employees themselves do not appreciate their role in this
regard. This can be achieved by increasing awareness of the impact of occupational
hazards in the environment of people working and providing knowledge about risk
factors and conditions governing the safe operation [21].
The issue is also a moral obligation to care for our own health, resulting from
working in the healthcare industry. Activities in this field should not only be the
priorities in relation to the charges, but the values are actively protected by the
workers themselves. The adverse effect of some environmental factors can not,
technically speaking, affect not only productivity, but also by reducing the capacity
for reproduction and deterioration in the quality of genetic material, significantly
affect the health of offspring, and in extreme cases, even prevent its possession.
Therefore intense protection of women is dictated by the broad public interest [21].
Aim of this study is to analyze a typical working environment of the profession
of midwife in the delivery room unit on the basis of the available research material
and the available literature on health & safety and risk assessment in the workplace
as a midwife.
The choice of theme is the justification for high feminization of the profession
and the related public interest in maintaining the health and behavior, not only current but also future generations.
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Marta Majchrzak, Barbara Kotlarz, Mariola Czajkowska, Katarzyna Stawicka,
Celina Gogola, Monika Mazurek, Izabela Mężyk, Mariola Bartusek,
Katarzyna Leszczyńska
THE RESEARCH MATERIAL
The study was conducted in stages from October 2007 to January 2010 in the
one of hospitals in Silesia. The first stage of the analysis concerned the working
conditions of midwives working in the unit of hospital room.
The next step was to identify workplaces and identify risk factors. The last stage
of the study was a comparative analysis of the most commonly used for jobs in
health care methods of risk assessment (PHA, RISK SCORE).
Selection was based on the hospital ward wide range of activity and structure in
which that is organizationally separate section of the department of Endocrinology
and High Risk Pregnancy. Functionally serves as a meeting pre-and perinatal, obstetric, neonatal, and observation rooms and intensive care in case of obstetric urgent
states in obstetrics. The unit includes two double bed rooms, one bed room with the
possibility of water immersion, and a hall preparatory to the position neonatal and
social part, plus bathroom, which is a also a place of physical preparation for childbirth giving birth. Childbirth block directly adjacent to part of the Operating block.
The study group consisted of 12 midwives, the midwife ward. The age of respondents was in the range 28 - 54 years and 2-29 years work experience. Three
midwives had a higher education degree, two - higher vocational education, including a further specialization. Other midwives had a secondary education degree.
METHOD OF RESEARCH
The research interview was used as a method of psychological measurement,
carried out based on the original questionnaire interview. It is characterized by the
possibility of standardization, although smaller than, for example, a questionnaire,
but picked up after following the steps makes it possible to obtain more detailed and
direct information about the course of specific work processes [41]. Interview questionnaire contained questions concerning the position of equipment, the availability
of protective and adverse factors, as well as knowledge of the standards of conduct
and use of protective measures. Midwives also were asked about any difficulties,
problems and limitations, as well as the applicability of solutions to simplify your
work.
Data obtained using this method was supplemented by direct and participative
observation [37]. During the study focused on the observation of the process of
compliance with applicable operation scheme of the procedure, the use of personal
protective equipment and the availability of equipment. In order to eliminate the
impact of the subjective assessment of the person examined and the examiner, some
of the processes of work fixed by the photographic observations [37]. However, due
to limitations of behavioral methods (different time occurrence of each activity), was
used also by archival analysis in the following documentation:
 instructions using inside in the unit,
 analysis of accidents and incidents potentially accidental, according to a
notebook stab and accidents,
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 existing standards of practice
 equipment manuals,
 plates with technical information of equipment
 charter of dangerous substances [11].
To assess the workplace PHA and the RISK SCORE methods was used, as recommended and most common method used for valuation and risk assessment of
complex and complicated work processes [33]. The study also used a purposeful,
based on criteria of thematic literature review covering the years 2000 - 2009.
THE RESULTS
WORKPLACE
In practice, organization and management issues of work includes the determination of the object - the object of work, workplace equipment, determining working
methods and how to handle the job. Individual job is the part that arises from the
internal organizational division of labor. So the workplace is the smallest in the
structure of the organization of a system of action, which forms part of the system of
higher order. The work station is not subject to division into subsystems [15].
The work station is analyzed in the following aspects:
1) aspect of the space in which processing takes place effort,
2) economic aspect, the specified ambient conditions, where work processes
run,
3) psychosocial aspect, the factors affecting their workers [18].
On the basis of the collected material distinguished functionally the workplace
direct and indirect contact with the patient.
Direct care and treatment activities performed at the bedside of a midwife patient, delivery chair, in a newborn corner and using the auxiliary equipment during
transport the patient on a trolley lying or sitting. In some cases, the midwife can
provide direct assistance to the patient using the points of sanitation in the bathroom.
The point of a treatment, hygiene maintenance, administrative work and the social
component is the position of indirect contact with the patient. A detailed analysis of
the positions illustrated in Table 1.
Table 1 Identification place of work
Delivery room
Place of work
Name of room
Midwives duty
office
Double delivery
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in direct contact with the patient
 neonatal corner;
 patient bed,
indirect contact with the
patient
 point of a treatment,
 point of hygiene,
 point of administrative
work,
 the social component;
Delivery room
Place of work
Name of room
in direct contact with the patient
 chair of birth,
 ancillary equipment (exercise ball, Sako bag,
mattress, chair of childbirth);
 chair of childbirth
One bad delivery  Bath
room
 ancillary equipment (bed accessories, exercise
ball, chair of childbirth);
 point of personal hygiene item (couch),
Bathroom
 Shower,
 sink,
 toilet;
 stroller lying
Coridor
 stroller sitting;
rooms
indirect contact with the
patient
work;
work;
 poin of preparation
work;
CHARACTERISTICS OF ACTIVITIES IN THE DELIVERY ROOM
Based on the analysis of the collected material characterization was performed
by midwives actions in direct and indirect contact with the patient. Difficult and
responsible work of midwives is to accompany the woman and her family in a special situation which is pregnancy and childbirth, as well as the provision of benefits
in saving human life and health in the course of obstetric pathology. Requires specific predisposition to the profession and availability for work. It is also fraught with
many problems of everyday life. Furthermore, midwives are working in continuous
operation, which involves the performance of work at night also. This represents an
additional burden not only mental and physical, but interfering with the basic circadian rhythm, the biological [21].
The activities of direct contact with the patient are connected with the operations
directly on patient care, as well as its close proximity to:
• adoption / transfer of patients in the elective,
• adoption / transfer of patients to emergency
• preparing pregnant for Caesarean section in elective or emergency,
• measurement of vital signs, including emergency health and / or life
• conducting education and health promotion with the patient and her family,
• establish / remove peripheral venipuncture,
• Connect / disconnect an intravenous drip,
• the supply of drugs administered orally, parenterally, vaginally, rectally,
• blood sampling for laboratory analysis
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• surveillance of the fetus (NST / OCT / CTG monitoring),
• Bladder catheterization,
• preparation of obstetric patients for surgery:
o arrangement of position,
o psychological support,
o assistance during surgery,
o episiotomy,
o perineal tissue protection,
 assistance in activities of hygiene in the patient supine (an independent and a
dependent):
o toilet of the body in the bed / help in performing the toilet in the
bed,
o change pads / help in changing the inserts,
o perineal shaving / surgical field
o toilet perineal
o application / removal of the pool,
o change of underwear / bed / help in changing underwear,
o making a bed empty / with the patient,
 construction of enemas,
 transport patients to / from the bathroom in a wheelchair sitting,
 assistance in the performance of personal hygiene in the bathroom,
 assistance in the preparation and eventual adoption of meals,
 maintenance and parturition,
o an obstetrician's external and internal / assist at trial
o use of facilities (Saco bag, exercise ball, mattress, chair childbirth,
shower, massage),
• conducting second stage of labor:
o protection of the perineum,
o episiotomy,
o birth of the fetus,
o assessment of the newborn, supllay and identification of the infant,
• conducting third stage of labor:
o give rise to the placenta,
o assessment of the placenta,
o suturing cut or ruptured perineum,
• care in the fourth stage of labor:
o postpartum supplies of women in puerperium piriod,
o observation of general and obstetric condition
o help newborn to catching the breast,
• Supply postpartum newborn:
o assessment of Apgar scale,
o observation during the first contact newborn with the mother after
birth,
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o take newborn of cesarean section (neonatal assessment, establishment of identifying armbands, cut of umbilical cord and umbilical
stump supplies),
o measurement circuits, the length and weight,
o execution procedure Crede
o participation in the resuscitation / CPR infant,
o newborn transfer to the maternity ward,
o neonatal transport in incubator,
• provide the patient in the maternity ward / septic / operating theater in a sitting position or lying
o move or help to moving the lying patient into the trolley,
o assistance in moving the wheelchair sitting,
o transfer of the patient in a wheelchair sitting or lying,
The activities directly related to patient care include administration, preparation
and cleanup. For jobs in the delivery room identified the following indirect contact
with the patient:
• establish and keeping records,
• social / hygienic / surgical hand washing,
• establishment of sterile clothing,
• preparing the supply of the infant,
• the transport in incubator
• set-up obstetrical procedures:
o perineal suturing / other obstetric injury,
o amnioscopy,
o amniocentesis,
o removal of the disc / neck seam,
o instrumental control of the uterine cavity,
o establishment of vacuum extractor,
o establishment of obstetric forceps,
• set-up, intravenous blood transfusion / infusion drip
• set-up, enemas,
• preparing the set for catheterization of the bladder,
• set-up, injection / blood collection,
• prepare a set and collect umbilical cord blood:
o blood gas analysis
o the blood group and BTA
o on stem cells
 set-up and download the material for histopathological examination,
 preparation of medicaments for the supply of oral and parenteral
 preparing a solution of disinfectants,
 preparation and distribution of meals, including the preparation of hot
beverages
 The transport truck lying / sitting
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 organize the workplace,
 washing and cleaning tools and equipment,
 picking and packing kits / including the need to use the welding machine
located on another floor /,
 folding laundry and packing operations,
 the transport sets to / from sterilization,
 the transport of material from the handy magazine.
Midwives work also accompany physical exertion associated with the preparation and carrying out direct patient care and the psychological stress resulting from
exposure to disease and suffering of others, especially in situations easily, because
of gender, identification with the patient. Another aggravating factor is time pressure, especially felt when performing activities related to providing emergency services in health and / or life [21].
Physical stress, which accompanies the work of this branch of midwifery result
from the activities of preventive, diagnostic, therapeutic, rehabilitative, and hygienic
and nursing care for patient. This implies a need for example: lifting, carrying and
transporting patients, equipment and medical equipment, as well as taking an comfortable body posture [21].
The remaining task is also to care for and ensure the safety of everyone residing
in the ward in the course of duty.
IDENTIFICATION OF HAZARDS
As a basis for hazard identification were used the following documents:
• analysis of accidents and incidents potentially accidental,
• analysis of technical documentation (manuals, plates with technical information of equipment, cards of hazardous substances),
• direct observation and photographic processes work,
• data from the questionnaire interview,
• examples of risk assessments for similar positions [11].
Data obtained midwives recognized as the most onerous threat of biological
agents, especially viral hepatitis, HIV and tuberculosis. It occurs as the potential
exposure to infection. The test also identified health effects resulting from occupational exposure to these factors. These results are shown in Table 2.
Table 2 Biological risks and their possible impact
Biological factors
HBV, HCV
HIV
Mycobacterium tuberculosis
Staphylococcus aureus
Possible health effects
severe infection of viral hepatitis and its consequences
death due to AIDS syndrome
severe systemic infection
light to moderately severe infections
Analysis of accidents and incidents potentially accident also pointed to numerous
instances of occupational exposure biological material. For the most frequent events
were needle-stick injuries, contamination of fetal blood and amniotic fluid. Accord126
ing to respondents the issues affecting growth of adverse events was in a hurry, time
pressure, and too few people on duty. Relevance assessment is confirmed by the
results of direct observation and photographic work processes, which indicate that as
the need to accelerate the run-time activities (eg in cases of risk health or life) decreases the degree of compliance with safety and behavior rules and procedures:
inject in the peripheral without gloves, "throwing" necessary equipment poisoned
gloves, etc.
As another group of midwife aggravating factors in her work respondents considered the psychological factors. They reveal the most in cases of health and life of
the patient or her child, both need to make quick decisions and actions. Awareness
of the importance of this responsibility and the effect of actions that are relevant not
only to preserve the health or life of two people at the same time, an additional factor aggravating the midwife at the workplace.
A major problem in assessing the midwives were also difficulties with interpersonal interactions. These conflicts occur not only in their own profession, but also in
dealing with other employees of the therapeutic team. Definitely, however, more
attention was paid to the conflicts on the level: the midwife - a doctor. Psychological
factors as a source of danger in the workplace are presented in Table 3.
Table 3 Psychological risk factors
Source of danger
Possible consequences
Action under time pressure mild to severe psychosomatic diseases
Stress
mild to severe psychosomatic diseases
Interpersonal conflicts mild to severe psychosomatic diseases
A significant element, affecting the assessment of psychological factors is the
fact that the identified factors were felt to be undesirable, regardless of the type of
activity. The impact of psychological factors were signs of burnout in varying degrees. Another group evaluated the occupational risk factors, physical factors are
presented in Table 4.
Table 4 Physical occupational risk factors and their possible impact
Source of danger
 permanent elements of workplace
equipment
 contact with the patient frightened /
aggressive
 moving parts / handling in the
workplace
 the need to move;
 wet flor
 forced the position of the body,
 the need to lift and carry patients
 physical injury: a blow, contusion;
 physical injury: pressing, crushing;
 fall on same level
 physical injury: sprain, dislocation, fracture;
 overload the musculoskeletal system: diseases of the
musculoskeletal apparatus;
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






Source of danger
part of an electric powered
artificial lighting
reflection of light;
noise,
monotony of sound;
contact with hot water
adverse microclimate
 death by electric shock;
 tiredness of the eyes;
 irritability, fatigue, deconcentration;
 thermal injury: scald;
 thermal injury: overheating;
Physical stress associated with performing activities of preventive, diagnostic,
therapeutic, rehabilitative, and hygiene - care in patient care, including directly with
the necessity of lifting, carrying and transporting patients, equipment and medical
equipment, as well as taking a forced, often bent posture.
Also, the possibility of using water immersion or accepting delivery in the water
creates, in the opinion of staff, additional risks associated with operating electrical
equipment wet or even just wet hands, especially in situations requiring a hurry.
The results also pointed to the adverse effects of microclimate, caused by the
need to ensure proper temperature the patient and her newborn baby, steaming hot
water over a large area in the event of water immersion, and also due to the need for
additional protective clothing (rubber apron or sterile foil and clothing: apron,
gloves, hat and mask) when working under radiant heat (Fig. 1). In particular, this
negative aspect was felt in the summer, at high ambient temperatures.
Fig. 1 Microclimate hot - work in an additional protective clothing under radiant
heat
The sudden occurrence of obstetric pathology involves the patient's rapid exit
from the tub or shower. There is therefore the possibility of slipping on wet surfaces.
In addition, fear of patient or her relatives about the health or life may be a factor in
exposure to physical injury as a result of a panic reaction to the threat.
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Among the physical factors affecting adversely also mentioned artificial lighting
and the resulting luminance of light reflection from the shimmering surface of the
furniture. As it was particularly disturbing glare reflective (Fig. 2).
Fig. 2 Diffuse glare
Of other physical factors have been identified noise caused by contact with medical equipment and organization of work (greater number of people on the morning
duty). It also stressed the threshold of subjective perception of noise nuisance and
the monotony of such a ticking clock, the sound of dripping water and evenness of
sound equipment working, as evidenced by a particularly detrimental when performing tasks requiring precision and increased vigilance, as well as at night, where it
was suggested that these sounds cause irritability and fatigue faster.
Among the hazards of chemical exposure to these materials were considered allergenic and irritating (disinfectants, medicines, personal protective equipment).
Occupational exposure to chemical agents in the field there have mostly during the
preparation of parenteral drugs for supply, liquid disinfectant preparation and use of
personal protective equipment (in particular latex gloves). Activities related to this
type of exposure is accompanied by direct caregivers (perform nursing activities hygiene) and indirect (preparatory acts, law enforcement, including disinfection).
They are presented in Table 5 As a consequence of its impact, the test recognized
the possibility of allergies and irritation of mucous membranes.
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Table 5 Chemical occupational risks and their impact
Factor
Drugs
Disinfectants
Personal protective equipment
The possibility of exposure
 fluid gushed from the the ampoule during
dissolution of the drug,
 camera slipped into fluid shunting of fluid
from the plastic bag for transfusion;
 splash of disinfectant liquid preparation,
 Inhalation of vapors prepared solution;
 needle-stick/prick / injury during the washing and cleaning equipment,
 splash in the preparation of biological material for histopathological examination
(contact with formalin);
 To exercise direct patient care,
 Execution of preparation and cleaning;
Effects
 low-grade infection (allergy);
 irritation of the mucous
membrane of the eye;
 irritation of the mucous
membranes of the respiratory system;
Comparison of risk assessments at the point of newborns made using the methods of PHA and RISC SCORE
The choice of method for evaluation of working conditions remain the responsibility of the evaluator. Method of assessment should, however, correspond to the
nature of the business, organizational structure, applied technologies, means of production, etc. When selecting the method should also be guided by her knowledge,
the ability to use, versatility and the desired degree of precision [32].
Workplace evaluation process, a midwife is a high degree of complexity and the
difficulty. The complexity is due to the multidimensional aspect of the job as a
midwife, and the difficulties arise from the complexity of the work processes themselves. It is not always appropriate or possible, due to the logic function, the distribution of its constituent parts. Therefore, in estimating the losses to be made a detailed analysis of all elements of exposure, but comprehensively evaluate the effects
caused by them [32,33].
Factor that hinders risk assessment is the choice of the method. Simple, very
complicated methods such as PHA, while being easy to use even for people with
little experience in the field of risk assessment, however, may not reflect all aspects
of exposure. To complete the risk assessment required by this method is to identify
hazards, sources of their formation, assessment of harm and likelihood of occurrence. For each of these sources of threat to isolated risk factor, and determine the
possible effects of preventive measures implemented. Then, the effects are assigned
to the appropriate level of damage (S) and estimated the possibility of their occurrence (P) (Fig. 3). The master table at the intersection of the "S" and "P" reads the
value of risk "R" [10,31,32,33].
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Fig. 3 Components of methods: PHA and RISK SCORE
Risk assessment method for PHA showed that occupational exposure of midwives in neonatal point is in the range of "acceptable risk" (for a value of 1 - 3) "acceptable after the acceptance of risk" (for a value of 4 -9). The greatest risk value
R = 8 was obtained for the threat to the hot climate. For other biological agents, and
the risk of physical injury and the risk of stress value is 6 While evaluating the overload of traffic and the risk of chemical agents is equal to the second The factor of
exposure to blood and IMPI estimated risk at level 6, which allows you to work in
this position following a risk assessment (Table 6). Assessment of the likelihood of
consequences, rather than an event, facilitate the estimation of potential damage, but
does not indicate the frequency of exposure to it [31].
Table 6 Exposure assessment for exposure to blood and IPMI by PHA
Type of risk
Effects „S”
(lovel)
Exposure to blood
and IPMI
(hepatitis, HIV)
S=3
serious injuries
significant
damage
The probability of
damage „P”
(lovel)
P=2
unlikely
occurring once in 10
years
Assessment of risk
R=SxP
R=6
acceptable approval after the
risk assessment
The risk assessment RISK SCORE method requires, in addition to identifying
threats and their sources, evaluating the risk and likelihood of an event, an additional
assessment of the frequency of exposure (Fig. 3) [10]. For each of these sources of
threat were isolated risk factor, possible injury and determined the frequency of
exposure and likelihood of occurrence. It was also implemented preventive
measures. Effects assigned to the appropriate level of damage (S), and then estimated the frequency of exposure (E) and the possibility of the event (P). The resulting
numerical values multiplied by the following formula: S x E x P and obtained in this
way, the value of risk (R). The model table assigned to read the values obtained for
each category of risk and preventive action. For most of the identified factors, the
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exposure value E is "6", due to the fact that midwives working in shifts (12 hours)
these actions are carried out at least a few times during the call. Additionally, we
should take into account the existence of health emergencies or neonatal life that
require quick decision-making, not only but also actions. It is not so simple unconditional transfer of the popular methods RISK SCORE (created for the U.S. Navy)
into the hospital, because some problems may hinder the estimation of the likelihood
of injury or event. An important feature of this method is the possibility of some
elements of risk assessment as a constant exposure, such as a seaman during the
voyage is always vulnerable to drowning, regardless of their operations [31]. Treating each patient as a potential source of infection, so you qualify for exposure to the
exposure of certain factors as "permanent" or frequent, regardless of the type of
activity. The problem in applying this method may, however, estimate the frequency
of exposure when working in 12-hour clock. The work of a midwife in the delivery
room because you can not predict the permanent schedule occurrence of specific
activities, for example, not every duty end with the adoption of confinement, for
several, several duty may not be necessary to prepare patients for elective or emergency caesarean section, or on the contrary, this situation can occur many times
during the next duty. The changing conditions of occupational exposure may also be
the result of sudden deterioration in patient health status, or overlapping and additive
risks.
Evaluated by this method risk factor: exposure to blood and IMPI, showed a risk
value of R = 126th. This is a category of "important risk" that requires corrective
action is the result of inclusion in the assessment of an additional factor, which is the
frequency of exposure (Table 7), which significantly influenced the final risk value.
Table 7 Exposure assessment for exposure to blood and IPMI using RISC SCORE
Probability „P”
Risk
of a risks
R = S x E x P / asses(numerical
ment of risk
value)
S=7
E=3
P=6
R = 126
Exposure to
blood and IPMI large / serious occasional / at least
significant risk / needs
quait possible
(hepatitis, HIV)
injury
once a week
improvement
Type of risk
Effects „S”
(numerical
value)
Frequency of exposure „E”
(numerical value)
Isolation and individual exposure assessment of this factor does not fully reflect
the risk arising from the process of working in conditions that require urgent action.
The evaluation of each factor in a situation typical of exposure and the existence of
stressors lead to a double assessment of one workplace. In the case of jump risk
from acceptable to unacceptable level of risk the employer would be forced to ban
their work in this position in a hurry and need to take action to lower this risk. While
working in conditions typical for the same activity would be permitted.
The factors: stress and the risk of physical injury associated with the impact of
the subject property, the value of the risk set at 54th This category requires only
occupational risk of audit activities. The values for other risk factors, exposure does
not exceed 18, thus providing an acceptable risk category. Corrective actions for this
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category provides for the control position. Comparing used for risk assessment
methods for PHA and RISC SCORE, observed differences in the valuation of risk
for the same factor for a given position. These differences are caused by a choice of
different parameters of evaluation, may significantly influence the final risk assessment. The use of simple methods, two parameter may lead to underestimation of the
estimated value of the risk and undervalue the aspect of exposure. Inclusion of an
additional parameter value may increase risk and lead to the need for corrective
action.
Despite the difficulties in choosing a method, carrying out risk assessment even
less perfect method is better than no assessment at all positions. Difficulties in assessing the risk factors for not just pay special attention to evaluating and analyzing
the work process may indicate situations where elimination would reduce the risk to
life or health worker. But it is important to assess risks in the medical professions
reflect the current status of occupational risk and allowed to take adequate steps to
risks.
DISCUSSION
Midwife workplace is the position of a complex, involving both the functional
dimension and subjective. Functionally understood the scope of job activities attributed to the employee to perform, resulting from the division of the general organization of the sub-goals. Modification of job analysis in terms of subjective proposed
by Ksykiewicz-Dorota, describing them as a place the employee in the organizational structure in terms of access to power, which divides the job of executive and managerial positions [15, 18]. Moreover, considering the work of a midwife seems sensible separation of concepts: the workplace and workstation [16,18]. For example,
the segmental midwife job will consist of individual work stations, among others
point of administrative work, whether a treatment point of the patient bed.
Workplace assessment can be made in the context of diagnosis (actual) and
prognostic (model). Analyzing jobs in health care, do not settle for reaching the state
average, but you try to achieve the optimum condition [2,18].
Considering the negative impact of work environment factors on the health
worker can be divided according to the hazard, or because of their origin. Nuisance
factors such as labor to physical activity, shift work system adverse weather conditions or climate, as well as not ergonomic or forced posture. Contrast, chemicals
such as gases, aerosols, dust and physical (noise, vibration and radiation) is one of
the factors that are harmful. Factors can be dangerous immediate health hazard and /
or life and require strict application of specific protective measures [13,22].
Legislative requirements (eg the obligation to carry out a risk assessment) and
raise awareness of professional staff, general working conditions and technical development - economic development makes it decreases the mortality caused by
accidents at work, but growing number of cases of occupational diseases. Epidemiologic studies have shown that the incidence of infectious diseases among health care
133
workers is higher among workers with both short (little experience) and long (routine) work experience [22].
The biological hazards in the workplace midwives are the most important nosocomial infections, which are dealt with in terms of contact with the patient, the patient with a health professional or health care professional with the patient [22]. The
level of occupational risks associated with biological hazards affect not only the risk
of the infection, but also the risk of health effects and its ability to protect themselves against the damaging effects [26]. It should be remembered also on the presence of factors "outside the infectious" affecting the increase in hospital infections,
which include both their own behavior (among others. Inappropriate hygienic habits,
non-sanitary regime) as well as factors related to work organization (eg, inadequate
housing conditions , improper operation of sanitary-epidemiological division) or the
development of science [10.22]. German sources estimate that each year more than
500 000 employees is needle stick injury [1]. U.S. statistics, in turn, indicate that at
600 000 - 800 000 registered number of stab more than half of incidents happened to
nurses [35]. Also in the Birmingham study showed that nearly 40% of the respondents has been worn needle injury [4]. In 40% of cases of hepatitis B and C among
health workers is due to occupational exposure [35].
Own wounds, injuries and lesions on the skin or mucous membranes increase the
risk of infection, the employee at the time of contact with infectious material. It was
found that over three-quarters in the skin lesions are associated with the exercise of
ordinary care and hygiene and most of them are associated with self harm (84%).
Only 5% arise in connection with injuries caused by a colleague and 11% of the
patient [19,22]
An important risk factor is also the possibility of contamination of food and
foodstuffs by the biological material contaminated outer clothing (working) staff
[14]. In 2004 Poland was diagnosed in 210 cases of diseases caused by biological
factors, including infections, 136 were hepatitis B and C [5].
Thus, HBV infection, which in 55-60% of cases of hepatitis B has a proven link
to medical treatment remains a serious problem among the biological agents. The
greatest risk of HCV infection is associated with hematogenic, and the largest age
group among the states most often this type of infection as an occupational disease,
is a nurse at the age of 30-39 years [22].
Tuberculosis, was the second after hepatitis, an occupational disease recorded in
Poland, still represents an increased risk of occupational infection, bacillus, despite
the decline in incidence since 1998, when he recorded 192 cases in 2003 and 2005
alone more than 100 less, but due to the effects of health and social number of new
cases is still regarded as very high. In relation to nurses and midwives in 2003, tuberculosis as an occupational disease held in more than 47 people, representing over
half of all registered cases [35]. Also, studies conducted in Turkey, Estonia, Croatia
and Japan indicate an increased risk among health care workers, especially pulmonary and pediatrics departments. You can not miss here included workers directly in
the environment, such as environmentally midwife - the family [22].
134
Nurses also excel in the statistics of occupational HIV exposure, followed by
doctors and laboratory staff. Worldwide, hundreds of documented cases of HIV
infection in the workplace health workers. But even among these cases, nonbusiness can not ignore the risk factors that may affect as many as 95% of cases
[19].
Also frequently encountered biological agent in a population of CMV is cytomegalovirus, which, depending on the socio-economic environment can infect even
40-100% of the population. Viral shedding lasts for a long time after the transition
from primary infection in latent form, through saliva, tears, urine, milk, vaginal
secretions and semen. In the absence of signs of infection, reaching up to 99%, the
infection may be an important risk factor in terms of professional work as a midwife
[22].
In recent years, an increasingly important threat is the growth of fungal infections. Fungal source of infection can be both patient and staff of the hospital environment itself. It is estimated that up to half of the lesion within the nail plates are
caused by fungi, which occur in the adult population is estimated at 15-70%. The
diversity of transmission routes (oral, inhalation, or sexual contact), ease of growth,
an excellent preparation for life, combined with inadequate knowledge about the
symptoms and the presence of enabling factors (such as hospital complex nutrients)
and underestimation of fungal aspect of hospital infections, exacerbate trend. The
most important fungal pathogens in the epidemiology of hospital infections include
fungi of the genus Candida, which occupy fourth place as a factor causing hospital
infections [10,22].
Another group of an occupational exposure to chemical agents. Chemical regarded as harmful, if the conditions of contact with the human body can cause certain biological or health effects directly during or after exposure, and even in subsequent generations [29]. It is believed that each year there are approximately 2 000
new substances, and their total number exceeds already 100 000 [30]. So, in the
work environment is also a midwife chemical agents will represent a serious problem. Absorption occurs by inhalation, skin and gastrointestinal tract, and the adverse
effect may manifest itself in a toxic, irritating, allergenic, carcinogenic, mutagenic
and an impediment to the functions of the body [22, 24].
Toxicity effect of each chemical is dependent on its physicochemical properties
(eg chemical structure, solubility, dissociation and ionization) and the biological
properties of the body, which works (cell structure, and porosity, sex, age, genetic
characteristics, coexisting illnesses, etc.) [22,28]. The WHO data shows that chemical poisoning are in fourth place among all causes of death [30].
An important but often overlooked feature of exposure to chemical agents is
their accumulation of actions. A wide range of the measures and the associated large
number of peer interaction opportunities mean that interactions occur at different
stages of each process, and their ultimate effects are difficult to predict [34].
The research of the American Institute for Occupational Safety and Health
(NIOSH) that is used in hospitals, almost 160 of irritants and 135 having a carcino135
genic, mutagenic and teratogenic [40]. Particularly at risk are those working in the
fields of surgical, endoscopic, X-ray workers, cleaners [8]. Toxic effects may be
manifested locally (irritation, allergy), organ, or have a long-time effects: cancer,
fetal damage, gene mutations. Result of exposure to chemicals may also be acute
and chronic poisoning, the latter being predominant in the course of occupational
exposure. Irritating to eyes and skin act primarily acids, alkalis and organic solvents.
The airways are damaged by the steam and gases [22]. It should be remembered that
chemical brings not only as described above, the risk for those directly affected, but
the nature of explosive or flammable substances may cause some of the risk of a
third party, such as the behavior of compressed oxygen in contact with fats, synthetic materials (grease, fat creams, synthetic clothing) [15,24].
Situations where there is contact with toxic agents, among others.:
 preparation and use of disinfectants and disinfectant,
 preparation of intravenous drugs and drug-commissioned,
 assistance during anesthesia,
 short-term administration of oxygen,
 use of protective equipment during treatments nursing hygiene
 sterilization process and contact with the material sterilized (especially gas
sterilization) [22, 41].
Another group poses an occupational hazard, there are physical factors which
include: elements of workplace equipment, noise (including the Infrasonic and ultrasonic), microclimate, electromagnetic radiation (in the visible and invisible) [22].
For all the noise is considered unpleasant or unwanted sound, annoying or inconvenient that may be in the form of noise, clicks, tones, etc. Hazard noise refers to
the impact directly on the ear through a gradual adaptation to irreversible injury,
acoustic and other body functions (eg tachycardia, hypertension, peptic ulcer disease, and motility disorders, neuroses). The harmful effect of noise on the human
body depends on its intensity, frequency, nature and duration. Exposure to noise is
also in contact with medical equipment that uses ultrasound (ultrasound, ultrasonic
cleaners) and equipment emitting low frequency sounds (fans, means of transport).
In addition, infrasound can be received not only by the ear, but also by the sensory
receptors of vibration and in extreme cases, through the phenomenon of resonance
organ, even lead to death [22,36,39].
While recognizing the risk factors should pay attention to subjectively perceived
noise nuisance threshold, which can be well below established limits, for example,
monotonous sounds (ticking clock, the sound of dripping water and the working
noise apparatus). This is especially important when performing tasks requiring precision, or to be particularly vigilant during the night, where these sounds can cause
distraction, annoyance, and even act sleepy [36].
The term climate refers to the hygienic aspect of the physical characteristics of
indoor air. Optimal conditions in which the thermoregulatory process occurs transparently to the man, described as "comfort waist". Gives comfort to all employees
regardless of sex and age the most favorable conditions for work, encourages excellence, makes full use of time and does not require the employee acclimation process.
136
Analyzing the heat balance between organism and environment employees should
also consider the effect of clothing, which can be a barrier between the worker and
the environment [22,36].
Irregularities in the physical characteristics of air is called a hot climate (positive
energy balance calculated on the basis of an exchange by convection and radiation)
or cold (negative heat balance calculated as previously) [22]. Workplace exposure
assessment to the hot climate is based on the so-called. thermal load index (WBGT
expressed in Celsius degree) in relation to the severity of the work done in this position and duration of action of harmful factors. Apart from the micro-climatic conditions must also take into account the precision of their operations for a given position. Mobilization of defense mechanisms also require a negative energy balance,
which is defined as a local cold stress (cold environment, heat stress cold, cold discomfort general) and evaluated by. local action of cold environment with air cooling
power index (WCI) [15,22,25].
Compliance with the recommendations of the PN-EN 12464-1:2003 (U) allows
you to create optimal conditions for visual perception. In addition to assessing the
appropriate level of illumination, you should also pay attention to aspects such as:
color design, aesthetics and subjective feelings of the employee, the ability to distinguish details, viewing comfort, the ability to efficiently complete perception and
visual efficiency. Adverse effects associated with lighting is the phenomenon of
reflection, especially fast to fatigue of the eyes. It is closely correlated with the duration and degree of precision operations [22,27].
In addition to optical radiation, is receiving the organ of vision, electromagnetic
radiation consists of ionizing radiation (α, β, γ and X-ray) and non ioniziation (invisible: ultraviolet and infrared, laser, radio and microwave and low frequency of 50
Hz) 39].
The consequences of excessive exposure to electromagnetic fields, particularly
ionizing radiation, are very serious and we must remember that they may be distant
consequences (such as radiation sickness, shorter life expectancy), and even its disclosure can only occur in later generations of irradiated [9] . This aspect is too little
appreciated, because approximately every tenth of a midwife is aware of this risk
[17].
In assessing the work of midwives in the field of physical load, estimated energy
expenditure, which consists of the severity of work, effort and mono typical static
cutting moves. The assessment can be made as estimates and measuring. The most
aggravating is considered static, forced body position, ie one that can not be changed
when performing continuously for 1 hour. The amount of physical stress affects not
only the type, intensity and duration, but also working conditions, procedure and
characteristics of the worker [15]. Data from the 2000 PIP physical work load was
the cause of 9% of work accidents among health workers [20]. In terms of severity
of work to include the work of the heaviest care and hygiene, nursing, medical and
transportation. Among the types of activities may include: lifting and transport of
137
patients and equipment, participation in resuscitation, changing linen and making
beds, assisting the medical treatment, long-term participation in the visit [21].
In the assessment of physical working conditions can not be overlooked aspect
of shift work, which is a factor to affect the health and well-being and family life
and distorting circadian rhythm worker [7]. The most common form of system in
Poland is "a day - night" (12-hour shifts). This system, widely approved by workers
and employers in assessing the physiological flow is considered to be more burdensome, physically and mentally. Graded physical load here is the work of medium
heavy and heavy, while the energy expenditure for the work in an 8-hour work qualifies her to the light and medium duty. Working in two shifts, compared with threeshift system, resulting in greater fatigue and mental fatigue, which in turn reduces
productivity and increases the number of errors [6,20].
Psychological disturbance in the work of midwives due to its special contact
with someone who is sick and suffering, responsibility for the health and lives of
others, and endangering the health of their own [20]. Excessive empathy and identification with the suffering of charges in connection with shift work is the cause of
exceeding the adaptive capacity of the organism and the emergence of emotional
stress that causes fatigue, lack of concentration, somatic symptoms and eventually
burnout syndrome [12,17, 37, 41].
Feel unwell in the workplace also aggravate conflicts with patients, their families, colleagues and superiors [20]. Kowalczuk et al study showed that four out of
five midwives experiences of violence in the workplace. Most exhibited a form of
verbal aggression was that midwives experienced by both the patients and their
families, as well as from doctors [17]. Excessive bureaucracy and multiplication of
documentation are, in turn, factors that reduce the time of direct nursing care of
patients. This leads to an acceleration of labor, shortening or non-use of statutory
breaks, leaving work for the next change or even failure to carry out activities [20].
Working to pay the stress has an impact on its quality. There may be chaotic and
pointless activity, reduces the desire to work, there are somatic and functional symptoms (neurosis), increased sickness absence [12].
The workload of midwives, like nurses, are also affected by factors not directly
arising from the work process. These are among the intangible factors of working
environment. Significant differences exist when comparing the work of Polish nurses with the work of foreign nurses. Result, amongst other the use of another model
care systems, insurance, architectural and diversity of the medical profession (especially in the field of direct care) [20].
Problems, which are indicated in our conditions are the most common problems
of financial, personnel, architectural barriers, lack of equipment, and a lack of job or
failure to comply with safety regulations. Nor can we omit the bad financial situation of many health care centers, which in practice translates into a decrease in number of jobs and lower supply in kind. Poor conditions and inadequate material supply
of jobs and the provision of clothing are variable flaw affecting many institutions
and significantly affect the increased burden of work [20]. Satisfaction with the job
138
of technical equipment in the evaluation of midwives and nurses, places them in
second place among the lowest occupations evaluating this aspect [23].
In the opinion of those interested there is also a lack of correlation between the
categorization of patients and nursing staffing. Also complained of lack of professional prestige, although the CBOS research from 1997 shows that nurses occupy
second place after the scientists, with the rank of trusted professions society. [3] Due
to the fact that nurses work in society is identified with the work of a midwife, a
high level of confidence also applies to this professional group.
CONCLUSIONS
1. Midwives in a good way to orient in the field of biological agents, paying more
attention to the risk of bacterial and viral factors (including the occurrence of
HCV infection, HBV, HIV and tuberculosis), but fungal underestimating aspect
of this group of threats.
2. Psychological factors associated with the physical work environment are surveyed the most factors influencing the reduction in job satisfaction.
3. Analysis of the working environment in the delivery room on the ward health &
safety and risk assessment in the workplace midwife showed a lot of risks resulting from exposure of midwives to the impact of harmful and dangerous factors in
the performance of professional duties, the relationship can be observed that
compliance with policies and procedures while maintaining the safety and health
is inversely proportional to the speed of execution steps ii number of participating persons.
4. The specificity of the work as a midwife, the complexity of work processes and a
variety of occupational hazards is a factor that greatly impeded the assessment of
occupational risk. Because of this risk assessment as a midwife is a difficult and
iterative process, requiring interaction with the health and safety department staff
employees that provide jobs for a given position. The process of risk assessment
for the job as a midwife therefore requires a detailed analysis of all possible elements of a comprehensive evaluation of exposure and their effects.
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ABSTRACT
Improve knowledge and awareness of creating and maintaining a safe working
environment, not only for the preservation of health in the workplace, but it enables the fulfillment of a statutory duty to maintain and enforce safety in the workplace. The study was conducted in the stages during 2007 - 2009 years in one of
the hospitals in Silesia. The first phase concerned the identification and recognition of workplace risk factors, followed by an analysis of the working conditions of
midwives working in positions in the unit of the delivery room. The final element
of the study was a comparative analysis of the most commonly used for jobs in
health care methods of risk assessment (PHA, RISK SCORE). Identification of
risk factors and the assessment showed that the work of midwives is subject to a
number of occupational exposures. Among the biological factors may include
hepatitis B and C, HIV, Mycobacterium tuberculosis. Overload of traffic, minor
injuries and burns may be an effect of physical factors. Chemical agents and cause
the most allergies, rarely burns and poisoning. Often stressed situations was also
stress and health hazard situations and lives of patients and newborns. A proper
diagnosis and exposure assessment is a necessary condition to minimize risks. Risk
assessment as a midwife requires not only interdisciplinary knowledge, but also the
use of different scales and methods of risk assessment.
142
STRESZCZENIE
Pogłębianie wiedzy i świadomości w zakresie tworzenia i utrzymania bezpiecznego środowiska pracy, pozwala nie tylko na zachowanie zdrowia w miejscu
pracy, ale umożliwia spełnienie ustawowego obowiązku, jakim jest zachowanie i
przestrzeganie zasad bhp na stanowisku pracy. Badanie przeprowadzono etapami
w okresie 2007 – 2009 r. w jednym ze szpitali śląskich. Pierwszy etap dotyczył
identyfikacji stanowisk roboczych i rozpoznania czynników ryzyka, następnie
dokonano analizy warunków pracy położnych na stanowiskach roboczych w odcinku Sali Porodowej. Ostatnim elementem badania była analiza porównawcza
najczęściej stosowanych dla stanowisk pracy w ochronie zdrowia metod oceny
ryzyka zawodowego (PHA, RISK SCORE). Identyfikacja czynników ryzyka i jego
ocena wykazała, że praca położnej obarczona jest wieloma narażeniami zawodowymi. Wśród czynników biologicznych wymienić można WZW typu B i C, HIV,
Mycobacterium tuberculosis. Przeciążenie układu ruchu, drobne urazy i oparzenia
mogą być efektem działania czynników fizycznych. Czynniki chemiczne natomiast
powodują najczęściej alergię, rzadziej oparzenia i zatrucia. Często podkreślaną
uciążliwością był również stres i sytuacje zagrożenia zdrowia i życia pacjentek
oraz noworodków. Właściwe rozpoznanie i ocena narażenia są niezbędnym warunkiem minimalizacji ryzyka zawodowego. Ocena ryzyka zawodowego na stanowisku położnej wymaga nie tylko wiedzy interdyscyplinarnej, ale również stosowania różnorodnych skal i metod oceny ryzyka.
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Risk assessment for midwives in the choosing

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