research papers in health and safety

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• Published: 25 November 2022

A study on occupational health and safety

• Lídia Maria Costa Araújo Magalhães 1 ,
• Ketyllem Tayanne da Silva Costa   ORCID: orcid.org/0000-0003-0304-2639 2 ,
• Gustavo Nepomuceno Capistrano 2 ,
• Maryanna Damasceno Leal 3 &
• Fábia Barbosa de Andrade 4  

BMC Public Health volume  22 , Article number:  2186 ( 2022 ) Cite this article

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This study aimed to evaluate and describe the indicators of occupational health, with a focus on the medical expertise and periodic medical examination.

This is exploratory-descriptive, cross-sectional, documentary, quantitative, and retrospective research, in the historical series: 2011 to 2015.

The number of lost days of work per worker and the frequency of licenses increased despite the decrease in the Absenteeism Duration Index and stabilization of the Frequency of Medical Workers. As for the adhesion of the workers to the Periodic Medical Examinations, it was decreasing, with a higher percentage in the year 2012 (35.3%). During the analyzed period, 5,186 workers performed the Periodic Medical Examination, and the majority (60.6%) presented non-ideal weight, 41.1% were sedentary, 33.2% had dyslipidemia, 29.0% were alcoholic, 3.2% were smokers, 5.9% had diabetics, and 16.4% reported high noise in the workplace, 27.8% inadequate lighting and 35.9% inadequate work furniture.

Conclusions

The results highlight the need to maintain and strengthen the Worker Health and Safety Policy with emphasis on surveillance, aiming at the promotion and protection of the health of the workers, based on the elaboration of the epidemiological profile of health and, consequently, the implementation of positive impact strategies.

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Introduction

Historically, in Brazil, Occupational Health and Safety (OHS) is strongly associated with the political-social and economic evolution of the country and is presented as the achievement of rights resulting from claims and struggles of the workers. Work is one of the determinants that most impact man’s conditions, quality of life, and health.

Working is essential for human beings since it is the way in which respect, integration, sociability, recognition, and bonds of friendship are obtained. On the other hand, the living conditions of Brazilian workers are aggravated by the alternation of stages of growth and accelerated industrialization with moments of recession, resulting in the government’s adoption of adjustment measures and financial cuts in social policies, such as education, health, safety, transportation, housing, and work, among others [ 1 , 2 ].

Nowadays, the epidemiological profile of workers' morbidity and mortality in Brazil is characterized by the coexistence of diseases that have an intrinsic relationship with working conditions: diseases related to work and typical work accidents, which have their frequency, appearance, and severity modified by the activity. Added to this reality are diseases common to the population as a whole, which have no etiological relationship with work [ 3 ].

Health Promotion and Surveillance refer to the pillar of the Occupational Safety and Health Care Policy (PASS, in Portuguese) that encompasses quality of life and vigilance actions in the environmental and work processes. Standing out among these are the institution of guidelines and programs in the area of mental health and occupational diseases of higher prevalence; the mandatory provision of Periodic Medical Examinations (PME) for all employees; the training in health and safety at work; the creation of an Internal Committee on Health and Safety at Work and a survey of environmental risks, with a stimulus to the active participation of employees in processes involving their health [ 4 , 5 ].

The PME aims, mainly, the prevention, enabling the health surveillance of the employees of a certain company or institution, contributing to the early identification of diseases related or not to work. It is carried out by an occupational doctor and employers must provide examinations for employees at specific times such as dismissal, admission, leaves of absence or change of function, in addition to periodic examinations, which will vary in frequency according to the workers' age (every two years for those between 18 and 45 years old and annually for those outside this age group) [ 6 ].

The PME is performed through clinical examinations, anamnesis, general and specific laboratory tests, according to the function developed by each worker. In addition, the occupational physician must adapt the exams to the particularities of each case, for example, people with disabilities or people who work with noise and may experience deafness caused by this fact. The result of the PME is not given by score or a question of approve or disapprove workers, it is related to the early diagnosis of health problems [ 6 ].

It is noteworthy that the information generated during the expertise act are important indicators of worker's health, privileged instruments for the construction of the morbidity and mortality profile of public servants, which will help to conduct the development of health promotion actions, since the expert databases issue a variety of data on the most prevalent diseases and the professionals who get sick [ 7 ].

It is of great importance to deepen the study in relation to the health of the federal public servant, considering the need to research, know and analyze the determining and conditioning factors of health problems related to processes and work environments. In this way, it is important to analyze workers' health indicators, which are reflections of the real health conditions of the server, with the objective of guiding managers in the planning and control of activities, in addition to allowing deductions regarding the effects of decisions and their results.

From this perspective, this study aimed to evaluate and describe occupational health indicators focusing on the Official Health Expertise and PME of federal public servants, including professors from the institution and administrative technicians from the education sector of the Federal University of Rio Grande do Norte.

Materials and methods

This is a cross-sectional, retrospective study with a quantitative approach, where secondary data were obtained regarding PME and official health expertise, specifically the SIAPE HEALTH module of federal public servants of a public institution of higher education in Brazil.

The information contained in this system is federal level and is entered by the experts who perform the exams, uploading them directly into the system, enabling access to the information by users. For the study, secondary and aggregated data from the SIAPE SAÚDE system database were evaluated, as well as management reports made available by the SIASS Unit (Subsistema Integrado de Atenção à Saúde do Servidor) from UFRN, responsible for storing such data.

The study was carried out at the Federal University of Rio Grande do Norte, Central Campus, especially at the Directorate of Attention to Servant Health (DAS), where the SIASS Unit is located, the latter being responsible for coordinating actions in attention to the health of the institution's servants, specifically, the performance of the Periodic Medical Examination and the Official Health Survey, objects of this study.

The period chosen for the study was from 2011 to 2015. The preference for this time interval was justified by the fact that the year 2011 marks the beginning of the PME through the computerized system SIAPE HEALTH, and the end of the study period in 2015 characterizes five complete years and the historical nature of epidemiological studies.

The population chosen for the study can be divided into levels of education, the teachers, technical-administrative in education, higher level positions are level E, while the technical-administrative in education, middle and basic level positions are levels C and D.

The official health expertise and the PME were used as a dependent variable. For each indicator, independent variables were selected: a) Official Health Expertise: gender, age, position, number of active statutory employees away, number of days of leave and number of days away; and b) PME: Gender, age, position, ethnicity, smoking, physical activity, BMI, hypertension, diabetes mellitus, dyslipidemia, spinal pain, inadequate furniture, inadequate lighting, likes what you do, good relationship with the boss, good relationship with colleagues and fast pace. In addition, the following indicators were observed: Absence Severity Index (IGA), Medical Frequency Leave (FML), Frequency of Workers on Sick Leave (FWML) and Absenteeism Duration Index (IDA), as recommended by the Permanent Commission and International Association on Occupational Health [ 8 ] and the authors Hensing et al. [ 9 ].

The information was obtained from Microsoft Excel spreadsheets, being possible to organize and sort the variables into categories. Then, the data were exported and analyzed in the software Statistical Package for the Social Science (SPSS). Relative and absolute frequency distribution was used for categorical variables, as well as measures of central tendency (average), measures of dispersion (standard deviation), and student's t-test for quantitative variables.

For data analysis, the chi-square test and the calculation of the odds ratio were used for correlation of the indicators, adopting a confidence interval of 95% and a significance level of 5% ( p  < 0.05) for all tests.

Concerning the ethical aspects, the project was submitted to the Research Ethics Committee of Federal University of Rio Grande do Norte where it was appraised and subsequently approved under opinion no. 1.707.691, from the principles of ethical and legal aspects that govern scientific research on human beings, as recommended by Resolution no. 466/12 [ 10 ], and the principles expressed in the Declaration of Helsinki.

The results showed that there were 4,293 (35%) departures from administrative records and 7,946 (65%) absences from work granted by expert examination.

This expert examination is a procedure carried out by a medical expert, whose function is to identify if there is the presence of an illness or to identify if there has been an accident that has made you totally or partially, temporarily, or permanently unable to perform your professional activities [ 11 ]. The magnitude of these absences can be portrayed when we calculate the sum of lost work time over the five years, which generated 179,916 days of absenteeism due to illness.

Data regarding the sociodemographic characteristics of the studied population revealed that 67.9% (8,312) of the departures occurred in female workers and, for males, 32.1% (3,927). Regarding the age group, 34.6% (4,234) of the licenses were approved for workers between 51 and 60 years old, 24.0% (2,934) from 41 to 50 years, 19.2% (2,355) from 31 to 40 years, 11.8% (1,449) from 18 to 30 years, and 10.4% (1,267) over 60 years.

In relation to the post variable, the number of workers occupying the position of administrative technician in education levels C and D predominated, with a prevalence of 62.2% (4,941), while 23.8% (1,889) workers were in higher-level positions.

Figure  1 shows the absence of workers at work due to health care in the period from 2011 to 2015. It is noteworthy that there is an increase between 2011 and 2013, when there is a peak of 7.1 days not worked. The following years show an oscillation, but with a tendency for growth.

Source: Elaborated by the Authors

Indicators of absenteeism, 2011–2015. Natal/RN, Brazel, 2017. Legend IGA = Absenteeism Severity Index; FLM = Frequency of Medical Licence; IDA = Absenteeism Duration Index; FTLM = Frequency of Workers on Medical Licence.

In this sense, it is also relevant to present the individual absence duration, according to the cause of illness, in order to facilitate the adoption of specific measures focused on the pathologies with the greatest impact on lost days of work. Figure  2 shows the IDA according to each International Classification of Diseases (ICD), 10 chapter, and the highest indexes refer to neoplasms (45.64), mental disorders (32.40), congenital malformations (27.00), and diseases of the circulatory system (23.96), respectively. These findings reveal that absences of longer duration were caused by pathologies of a chronic non-transmissible nature, except for causes of absences in chapter XVII of ICD-10.

Source: Elaborated by the author

Distribution of IDA, 2011–2015. Natal/RN, Brazil, 2017. Legend: C = ICD.10 chapter.

Figure  3 presents the results of this study regarding the adherence of the workers to the Periodic Medical Exam (PME), considering the historical series from 2011 to 2015, when an average of 4,362 workers were called.

Source: Elaborated by the authors

Distribution of call, adhesion, non-adhesion, and coverage ratio to PME, 2011–2015. Natal/RN, Brazil, 2017.

The Periodic Medical Exam consists of the periodic clinical and laboratorial evaluation of the worker, due to the existing risks in the work environment and occupational or professional diseases. The PME foresees the adoption of prevention, tracking, and early diagnosis measures for work-related diseases, besides those more prevalent in the general population, such as diabetes mellitus, hypertension, neoplasms, dyslipidemias, and ophthalmologic diseases. Also, the PME will be carried out during working hours, without any burden or need for compensating schedules on the part of the employees. It is important to point out that absenteeism is taken into consideration only due to the worker's personal illness, and this diagnosis cannot be related to someone in the employee's care.

Regarding the operationalization for the PME, it is important to mention that at the moment the server is called for the evaluation of occupational health, through personal e-mail, he/she must fill out the consent form as a way to prove the agreement to participate in periodic medical examinations. Thus, going from the situation "INVITED" to "CONFIRMED". It is worth pointing out the importance and potential of the PME, once it allows the early identification of risk factors for getting sick, as well as the construction of collective diagnoses in the Worker's Health area, which makes this action a health management instrument, for monitoring the health situation and work conditions, and the subsidies for interventions to improve the quality of life of the workers.

It can be observed that the call-up ratio increased by 42.0% from 2011 (0.49) to 2012 (0.91). From the year 2013 (0.84), there were oscillations characterized by drop and growth in the calls.

As for non-adherence, in 2012, there was a decrease, and in 2013 (0.78), 2014 (0.8), and 2015 (0.86), there was an increase in the results, characterizing a relevant increase of 15. 0% between the years of 2011 (0.71) and 2015 (0.86).

About PME membership, it is clear that growth occurred only in 2012 (0.35). Then, the index decreased throughout the series, namely: 2013 (0.22), 2014 (0.2) and 2015 (0.14), which explains the non-adherence data, that comprehends the number of called servers that didn't do the PME in the analyzed year, having as reference the total number of UFRN's servers summoned in the evaluated year as being an unfavorable reality in relation to the PME recommendation. This may be related to factors such as excessive work activities of workers, periodic examinations performed through private health insurance, and to the lack of recognition of the importance of PME by workers.

The coverage ratio of the PME represents the servers that have concluded the PME and those that have an updated Occupational Health Certificate in the analyzed year, with the total number of servers at UFRN in the analyzed period as a reference. This coverage ratio increased significantly in the year 2012 (0.4), showing a growth of 26.0% in relation to 2011. Thereafter, the ratio decreased, with an average of 0.26 between the years of 2013 (0.33), 2014 (0.26) and 2015 (0.2), as shown in Fig.  3 .

In the list of risk factors, health indicators of different epidemiological natures were analyzed. Among them, those related to cardiovascular diseases and occupational risk factors, such as the existence of inadequate work furniture and accelerated work rhythm, are presented in Tables 1 and 2 .

In the list of chronic pathologies covering categories II and III of the Schilling classification, the most common causes of morbidity among workers are: Systemic Arterial Hypertension (SAH), chronic respiratory diseases, diseases of the locomotor system and mental disorders. These are pathologies of multiple etiology in which work is considered a risk factor associated with the increased probability of occurrence of these diseases [ 12 ]. Thus, the present study highlights cardiovascular diseases, especially SAH.

Table 1 shows the distribution of the aforementioned risk factors associated with SAH. It is pointed out that 60.6% (3,143) of the workers that performed the EMP presented non-ideal weight; 58.7% (3,044) practiced some type of physical activity; 70.8% (3,670) denied alcohol use; 96.5% (5.005) did not smoke; 93.9% (4,870) did not have diabetes mellitus (DM); and 66.6% (3,453) did not have dyslipidemia. The association between hypertension and all correlated variables was significant at p  < 0.001. As for the Odds Ratio calculation, we considered the hypertension disease in relation to the following variables: BMI, sedentary lifestyle, alcoholism, smoking, diabetes, and dyslipidemia. The OR calculation does not imply a cause-and-effect relationship, it only suggests that there is an association.

In Table 2 , it is possible to observe that 35.9% of the interviewed workers are not adequate for their activities. In addition, 16.4% report loud noise in the workplace and 27.8% do not have adequate lighting. Social factors were also obtained, noting that 3.7% of the workers surveyed say they do not have a good relationship with their co-workers, while 4.4% do not have a good relationship with their boss and 2.5% show dissatisfaction with what they are doing.

It should be noted that absenteeism is a term used to denote the employee's absence from work [ 13 ]. The International Organization of Work (OIT) defines it as the period of absence of work that is accepted as attributable to an incapacity of the individual, except for that derived from normal pregnancy or prison [ 14 ].

According to the report of the National Audit Office [ 15 ], in the city of Guernsey, United Kingdom, approximately 3.8% of working time was lost due to illness, and civil workers became sick for an average of 8.7 days in 2005. In Chile, health workers belong to the category that has the highest rates of disability due to illness, with 14.3 days of absence per worker per year; unlike the university workers, who present 6 days of work lost per year, similar to the results of this research [ 16 ]. These findings highlight the data shown in Fig.  1 .

Studies found an average of 7.5 lost days of work per year per worker in the nursing area of a university hospital in Brazil [ 17 ]. Santos and Mattos [ 18 ] observed 9.3 days of absenteeism due to disease for each municipal worker of the city of Porto Alegre in 2005. The studies reported 9.1 and 10.3 days of absence due to illness for each public worker of the municipalities of Goiânia and São Paulo, respectively [ 19 , 20 ].

The worker and financial conditions can cause work accidents and environmental conditions, increase work capacity and the market, which may exclude work and consumption capacity. The employee is also hit with productivity, lack of manpower, loss of manpower and/or equipment damage [ 21 ].

The World Health Organization (WHO) estimates about 36 million annual deaths from Chronic Non-Communicable Diseases (NCDs), composed mainly of circulatory diseases, neoplasms, chronic respiratory diseases and Diabetes Mellitus (DM), which have risk factors.—smoking, alcohol, physical inactivity, unhealthy diet and obesity—modifiable in common [ 22 , 23 ].

An important characteristic of epidemiological patterns in Brazil concerns the changes in the composition of morbidity and mortality by groups of causes. Thus, the high prevalence of deaths from infectious and parasitic diseases, present at the beginning of the twentieth century, gave way to NCDs and injuries related to accidents and violence [ 24 ].

In Brazil, according to the Ministry of Health [ 23 ], NCDs are among the main causes of hospital admissions, and the financial cost to the Unified Health System (SUS) represents a growing impact. Estimates for Brazil suggest that the loss of productivity at work and the decrease in family income resulting from chronic pathologies such as diabetes, heart disease and stroke involved spending of US$ 4.18 billion between 2006 and 2015 [ 25 ].

The researchers Moura, Carvalho and Silva (2007) [ 26 ] carried out a study on the repercussion of CNCDs in the granting of social security benefits by the National Institute of Social Security (INSS) and identified musculoskeletal and circulatory system diseases as the main causes for granting sick pay.

This reality is also revealed among public servants in several studies that present the main groups of causes of sick leave for this category of workers, with high rates of absenteeism due to diseases of the musculoskeletal system and connective tissue, mental and behavioral disorders, chronic respiratory diseases and circulatory system diseases [ 7 , 19 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].

The implementation of strategies to reduce absenteeism is a great challenge for employers, and it is necessary to analyze the events in the workplace to delineate situational diagnoses and guarantee actions to promote worker health. For the authors, the change in the epidemiological profile of illness and the increase in the prevalence of chronic diseases, as shown in Fig.  2 , reveal concern for the global scenario regarding the impact of these diseases on workers' health, due to the growth in the number of lost workdays [ 21 ].

The epidemiological profile of morbidity and mortality in Brazilian workers is characterized by the coexistence of diseases that have an intrinsic relation with working conditions, and in addition, diseases common to the population are observed, which are not etiologically related to the work [ 3 ]. In this reality, it is important to emphasize the importance of the employees performing the Periodic Medical Examination (PME), for the prevention and/or possible early detection of the pathologies that generate the greatest impact on the lost days of work, highlighting the neoplasms [ 22 ].

The importance of performing the PME in the screening of risk factors for chronic non-communicable diseases, such as dyslipidemia, sedentary lifestyle, obesity, arterial hypertension, diabetes mellitus, alcoholism, and smoking is highlighted. In addition, through the PME, the workers will be guided and sent to participate in the various health promotion programs offered by the institution. Through these strategies, it is possible to reduce the prevalence of diseases of the circulatory system, another important cause of absenteeism, as shown in Fig.  2 .

As for Fig.  3 , which shows data on the PME, despite weaknesses, it is evident that the most satisfactory results of PME adherence occurred in the year 2012, a time when workers composed the Integrated Subsystem Unit (SIASS in Portuguese), as well as the constant discussion in forums, national meetings, and events related to the PASS, in a context of articulation in defense of the strengthening of the actions of attention to workers' health, which may have contributed to the results [ 23 , 24 , 25 ].

On the other hand, the situational diagnosis of low PME adherence throughout the historical series was possibly influenced by the recent history of PASS construction and the negative impact of the lack of structuring, planning, and evaluation of the actions. Plus, the largest investments and training, by the Ministry of Planning of Brazil, were related to the expert area which reflects as the main activity of the PASS [ 4 ].

The implementation of actions of health surveillance and promotion are major challenges for the consolidation of SIASS, since it is still a recent practice to promote health in public sector workplaces. It is necessary to elaborate indicators to support the actions and allow the evaluation of the results, considering that the information generated through indicators consolidates the control and planning of the organizational processes, as well as supports the decision making [ 25 , 26 ].

This is a prevention tool that has been implemented in Brazil with workers from federal agencies to identify risk factors associated with future illnesses. This approach in the federal public service has had an impact on the quality of preventive health, avoiding the removal of workers from their workplace for a cause classified as a possible prevention of this disease. Another aspect is the increasing number of absences that have been occurring in recent years, that is, the numbers of absenteeism due to physical and mental illnesses, a fact that occurs at increasingly younger workers' ages, which reveals the need for special attention and protector follow-up in their quality of life.

The results presented in this study deserve attention and can contribute to discussions between the professionals of the technical team and managers of the SIASS Unit and PROGESP/UFRN, as it is believed that the production of knowledge about the subject under study can provide the University with instruments, as well as other institutions at the federal public service level, through the PME as an indicator for planning and evaluating Occupational Health actions.

Thus, continuous investments in health policies aimed at public servants are suggested, which contributes to the reduction of illness and early retirement, resulting from disability. In this sense, investment in research that allows a better understanding of the relationship between health and work in the public service is also recommended.

It should be noted that this study had some limitations, as the use of self-reported data by employees who completed the PME may underestimate or overestimate the results presented.

In order to meet the proposed objective, there was the occurrence of neoplasms, mental disorders, and diseases of the circulatory system in terms of duration of absenteeism (IDA), which were the causes of the absences with a longer duration, which ratifies the epidemiological importance and the impact of non-communicable chronic diseases on workers' health. The gravity index of absenteeism revealed that the number of lost days of work per year per worker increased over the historical series, as well as the frequency of absences.

With regard to the epidemiological profile of the employees who underwent the PME throughout the historical series, it was possible to identify a significant prevalence of overweight in the population. The working conditions were considered satisfactory in the perception of the workers. It should be noted that this study presented some limitations, since the use of self-reported data by the workers may underestimate or overestimate the presented results.

Also observed through this study is the need to maintain and strengthen the PASS with emphasis on surveillance, aiming at the promotion and protection of the health of the workers, based on the elaboration of the epidemiological health profile and, consequently, the implementation of strategies of positive impact for OHS.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

International Classification of Diseases 

Diabetes mellitus

Frequency of Medical Licence

Frequency of Workers on Medical Licence

Occupational Health and Safety

Absenteeism Duration Index

Absence Severity Index

International Organization of Work

Occupational Safety and Health Care Policy

Periodic Medical Examinations

Systemic Arterial Hypertension

Integrated Subsystem Unit

Statistical Package for Social Science

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This study was partially funded by the Coordination for the Improvement of Higher Education Personnel—Brazil (CAPES)—Financial Code 001. Funders have no role in the study design, data collection and analysis, publication decision or preparation of the manuscript.

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Lídia Maria Costa Araújo Magalhães

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Ketyllem Tayanne da Silva Costa & Gustavo Nepomuceno Capistrano

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L.M.C.A.M. was the principal investigator of the project and responsible for administration, coordination, and funding acquisition. L.M.C.A.M. and F.B.A. were involved in conceptualization and in the study design. L.M.C.A.M. carried out the investigation. L.M.C.A.M., K.T.S.C., G.N.C. and M.D.L. were involved in formal analysis and data curation and wrote the main manuscript text. F.B.A. reviewed and edited the manuscript. All authors reviewed the manuscript. The author(s) read and approved the final manuscript.

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Magalhães, L.M.C.A., Silva Costa, K.T., Capistrano, G.N. et al. A study on occupational health and safety. BMC Public Health 22 , 2186 (2022). https://doi.org/10.1186/s12889-022-14584-w

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1.1 Introduction

1.2 survey results comparison, 1.3 closing remarks, chapter 1: introduction to challenges for health and safety in research.

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O. Kuzmina and S. Hoyle, in Challenges for Health and Safety in Higher Education and Research Organisations, ed. O. Kuzmina and S. Hoyle, The Royal Society of Chemistry, 2020, pp. 1-18.

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Results from the University and Research Institutions survey are presented in this chapter revealing what are the most common challenges faced by health and safety professionals, managers and researchers in these organisations. Barriers discovered are collated in five categories: physical, economical, organisational, behavioural and industry specific. Where appropriate this chapter directs the reader to a relevant chapter for further in-depth analysis. The appendix at the end of the chapter is a collection of feedback from survey responders on how workplace health and safety, in their view, could be improved.

This is the first time I have been involved with writing and helping to produce a book. All was going well; chapter drafts were being sent to us by the various authors and we enjoyed reading about experiences and the challenges faced in our sector (we hope you do too!). Our day-to-day work was busy and my team were focused on providing great advice and support to our academic colleagues. We were preparing for various challenges and reviewing how we could improve and provide staff and students with skills to apply principles of risk assessment to their work. Then on 18th March our university was effectively closed, and all work was stopped due to COVID19.

The effect of this was acute – labs having to be safely shut down in a very short period of time, and stressful for all involved due to the logistics of being able to achieve this while also thinking about the potential impact on work, life, family and our future.

It is June 5th and in the UK the lockdown is being eased. Olga and I must admit that for the last few months this chapter has been left to gather dust while we worked remotely to support our Departments in their decision making, and provided advice on assessments for work on COVID19 related projects. For the last two weeks I have returned to our campuses in London to help with planning for the gradual reintroduction of staff and students into our buildings and for work to start again in this ‘new normal’.

Many of the chapters in this book have been written and completed before the COVID19 crisis, however I think the experiences are still relevant to practitioners in our sector and beyond, even with the introduction of social distancing and other COVID19 controls. The COVID19 work requirements will require us as a profession to adapt and be even more innovative in our approaches. We don't believe that higher education, and in fact most workplaces, will be able to return to pre COVID19 working for a while yet. Looking through the chapter titles our authors have provided, you can see that the challenges to operating successfully with social distancing and other strategies to reduce infection will require significant thought and planning. Therefore, we think we can confidently say that a revised edition of this book will contain reflections by our returning authors (and new ones) on how they and their workplaces adapted to COVID19 and how it influenced their approaches.

Crucially I would say that in my experience so far during this crisis, the work done by technical staff, admin support and estates to get buildings and procedures ready for a phased return of researchers has been magnificent. Academic leadership from our Departments and Faculty has been excellent, and we have all pulled together to provide support to each other and direction through these difficult times. We are on the cusp of having the first few researchers return to work on the 8th June, with more returning over the coming weeks. Currently the plan for our Departments is to achieve up to 25% occupancy of research buildings using cohort models or similar that allow lab-based researchers within a department to complete their lab work while remaining socially distant. Where this is not possible, other control measures must be used. Departments have ‘COVID19 oversight’ management teams to receive feedback from the researchers to ensure procedures reflect their needs. My team have produced ‘return to work’ induction materials delivered via online learning platforms to ensure researchers are reassured that buildings are safe to return to, and to provide information on the new procedures for them and their colleagues to work safely. Face-to-face inductions and training are moving online which creates additional challenges. The next large piece of work for us is to support our colleagues in teaching to plan for lab practicals for returning students in October.

All areas of health and safety described in this book will be impacted by the reaction to the COVID19 crisis, those of us in health and safety operations are in a unique position to provide advice and support to many operational areas. The changes to our working practices and behaviours will be profound, but we hope that it will lead to improved communication and trust between health and safety advisers, academics and students. Then, no matter what the conditions, we will achieve a safe working environment and a healthy balance between work and home.

Research laboratories provide a unique environment of continually evolving work, varying levels of individual competence and increasingly shared workspaces between different projects and research groups. Health and safety management in research laboratories faces unique challenges to ensure that science and knowledge is advanced without being a barrier to scientific progress. Health and safety, rather than being a barrier, needs to be an enabler to these aims in these dynamic and challenging environments.

A recent review and critique of academic lab safety 1   highlights how little progress has been made over the past ten years to improve safety practices and culture in the academic environment. The aims of this book are to examine some of these challenges in detail, from the perspective of the health and safety practitioner, researcher and academic. This book is an analysis of health and safety management in the research laboratory environment across a broad spectrum of topics (predominantly within the university sector). As well as literature reviews and chapters on specific topics by individual experts we have revisited a survey, the results of which were first published in Nature. 2   It is interesting to note the differences seven years on and reflect on why these have occurred and, most importantly, what can be improved to support researchers and enable safe scientific progress.

What are the challenges that modern researchers face and how do these impact on safety culture and the implementation of a safety management system? Various barriers have been identified 2,3   or conjectured in previous studies. The shift in focus from theory, reflection and evolution of ideas to milestones, defined end points and real-world applications with monetary value has significantly changed the economic landscape at many universities. Academic and research careers are hard to achieve and maintain, with pressure from internal reviews, funding bodies, politicians, the public and business to ensure continual progress and value for money. Obtaining funding to do research is extremely competitive, even at the most prestigious institutions. Time is critical to ensuring work that is funded is then completed on time and within budget. Key stakeholders are the organisations hosting the research. They must ensure that their estates and infrastructure can keep pace with technical requirements, the need for flexible lab spaces and deliver a modern comfortable environment for study and work. The need for a physical space to be able to accommodate diverse research activities while achieving the lowest impact on the environment has never been greater, more challenging and expensive.

These factors have an impact on end user health and safety operations in various ways. From the need to ‘take a shortcut’ due to time pressure to meet a milestone, install an item of equipment in a less than optimal lab environment with insufficient cooling or extraction, to working in an overcrowded lab space. From the lab bench it can appear that the organisation or university is not managing its space with their scientific requirements or health and safety in mind, potentially leading to a poor relationship between researchers and ‘central services’ and poor safety culture. A recent review of what researchers think of the culture they work in by The Wellcome Trust 4   indicated that ‘their working culture is best when it is collaborative, inclusive, supportive and creative, when researchers are given time to focus on their research priorities, when leadership is transparent and open, and when individuals have a sense of safety and security’. But too often research culture is not ‘at its best’.

It is critical that health and safety in a research lab environment is practicable to those working in the labs and those that support the researchers (technicians, estates staff and contractors). Over the last 20 years there has been a definite shift of approach in health and safety from prescriptive top-down management to a consultative approach to facilitate this.

Team leaders are responsible for their group members and reliant on their PhD students, research assistants and postdoctoral researchers to ensure their projects are progressed. These individuals will have different technical competencies as well as different attitudes towards health and safety. Their previous training, either formal or informal will determine their personal attitudes and approach to safety in the lab environment. Those in the lab face the risks on a day-to-day basis and make critical decisions about risk based on their competence and the prevailing culture they are working in. They are constantly monitoring experiments and adjusting processes and procedures based on previous results. A key skill for researchers is to be able to identify when a risk has changed significantly and be able to either ask for help or devise a suitable control measure. How do researchers gain these skills? Is it trial and error? Or, is there a need to integrate risk, hazard and safety considerations into undergraduate degree courses formally and on a wider basis across the sector?

On a day-to-day basis, academic leaders are reliant on individual members of their research groups to ensure the work is done safely and the labs managed appropriately. The researchers are then reliant on the academic to continue to gain funding to continue research. This needs to be maintained to ensure work progresses, careers are successful and scientific knowledge improves. If the working environment is not optimal it is foreseeable that health and safety could be a secondary consideration and either ignored or bypassed.

The nature of cutting-edge research science in a multi-disciplinary setting (science, engineering and medicine) can lead to a focus by health and safety support services on bureaucratic solutions. This is driven by the regulatory landscape of the host country, and the need to comply with separate Regulations relating to individual hazards and risks. For example, in the UK a laboratory could be subject to multiple regulatory requirements depending on the hazards and risks they are dealing with. These hazards and risks are often fundamental to the research, restricting the ability to substitute hazards with those which are less hazardous. The lab worker normally experiences this as a large volume of paperwork, which from their perspective can be thought of as a barrier to completing research activity in a timely manner. The worker may perceive it as unhelpful and a way for the institution to ‘cover their own backs’. Chapter 2 of this book examines how these risks should be managed from a legal perspective to ensure that compliance and a safe working environment can be achieved.

Technology has reduced barriers to international communication, resulting in increased opportunities for research and collaboration. Scientific research groups are international in composition. Individuals not only bring their personal experiences and attitudes to the workplace but also their cultural influences. The short-term nature of most research contracts requires scientists to continually seek further employment, either at home or abroad, so these cultural influences on the approach to health and safety are a significant factor when assessing health and safety culture within the workplace.

On the other hand, technology, and specifically combined software solutions, do not appear to have been able to be fully utilised. The challenge of creating a flexible system of interactive online assessment forms, health and safety training records, computerised lab notebooks and health and safety management software is difficult to achieve across a large teaching and research organisation with multiple disciplines. The researcher is then confronted with a fragmented system within their organisation that can be inefficient and confusing.

Are health and safety practices in research laboratories less stringent than in other sectors? In a manufacturing environment, process-related safety rules are followed. These rules may seem to be excessive and are often criticised by safety professionals. 5   The impression is that industry and manufacturing have a tighter control of health and safety due to adherence to requirements set by quality control or safety management systems, fewer changes in established processes, strict policies related to employment, and are more sensitive to the financial impact of delays to business activities. In 2019 the ACS President Elect of the American Chemical Society (ACS) ran an initiative on collaborations and safety, specifically “Bridging the (Safety) Gap between Academia & Industry”. 6   As researchers move into industry and vice a versa there is an opportunity to identify what these differences are and whether they can be harnessed to improve safety culture in both sectors.

In 2013 Nature Journal published results from a survey among laboratory workers revealing that despite 86% of the scientists considering their lab to be “safe”, almost half of them had experienced work related injuries. 2   We have conducted a similar survey and collected 427 replies from mainly UK based researchers (but also from some US, EU and Asian organisations). Approximately a third of the responses were from students, the rest comprised of postdoctoral research assistants, research fellows, technicians and other support staff. Scientists within industrial research development were also represented ( Figure 1.1 ).

Representation of the responders of the survey by their position.

Like the 2013 survey, invitation to take part was by email and social media. Similarly, 86% of responders considered their lab as “safe” ( Figure 1.2 ). The percentage of responders who indicated they had experienced some injury was 35% in our survey (46% in the 2013 survey).

Perception of laboratory safety by the survey responders.

The most commonly occurring injuries are lacerations/cuts/bites, thermal burns and needle pricks ( Figure 1.3 ). In our survey, 14% of responders did not report their incidents to their supervisors. The willingness of an organisation to receive data on incidents is critical to establishing a good reporting culture. The organisation must review its resources for following up and closing out incidents. Clear guidance on what needs to be reported, as well as a simple, easy to use reporting mechanism is essential. Trained individuals completing the investigations, closing them out and identifying recommendations that can be implemented to reduce risks of reoccurrence are also a key factor. The research scientist needs to be reassured that if they do report an incident that it will be dealt with quickly and efficiently.

Types of injuries reported to be experienced by the survey responders.

In 2013 40% of researchers admitted that they had not received suitable safety training. Our survey indicated that less than 5% of responders had not received training on specific hazards in their work. The survey did not attempt to identify how useful the responders found their health and safety training.

It was previously indicated that two thirds of British scientists were using formal risk assessment templates; our survey showed the use of formal organisational risk assessment templates to be 70% in this sample. However, it is worrying that 2% of responders admitted not assessing the risks, and 27% conducted informal risk assessments. Risk assessment is the cornerstone of health and safety in the UK so strategies for ensuring the process is understood and applied appropriately are essential.

Figure 1.4 represents the opinions of the responders to selected statements regarding safety culture. While 89% of responders agreed that “Safety is paramount and takes precedence over all other lab priorities”, almost one fifth of them also admitted that safety rules impact negatively on their productivity.

Responses to the selected statements about safety and its perception.

The majority of the responders admited that safety inspections improve safety compliance which is already known from other studies. 7   What is key is that the inspection process is perceived to be there for the health, safety and wellbeing of the researcher rather than institutional compliance. The majority of inspections are completed by health and safety officers, who can be seen as ‘outsiders’ 8   and therefore either not qualified or ‘safety police’, only listened to when in the lab. Some responders suggested increasing the number of inspections as a solution to improve safety in their lab. While this seems to be a logical suggestion, more inspections by safety officers, in our opinion, will not deliver the systemic improvements in lab safety that are needed. Current methods are taking a more collaborative approach, giving the responsibility for monitoring and inspecting to the researchers and their peers and ensuring that research leaders and senior management are taking part in the inspections with support from health and safety practitioners.

Of the respondents, 21% believed that they do not have any safety duties or were not sure what their safety duties are. At a time when health and safety in labs has a relatively high profile (due to serious incidents over the last 10 years) this is a worrying indication. Part of acting responsibly is to know what your responsibilities are. Then you can ensure your actions will not only keep you safe but also those around you. In the UK, the University Safety and Health Association (USHA) produced a Safety Leadership and Management Guidance document 9   for Higher Education Institutions (HEIs). This provided a template for all management and worker levels to understand their health and safety responsibilities. Potentially using this as a training tool, HEIs in the UK could improve individuals understanding of their health and safety responsibilities, depending on their position within the organisation. It is not currently possible to identify how many UK HEIs have provided training to not only senior management but all workers based on this document.

Almost one third of the responders for our survey were working in chemistry laboratories. Respondents from biological, physical and medical sciences also took part in the survey. Overall, we received a snapshot from experiences of workers from 17 disciplines, who worked in over 30 countries in many universities and research institutes.

We would echo the recent Nature Chemistry article 1   in which it is identified that to get more than ‘indications’ from these types of survey, health and safety practitioners and social scientists need to work together to devise suitable experiments and test hypotheses. Until then conclusions supported by data will not be possible.

The indicative responses we received have been collated into discreet categories, detailed below. Additionally, we collected the individual views on how safety could be improved at the end of this chapter in Appendix 1.

1.2.1 Category 1: Physical Barriers

Researchers identified that building infrastructure, ageing equipment, lack of appropriate equipment and space are serious barriers to working safely. Space constraints are often a reason why researchers neglect safety, particularly with the evolving nature of research work and research groups growing or moving in and out of universities on a regular basis. The work changes, but physical space does not. When new hazards are introduced this can result in engineering controls that are either too expensive (for example installation of a LEV system) or compromised to fit the space.

Lack of appropriate space also leads to overcrowded labs, inappropriate storage of reagents and waste, poor housekeeping and consequently more near-misses and accidents. The management of space and its contents is also an issue in research laboratories. Labs do not always have appointed managers or technical services to assist researchers in waste removal and housekeeping duties. These duties can often be neglected if the researchers are expected to complete these duties, partly due to a lack of time and partly due to attitude i.e. ‘I'm here to do research, not manage the lab on a day-to-day basis’. This is a persistent concern which does not have enough attention in the literature. In 2006 Francisco Javier Penas and others 10   described the implementation of industrial standards when designing and starting up a laboratory for chemical engineering teaching. Their experience proved to be a successful example of setting high safety expectations when assessing the risks from every point of view. The detailed design of the research labs and considerations when starting a new research site will be discussed in Chapters 12, 13 and 14.

The costs of clearance of legacy materials that have accumulated in a lab space can be considerable and will normally have to be paid for by the host department or School. In 2017–2018 when the Chemistry Department at Imperial College London relocated to a new building over 5 tonnes of chemicals were disposed of. Legacy material introduces increased risks associated with fire loading and takes up valuable working or storage space. Chapter 16 provides an insight into legacy materials and issues around old equipment and facilities.

1.2.2 Category 2: Economical Barriers

When responding to our survey researchers have blamed a lack of finances and limited funding streams for poor safety performance. Proposals are often submitted without consideration of what safety implications will arise if the grant is awarded and the work begins. Ideally a risk assessment of the work will be completed so that the physical spaces and engineering control measures can be designed in and costs identified at the earliest stage. As not all applications result in funding, there is limited appetite to spend a considerable amount of time detailing required safety infrastructure or ongoing requirements for each proposal submitted. However, if the application is successful, additional funds may be needed to ensure the required safety controls can be implemented. This can be significant sums of money. The funding bodies may assume (or require) that the organisation will cover the safety costs of a project via central funds. For example, if a scientific proposal involves work with high powered lasers, the UK Artificial Optical Radiation Regulations 2010 require engineering controls to be in place to prevent exposure to hazardous lasers. The costs for a system to achieve this can be significant. These costs will depend on several factors including:

What size is the space?

What are the existing services?

What new mechanical and engineering or electrical infrastructure will be required?

What interlocks, containment levels, safety protocols or licences does the research involve and what requirements or restrictions does that impose?

What furniture is required?

What equipment (if any) is to be included?

What level of professional fees will be required ( i.e. how much design will be required from architects, engineers, specialists etc. )?

If the funding body cannot fund the safety requirements the department or researcher must. This can lead to delays if the design assessment has not been done in advance of the work being funded. This is where safety requirements will be perceived as “barriers for effective work” and the organisation itself as “not supportive” as the funded work will not be possible to begin until it is safe to do so. It also places the safety officer or adviser in an awkward position as they could be pressured to ‘relax’ the rules or are perceived as barriers to effective research.

It is unfortunate that these economical barriers are not getting more attention in the literature. An individual approach may be needed for each organisation so that a process for efficiently identifying potential costs for new research can be established.

1.2.3 Category 3: Organisational Barriers

Our survey indicated that researchers are concerned by the lack of clear guidance, insufficient supervision and training, lack of accountability and a burgeoning bureaucracy. The reliance on documentation is perceived as a way for the organisation to reduce regulatory risks rather than as tools to aid the scientist and reduce the risks to themselves. The varied nature of work in a research laboratory and decentralised management of universities can exacerbate these issues. This can result in multiple documents from different parts of the organisation for the management of the same risk. This can lead to confusion or delays, particularly as the increase in multi-disciplinary work between departments, schools and laboratories continues. The lack of ease of access to electronic health and safety management systems in the research sector is a major problem for researchers, managers and health and safety practitioners. If the end user cannot easily find the correct documents or forms to complete easily, the researcher can be tempted to ignore the requirement.

A common criticism of health and safety management is that it is reliant on documents, rather than practicality. Researchers need to be able to access high quality training that reflects their type of work and be directly involved with decision making when it comes to the implementation of new policies or procedures. Researcher consultation takes time but will result in better practical solutions to safety issues and higher rates of compliance. Some organisations have instigated student-led organisations, 11–13   involving students in the management of safety 14,15   and developing specific safety training programmes (especially with practical components). 16–21   As noted in the recent Nature Chemistry article, there is a pressing need for more research on how to devise effective safety training, how to measure its impact and achieve improved safety attitudes, not only in the undergraduate teaching labs but in the research labs as well. 1   This is addressed in our book in the chapters dedicated to safety management of new sites (Chapter 9), spin-outs (Chapter 15) and training of safe chemists (Chapter 6) and generally throughout the university (Chapter 5).

Our ability to teach and educate new students on approaches to risk and to have a sensible view of risk is a key area that needs further development. The undergraduates of today are the researchers of tomorrow, so if safety culture is to improve further, training at this level is required. There will be benefits to integrating risk and safety management into undergraduate degree programmes. This would need to be carefully designed to be relevant to the field of study and connected to work that the student is undertaking. It should also form part of the marks associated with the work. For example, an MRes course director at the Imperial College London Department of Life Sciences introduced training in fieldwork risks and completion of a fieldwork risk assessment into their course. Students are provided with training and information and asked to write the assessment for their proposed fieldwork. The assessment is then marked according to specified marking criteria and provides up to 5% of the marks towards the student's degree. This incentive towards the final marks resulted in significant improvements in the assessment quality and the students’ feedback was very positive in terms of the learning outcomes and the skills gained for future employment. We are also seeing innovative approaches to teaching practical skills to students, for example, the ‘Chemical Kitchen’ is a part of the Imperial College London Pedagogy Transformation Project, 22   an interdisciplinary practical course that introduces students to the mindset and fundamental skills needed in a laboratory setting through a non-threatening parallel of cooking. It aims to teach practical laboratory skills, planning, creativity, safe working, precision, dexterity, making and recording observations, and the application of knowledge. Identifying opportunities for this type of learning and communicating safety knowledge to students in this manner increases the chances that key skills are learnt and embedded for future use. In this book, our authors provided insights into the teaching of students in Chapters 6 (Chemistry), 7 (Medicine) and 8 (outside the classroom).

Separately, a perceived lack of action on reported safety related infrastructure issues is highlighted in research institutions, particularly the university sector. Due to the complex nature of scientific buildings, an end user may not appreciate the complexity of fixing what appears a relatively simple issue. Feedback to end users on the current status of reported defects is critical to ensuring good communication between scientists and the estates team. Potentially delays in repairs to engineering controls (for example local exhaust ventilation systems) and therefore completion of experiments can increase risks if the experiments are conducted without the controls in place.

A successfully integrated safety programme has been reported that included institutional, administrative, and faculty efforts combined with an initiative from graduate and postdoctoral researchers. 21   However, there is a lack of successful documented examples on how these communication and collaborative networks can be achieved. Best practice examples in these areas would be a useful resource for research institutions to learn from.

Inevitably in the research lab there will be several rules for scientists to follow. In some cases, these rules are perceived as being prohibitive and overstated. For example, to comply with chemical storage requirements researchers will be required to store reagents in a dedicated location, not necessarily at their immediate work bench. If the reasons requiring the storage location are not made clear during training or induction the researcher may not follow the guidance, leading to a potentially hazardous situation.

Although discrete disciplines exist within a university setting, these lines are becoming blurred as more research funding focuses on interdisciplinary research and providing solutions to ‘real world issues’. This can result in researchers from one discipline, where they have achieved success in educational and research terms, to venture into another domain where their knowledge of the risks associated with this new area may not be so competent. This is particularly an issue in ‘hack spaces’ or ‘innovation spaces’ where the crossing over of different disciplines is desired. Health and safety considerations, lab design and how these areas are managed are critical to ensuring a safe working environment. These issues are explored in detail in Chapter 14 ‘Innovation Spaces – the new campus risk paradigm’.

The safety practitioner has a critical role to play in coordinating safety management systems and providing advice. The challenge is to provide advice on a range of subjects to meet the needs of researchers in the modern laboratory. Multiple hazards and risks may be present in any one laboratory. It is unlikely that any one individual can provide competent advice at a technical level on a wide range of hazards, for example, chemicals, lasers, ionising radiation, biological agents, machinery etc. This requires a collaborative approach to health and safety management in these types of situation. Scientists and technical staff have the relevant technical expertise and the safety practitioner then assists to guide them through the key concepts of safety and risk management. Unfortunately, the feedback received in our survey showed that researchers sometimes receive inconsistent safety advice and safety professionals themselves don't always lead by example. Clear feedback on safety issues from those advising helps ensure researchers can continue working safely and with minimal delays. The health and safety practitioner must understand their own limits of knowledge and competence and seek advice where it is lacking, or insufficient and know when to refer to other competent professionals. Part of the complexity for higher education institutions and research institutes is the size and locations of their sites. Many universities are on several different campuses, or sharing campuses with other organisations, for example medical campuses and the NHS in the UK. This makes planning for emergency responses more complicated. Specific considerations should be made to ensure all those who may need help can access it quickly and efficiently while ensuring the emergency services themselves can be guided to the required location, which on campuses with multiple entry points and buildings is not always clear. Liaising with emergency services is the subject of Chapter 11 of this book.

1.2.4 Category 4: Behavioural Barriers

Apathetic attitudes, carelessness, ignorance, work culture, cultural background, poor communication, overconfidence, lack of common sense, “old” habits and laziness were often named among factors negatively affecting research safety. A response from the survey was: “People don't realize how bad something can be until it really happens”. Researchers are often facing deadlines and may have to make a choice between productivity and safety. Much of the time the safety infringement will not result in an incident reinforcing the notion that safety is not required at that point in the experiment. Only when a combination of variables align will the incident occur. Behaviour in the lab setting must be led by the most experienced and senior managers. New members of a research group will generally replicate the behaviours they see around them. If that involves a lack of care when it comes to health and safety issues, this will in turn increase the risks of an incident occurring at some point in the future. Therefore, safety rules and procedures cannot be perceived as “unnecessary”, “childish”, and safety “micromanagement”.

Solutions to these issues rely on the safety practitioners ‘soft skills’ and ability to create collaborative teams across areas that they have no line management responsibility for. Improving communication of safety matters, 23   “embedding” a safety professional in high hazard department, 24   and following established guidance and recommendations 25–28   also are essential to improving safety culture. We could find limited documented evidence of implementation of a safety behaviour programme in a research environment. This is an area worthy of further study.

In this book we have several chapters written by non-UK collaborators. Research science and higher education establishments will often have high levels of international staff and students. Researchers will often move between different institutions and countries, and their attitudes or approaches to safety culture and processes will be imported to their host institution. Communication of local safety culture and expectations is critical in a higher education or research environment. Chapter 3 of our book examines this issue from a European perspective.

1.2.5 Category 5: Industry-specific Barriers

Due to the nature of the research work environment and the preference for shared lab areas, several simultaneous unrelated experiments may be occurring in any one lab area. The hazards and risks associated with these will also be varied, as well as the controls required to keep risk down as low as reasonably practicable. It is impossible to build a specific lab for every process, especially as the processes often change as the research evolves. New reagents are constantly being tested, novel compounds developed, and experiments being amended due to previous results and published research. Researchers claim that “it is often the case that the safest way to perform an operation is not particularly convenient, especially where a minor increase in risk yields a significant increase in efficiency”.

In the research environment, especially in universities, those in the lab and doing work may have the least amount of experience, for example PhD students and new postdoctoral researchers. They are often on short term contracts and under pressure to produce results to ensure their career can progress. The team leader will be a guiding role and will be available for advice but not generally in the lab with their staff and students. The tension between time required to complete study or work and safety rules creates pressure for those working at the lab bench to take short cuts when it comes to safety. The relatively high turnover of staff and students from these positions inevitably leads to research groups losing valuable experience and knowledge of safety matters. In our experience there is little evidence of teams having formal handovers of local safety information to new staff and students. The safety culture in any one research team is being undermined by the continual replacement of researchers. Even responsible researchers are struggling to pass on their knowledge when leaving to preserve the same level of safety awareness. Reducing the risks from this is difficult without having lab managers or technical staff to support the researchers and not only provide advice but also monitor safety procedures in the lab and ensure consistency of approach to lab rules that are in place over a long period of time. The constant turnover of lab staff and students also requires the institution to ensure its training and induction procedures are restated frequently to ensure new starters have the same information as those that came before them. Reiteration of safety training and providing clear and concise practical guidance will help to make work in the labs safe. However, nothing will work without the support of the supervisors and dedication of research and support staff. The organisation needs to be focused on safety and have a coherent plan and allocate enough resources to support the implementation and maintenance of safety. In our experiences the technical support teams within departments, schools or faculty provide an organisational memory and are often called upon to assist academics and teaching beyond their normal duties. They are often involved in training in equipment and procedures and have key skills that the research and teaching activities benefit from. The role of technical staff in maintaining good health and safety is the subject of Chapter 10.

One item that the university and research institutions should be leading on is how they can reduce their impact on the environment. Running science labs and supporting research and teaching is an energy hungry business and can have significant impacts on the environment if not suitably managed. Various national schemes are being implemented across the sector to provide incentives for improvements to sustainability and the environment. These issues are discussed in Chapter 17, ‘Green and Sustainable while avoiding risks’.

An area that has received more attention in the last five years is stress and wellbeing within the higher education sector. Several initiatives have been launched for not only students but also staff, including access to confidential care lines, designing work programmes and teaching to reduce risks of overwork, raising awareness related to mental health issues and encouraging individuals to seek help where needed. Mental health and other training programmes for managers, tutors and others have been instigated and broadly they appear to be providing support where needed. A report by Universities UK in 2018  29   recommended a ‘whole universities approach’ meaning that all aspects of university life promote and support student and staff mental health. Many organisations have invested in training for mental health first aiders and awareness campaigns, however changing the core systemic issues to reduce risks of stress and overwork for staff will require in depth analysis, management structures and review of resources. Chapter 4 looks at stress and workplace wellbeing in a Higher Education (HE) and Research establishment in more detail and provides insights on how this is being managed in some institutions.

Our book ends with a chapter titled ‘Organise not Agonise – Getting the Best from Audits and Inspections’. This chapter covers concerns, successes and causes of failures around auditing, starting with a focus on interfaces, where there is often uncertainty and lack of knowledge as to who is responsible or in control in a research or university environment. Such areas have been the cause of most health and safety management problems, and as such are generally the most fruitful for an auditor.

We hope the information contained in this book will be of interest to you and provide useful examples of how to approach certain issues within the research and higher education sector. Ideally, it will lead to greater discussion in these organisations at senior management level with Finance Officers, Human Resources and Safety Directors, about how to further improve safety performance. By putting these chapters together, we have learned a lot, and it is our wish that you do to.

The survey provided some interesting views on how safety could be improved in the research setting. These are summarised here:

Having a system where an individual requires retraining if they have been seen to use an unsafe method x number of times ( x can be varied depending on how common the technique is and how unsafe they're being). Similar to a ‘three strikes and you're out’ system.

Introducing a well-advertised (and adequate) safety upgrade funding scheme. This is infrastructure and can't be paid for, in the main, by research grants.

Centralising and digitalising health and safety associated paperwork.

Offering supervisors and managers more training into good management skills and how they need to balance managing experimental outcomes and workers mental and physical health. Often a culture prevails of pushing or demanding too much from their workforce, and this leads to mental health issues and lapses in health and safety.

Ensuring that senior research investigators visit their laboratory space at least twice a week. I know of one group that has received only two visits from their supervisor/research lead in one year!

Focussing on real risks, rather than perceived risk. A safety culture anchored in data and statistics would be very welcome.

Getting supervisors to visit the labs more often and to accept the word/guidance of technical staff.

Appointing informal safety officers (like fire wardens).

Having “Keep your lab tidy” campaigns.

Holding monthly updates on lab activity across the research group while paying close attention to any safety breaches.

Implementing visible sanctions for non-compliance (such as closing labs).

  Following on the last suggestion we also received a quote from one of the responders: “I would like to think health and safety could be improved by providing incentives but trying that I have achieved no tangible results in the past. Funny enough, it is by threatening disciplinary action that engages people more but for all the wrong reasons”. We hope the experiences shared in this book will help you to avoid situations where sanctions and disciplinary actions have to be implemented.

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A Scoping Review of Interventions to Improve Occupational Safety and Health of Construction Workers

Affiliations.

• 1 Department of Public Health, McCann Healthcare Worldwide Japan Inc., Tokyo, Japan.
• 2 Department of Research, Down to Earth Inc., Tokyo, Japan.
• 3 Department of Global Studies, Tokai University, Hiratsuka, Japan.
• 4 Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
• 5 Department of Medical Oncology and Department of Population Sciences, Dana-Faber Cancer Institute, Boston, MA, USA.
• PMID: 37565269
• PMCID: PMC10631273
• DOI: 10.1177/08901171231193783

Objective: This review comprehensively examines interventions which sought to improve the occupational safety and/or health of construction workers. Factors that explain the (in)effectiveness of interventions were also summarized.

Data source: This review consisted of a search using two electronic databases, PubMed and Web of Science.

Study inclusion and exclusion criteria: Targeted workers in the construction industry; had at least one primary outcome that aimed to improve occupational safety and/or health; were published between January 01, 1990 and December 01, 2019; and were written in English.

Data extraction and synthesis: Two researchers independently carried out the process of reviewing the titles, abstracts and full texts, and extracted all data. If there were differences, discussions were held until a consensus was reached.

Results: A total of 1297 articles were retrieved and 24 were selected for final evaluation. Seventeen studies reported significant intervention effects, while 7 found their primary outcome not significantly improved.

Conclusion: Future research should place more effort on interventions aimed at improving both occupational safety and health outcomes in an integrated manner, with environmental interventions that accompany behavioral interventions at the individual level. Besides, additional effort is also needed to ensure the involvement of relevant stakeholders in designing the intervention, avoiding contamination effects (through cluster randomization), optimizing the "dosage" of intervention, and improving measurement of outcomes.

Keywords: construction workers; interventions; occupational safety and health; scoping review.

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Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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A bibliometric and scientometric network analysis of occupational safety and health in the electric power industry: future implication of digital pathways.

1. Introduction

2. materials and methods, 2.1. literature collection, 2.2. scientometric analysis, 2.3. qualitative discussion, 3.1. descriptive data analysis, 3.2. countries/regions cooperation analysis, 3.3. journal co-citation analysis, 3.4. keywords co-occurrence analysis, 3.5. temporal trend analysis, 4. discussion, 4.1. emerging research topics and trends, 4.1.1. safety management: causes and prevention, 4.1.2. occupational exposure in the electricity industry, 4.1.3. electrical incidents management, 4.1.4. risk analysis and management in the renewable energy revolution, 4.2. research gaps and future implications of digital pathways, 4.2.1. analysis, prevention, and emergency planning for electrical accidents, 4.2.2. hazards in electric power work environments, 4.2.3. barriers and facilitators of safety climate improvement, 4.2.4. safety and health of renewable energies, 4.3. research trends in occupational safety and health in the electrical industry.

• Strengthening robust emergency preparedness, planning strategies, and effective risk communication strategies.
• Identifying and evaluating strategies that facilitate real-time communication of occupational risks to workers.
• Exploration of the integration of advanced technologies to enhance the accuracy and efficiency of assessing and monitoring occupational risk exposures in the electrical power industry.
• The development of early warning systems to detect and alert workers about potential safety hazards or incidents.
• The enhancement of safety policies and strategies through digital technologies by evaluating their implementation and identifying barriers and facilitators.
• Leveraging real-time monitoring to enhance safety climate.
• The utilization of digital technologies for comprehensive risk analysis and developing targeted risk mitigation strategies.
• Designing digital platforms, interventions and safety training related to the electrical power industry, particularly the renewable energy sector, to enhance workers’ risk perception and safety culture.

5. Conclusions

Conflicts of interest.

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• Rahmani, A.; Khadem, M.; Madreseh, E.; Aghaei, H.A.; Raei, M.; Karchani, M. Descriptive study of occupational accidents and their causes among electricity distribution company workers at an eight-year period in Iran. Saf. Health Work. 2013 , 4 , 160–165. [ Google Scholar ] [ CrossRef ]
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Wong, K.P.; Meng, X. A Bibliometric and Scientometric Network Analysis of Occupational Safety and Health in the Electric Power Industry: Future Implication of Digital Pathways. Sustainability 2024 , 16 , 5358. https://doi.org/10.3390/su16135358

Wong KP, Meng X. A Bibliometric and Scientometric Network Analysis of Occupational Safety and Health in the Electric Power Industry: Future Implication of Digital Pathways. Sustainability . 2024; 16(13):5358. https://doi.org/10.3390/su16135358

Wong, Ka Po, and Xiangcheng Meng. 2024. "A Bibliometric and Scientometric Network Analysis of Occupational Safety and Health in the Electric Power Industry: Future Implication of Digital Pathways" Sustainability 16, no. 13: 5358. https://doi.org/10.3390/su16135358

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On Research: How do engineering students view safety?

What’s your study about?

This is very much an exploratory work to help us understand how engineering students think about safety, how they conceptualize it. Do they think engineering safety is an important part of their future work? Have they received safety-related education? We’re talking about systems safety. If I’m a young engineer who just entered the workforce and I designed my widget that works within a larger system, how does the thing that I designed contribute to safety outcomes?

What are the biggest takeaways from the study?

Students’ understanding of engineering safety, systems safety and their value of it is quite uneven across engineering majors. Some fields that have had historically large safety failures seem to be more interested in and receive more safety-related education, such as aerospace engineering.

Those who had less positive views and were less knowledgeable about safety may be learning about safety in an abstract way, if they’re learning about it at all.

What surprised you about the results?

Computer science engineering students had a distinctly less positive view about the importance of safety and were distinctly less knowledgeable. That’s concerning because they’ll continue to have this outsized impact on so many of our future systems.

There also may be sort of a public relations issue when it comes to safety. Students in computer science and other majors might see safety as getting in the way of efficiency instead of supporting high-quality work.

In what way does this research directly affect workers?

The relationship between people’s attitudes and safety culture and safety outcomes is quite muddled. But what seems obvious is the way that students conceptualize safety – and how important they think safety is to begin with – will influence the way that early career professionals engage with their work. If you work in an organization where safety is an important part of your work, systems safety needs to be a high priority training for early career professionals.

What other industries could this study impact?

Any industry that has failures that have large-scale consequences and industries that have high-risk activities. Any industry that has high-impact failures would also benefit.

What are the next steps in this research?

We’ve since seen that there are other ways that we could have asked the students about their attitude toward safety. We did analysis that will help us design a better survey in the future.

Another avenue is surveying other engineering institutions to understand what it is that they’re teaching their students about engineering safety and systematic safety.

Read the full study .

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Published on 25.6.2024 in Vol 26 (2024)

Wearable Technologies for Detecting Burnout and Well-Being in Health Care Professionals: Scoping Review

Authors of this article:

• Milica Barac 1 * , BS   ; 
• Samantha Scaletty 1 * , BS   ; 
• Leslie C Hassett 2 , MLS   ; 
• Ashley Stillwell 3 , DO   ; 
• Paul E Croarkin 4 , DO, MS   ; 
• Mohit Chauhan 5 , MD   ; 
• Sherry Chesak 6 , PhD   ; 
• William V Bobo 5 , MD, MPH   ; 
• Arjun P Athreya 1, 4 * , MS, PhD   ; 
• Liselotte N Dyrbye 7 * , MD, MPHE  

1 Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, United States

2 Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, United States

3 Department of Family Medicine, Mayo Clinic, Phoenix, AZ, United States

4 Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States

5 Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States

6 Department of Nursing, Mayo Clinic, Rochester, MN, United States

7 Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States

*these authors contributed equally

Corresponding Author:

Liselotte N Dyrbye, MD, MPHE

Department of Medicine

University of Colorado School of Medicine

Mail Stop C290, Fitzsimons Bldg

13001 E 17th Pl. Rm #E1347

Aurora, CO, 80045

United States

Phone: 1 303 724 4982

Email: [email protected]

Background: The occupational burnout epidemic is a growing issue, and in the United States, up to 60% of medical students, residents, physicians, and registered nurses experience symptoms. Wearable technologies may provide an opportunity to predict the onset of burnout and other forms of distress using physiological markers.

Objective: This study aims to identify physiological biomarkers of burnout, and establish what gaps are currently present in the use of wearable technologies for burnout prediction among health care professionals (HCPs).

Methods: A comprehensive search of several databases was performed on June 7, 2022. No date limits were set for the search. The databases were Ovid: MEDLINE(R), Embase, Healthstar, APA PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science Core Collection via Clarivate Analytics, Scopus via Elsevier, EBSCOhost: Academic Search Premier, CINAHL with Full Text, and Business Source Premier. Studies observing anxiety, burnout, stress, and depression using a wearable device worn by an HCP were included, with HCP defined as medical students, residents, physicians, and nurses. Bias was assessed using the Newcastle Ottawa Quality Assessment Form for Cohort Studies.

Results: The initial search yielded 505 papers, from which 10 (1.95%) studies were included in this review. The majority (n=9) used wrist-worn biosensors and described observational cohort studies (n=8), with a low risk of bias. While no physiological measures were reliably associated with burnout or anxiety, step count and time in bed were associated with depressive symptoms, and heart rate and heart rate variability were associated with acute stress. Studies were limited with long-term observations (eg, ≥12 months) and large sample sizes, with limited integration of wearable data with system-level information (eg, acuity) to predict burnout. Reporting standards were also insufficient, particularly in device adherence and sampling frequency used for physiological measurements.

Conclusions: With wearables offering promise for digital health assessments of human functioning, it is possible to see wearables as a frontier for predicting burnout. Future digital health studies exploring the utility of wearable technologies for burnout prediction should address the limitations of data standardization and strategies to improve adherence and inclusivity in study participation.

Introduction

Burnout is an occupational syndrome characterized by emotional exhaustion, depersonalization, and feelings of reduced personal accomplishment caused by chronic, unmitigated high levels of job-related stress [ 1 ]. Burnout is common among health care professionals (HCPs, also referred to as health care workers), impacting an estimated 35% to 54% of nurses and physicians, and between 45% and 60% of medical students and resident physicians in the United States [ 2 ]. Several studies also reveal a high prevalence of depression and anxiety in HCPs that preceded the coronavirus pandemic [ 3 - 9 ]. Data further suggests that burnout and other forms of distress have increased among HCPs as a result of the COVID-19 pandemic [ 10 - 12 ].

This is concerning because the well-being of HCPs impacts the quality of patient care and patients’ access to care. Several meta-analyses and systematic reviews have reported associations between burnout and negative impacts on the quality of care provided to patients, including increasing the risk of medical errors [ 13 ], malpractice claims [ 14 ], nosocomial infections [ 15 ], and mortality [ 16 ]. Additionally, other studies have found that HCPs who report experiencing burnout are more likely to reduce their time taking care of patients and quit, all of which negatively impact patient’s access to care and add a burden to the global health care system [ 2 ]. The impacts of burnout go beyond the workplace, as HCPs with reported burnout are at increased risk of cardiovascular diseases [ 17 , 18 ], suicidal ideation [ 13 , 19 ], substance use disorders [ 20 ], uncontrolled stress [ 21 ], car accidents [ 22 ], and quality of life [ 23 ].

Contributors of burnout in HCPs are multifactorial and complex. While most factors contributing to burnout originate from system-level factors within the work environment, some risk factors originate from the personal domain or challenges in the personal-professional interface, such as work-home conflict ( Figure 1 ). Due to the complexity of the factors involved, no model exists for predicting when an individual HCP or group of HCPs are at risk for developing burnout or other forms of distress. In response to the negative outcomes of burnout for HCPs and patients, the National Academies of Science, Engineering, and Medicine recommends health care organizations monitor (through frequent surveys) and respond to burnout. This approach is retrospective, as the time required for health care organizations to administer surveys, HCPs to complete them, and the additional time needed to analyze and interpret results all delay any response to burnout. A better approach would be a proactive one, where organizations or individual HCPs could predict and respond to high levels of job stress before the manifestation of burnout and associated personal and professional consequences result.

Previous studies and reviews suggest heart rate (HR) [ 24 ], heart rate variability (HRV) [ 24 ], sleep [ 25 ], and skin temperature [ 26 ] vary in response to stress. Additionally, sleep or fatigue also relates to the risk of burnout [ 27 ], depression [ 28 ], and other related conditions [ 29 ]. These types of data can be collected passively from wearable devices. Over the past 5 years, the adoption of wearable devices worldwide has more than doubled [ 30 ]. Therefore, data collected passively from wearable devices could potentially provide an avenue for detecting individuals at risk for high job stress, burnout, depression, and other related conditions. If predictive, such real-time information obtained passively from wearable devices could dramatically shift the current reactive paradigm to a proactive one, potentially leading to meaningful intervention before patients and HCPs experience adverse health consequences of burnout.

Previous systematic reviews suggest wearable devices may have some utility in predicting depression severity and stress levels [ 31 ]. To our knowledge, there is no review that investigates this relationship among HCPs or explores the ability of wearable devices to detect burnout risk. Hence, a scoping review was conducted to identify and summarize studies exploring associations between burnout, anxiety, depression, and stress, with data obtained from wearable devices in cohorts of HCPs.

Data Sources and Search Strategy

A comprehensive search of several databases was performed on June 7, 2022. No date limits were set for the search. The databases (and their coverage periods) were Ovid: MEDLINE (1946 to Present and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily), Embase (1974+), Healthstar (1966+), APA PsycInfo (1987+), Cochrane Central Register of Controlled Trials (1991+), Cochrane Database of Systematic Reviews (2005+), Web of Science Core Collection via Clarivate Analytics (1975+), Scopus via Elsevier (1788+), EBSCOhost: Academic Search Premier, CINAHL with Full Text (1981+), and Business Source Premier.

The search strategy was designed and conducted by a medical librarian (LCH) with input from the study’s investigators (APA and LND). Controlled vocabulary supplemented with keywords was used. The actual strategies listing all search terms used and how they are combined are available in the Multimedia Appendix 1 .

Review Strategy

The initial search yielded 505 papers. Two reviewers (MB and SS) independently identified and screened the titles and abstracts of potentially eligible papers. The inclusion criteria of the initial round of screening were as follows: the study must include a validated measure of burnout, stress, anxiety, or depression and the study must include only data from a wearable device worn by an HCP. For this work, we defined HCP as being a medical student, resident, practicing physician, or registered nurse in a hospital or outpatient clinical setting. The full-text reviews of the papers that resulted from the initial screening, data extraction, and quality assessment were also performed independently and in pairs by 2 reviewers (MB and SS). Papers were not excluded due to their calculated quality score. During this process, 475 papers were omitted because they did not satisfy the inclusion criteria (n=472) or were duplicates (n=3). After the initial screening, the full text of 30 papers was assessed for eligibility. Any disagreement was resolved by consensus with other senior reviewers (APA and LND) and the final source list was created, with senior reviewers blinded to reviews of each other and primary reviewers (MB and SS). The study selection process is illustrated in Figure 2 . Tables 1 and 2 provide descriptions of the final 10 papers published from April 2017 to December 2021 included in this review.

a HR: heart rate.

b STC: step count.

c STAI: State-Trait Anxiety Inventory.

d EDA: electrodermal activity.

e EMA: ecological momentary assessment.

f PHQ-9: Patient Health Questionnaire.

g HRV: heart rate variability.

h RHR: resting heart rate.

i RR: respiratory rate.

j Not available.

k PSS: Perceived Stress Scale.

l MBI-HSS: Maslach Burnout Inventory–Human Services Survey.

m PROMIS : Performance of the Patient-Reported Outcomes.

n SC: skin conductance.

a STAI: State-Trait Anxiety Inventory.

c HR: heart rate.

d HRV: heart rate variability.

Extraction Strategy

Data extraction was mostly completed by a single researcher (MB). Other researchers (APA and SS) helped refine data extraction and review the tables. The following information was extracted from the papers and is included in Tables 1 and 2 : sample population (size and occupation), anxiety, burnout, stress or depression assessment instrument, additional measurements used, wearable device used, measured physiological variable, study duration, primary findings, and the author-determined quality assessment score.

Quality Assessment

The methodological quality of nonrandomized or observational studies was assessed by 2 reviewers (MB and SS) using the Newcastle Ottawa Quality Assessment Form for Cohort Studies [ 42 ]. The Newcastle-Ottawa Scale is a validated scale of 8 items in 3 domains: selection, comparability, and outcome. Studies are rated from 0 to 9, with those studies rating 0-2 (poor quality), 3-5 (fair quality), and 6-9 (good or high quality). All 10 studies received a Newcastle-Ottawa Scale rating of good or high quality.

Roles of Participating Health Care Professionals

Among the 10 reviewed studies, 8 were conducted in the United States, 1 study was conducted in Portugal [ 35 ], and another one was conducted in Canada [ 36 ]. Seven studies recruited either resident physicians (postgraduate medical trainees), practicing physicians, or a combination of both, primarily within the same specialty (eg, orthopedic surgery and emergency medicine). Two studies recruited registered nurses [ 32 , 40 ] and 1 study recruited medical students [ 35 ]. Sample sizes ranged from 20 to 775 participants per study (see Table 1 ). Only 3 studies had more than 100 participants [ 32 , 33 , 40 ].

Wearable Devices, Physiological Variables Collected, and Duration of Observation

Table 1 summarizes the sample population, sample size, physiological variables collected from wearable devices, and psychometrics used in the 10 studies. The devices used, length of data collection, and primary findings are listed in Table 2 . Out of the 10 studies, 9 used wrist-worn biosensors, such as the Fitbit Charge (n=4) [ 32 , 33 , 35 , 40 ] WHOOP (n=2) [ 34 , 38 ], Basis B1 (n=1) [ 35 ], Empatica E4 (n=1) [ 40 ], and the Microsoft Smart Band 2 (n=1) [ 35 ]. Sensors embedded within wrist-worn biosensors included optical heart sensors, electrical heart sensors, accelerometers, and skin temperature sensors. The other device used was a HealthPatch, an adhesive patch with 2 ECG electrodes used to measure HR and HRV. A variety of physiological variables were collected, with sleep being the most common, measured in 7 studies. Studies ranged in length of data collection, from a single 12-hour shift to a 14-month period. Only 5 studies collected data for more than 10 weeks [ 32 - 34 , 37 , 39 ].

Methodological Wearable Data Reporting

Only 2 studies explicitly stated the sampling frequency used when processing data from the wearable device [ 33 , 39 ]. Four of the studies discussed how the data were processed; however, the level of detail varied [ 32 , 33 , 35 , 40 ]. Three of the studies indicated the cutoff values for physiological variables or explained how outliers were addressed [ 32 , 33 , 40 ]. Only 4 studies explicitly stated how much raw data were retrieved from the devices [ 32 - 34 , 36 ].

Reported Relationships Among Burnout, Depressive Symptoms, Stress, and Anxiety With Data Obtained From Wearable Devices

Of the 10 included studies, 6 included a measure of burnout ( Table 1 ) [ 34 , 36 - 40 ]. Four of these 6 studies used the Maslach Burnout Inventory–Human Services Survey (MBI-HSS) [ 43 ]. In a cross-sectional study of 114 nurses, no relationship was found between MBI-HSS score and skin conductance, a measure of autonomic nervous activity, collected through an Empatica E4, for 1 shift [ 40 ]. Another study investigated the relationship between MBI-HSS score, self-reported work hours, physical activity, and sleep, as measured by a Fitbit, in a cohort of 59 residents [ 36 ]. No relationship was found between the change in burnout score and data collected from the Fitbit over 2 weeks. In the third study, no relationship was found between MBI-HSS score and sleep, as measured by a WHOOP, over the course of 4 weeks [ 38 ]. Last, in a study of 75 medicine and psychiatry residents, no relationship was found between burnout score and sleep or activity levels, as measured by Basis B1 health-tracking device, during their first 6 months of residency [ 39 ].

Two studies measured burnout using scales other than the 22-item MBI-HSS (widely considered the gold standard) [ 34 , 37 ]. In a study of 21 orthopedic residents and surgeons, no association was found between baseline abbreviated MBI scores and WHOOP measures collected over 12 weeks [ 34 ]. The final study investigated the association between burnout, as measured by a commonly used single-item measure, and sleep and activity level, as measured by a Fitbit. In this study, of 28 emergency medicine residents, there was no association between burnout scores and sleep or activity levels over the course of the 16-week study [ 37 ].

Depressive Symptoms, Stress, and Anxiety

A 14-month study of 775 medical residents found a relationship between depressive symptoms, as measured by the 9-item Patient Health Questionnaire [ 44 ], and step count (STC) and sleep as measured by a Fitbit Charge 2 [ 33 ]. Medical residents whose depressive symptoms worsened over the period of the study had a significantly higher skew in their hourly STC distributions and spent less time in bed than those whose symptoms did not worsen. In a study of 83 medical students, Perceived Stress Scale-4 scores related to HR and HRV, were measured by a Microsoft Smartband 2, at baseline and during an examination [ 35 ].

In a 10-week study of 113 nurses led by Feng et al [ 32 ], no relationship was found between the level of anxiety, as measured by the State-Trait Anxiety Inventory (STAI) [ 45 ], and wearable sensor data (eg, sleep and HR) collected using Fitbit Charge 2 smartwatch. Weenk et al [ 41 ] conducted a study of 20 surgeons and surgical residents who completed an abbreviated version of the STAI before and after performing surgery, and wore a HealthPatch. This adhesive patch calculates stress using an HR and HRV-dependent algorithm for 48 to 72 hours [ 41 ]. There was no correlation found between the STAI score and HealthPatch data.

Device Use Compliance and Experience

Seven studies reported data on participant adherence or experience with wearable devices. Chaukos et al [ 39 ] reported that 25 (40%) of their participants wore their device for more than 50% of the time for the first 3 months of the study, while another 13 (21%) participants wore the device for more than 75% of the time for the first 3 months. Other studies, such as one conducted by Sochacki et al [ 38 ] reported that of the 26 participants, 5 did not complete the minimum WHOOP compliance (4 weeks). Surgeons involved in a study by Jevsevar et al [ 34 ] reported a high percentage of device compliance at 83.2% of the total collection window, similar to the 93% compliance rate reported by Mendelsohn et al [ 36 ] and Sochacki et al [ 38 ]. Weenk et al [ 41 ] reported that 6 of 20 individuals experienced problems with their HealthPatch, similar to Marek et al [ 37 ] who reported 1 of 30 participants dropped out due to fitness tracker intolerance. Problems included connection failure (n=2), loss of skin contact (n=2), and skin irritation (n=2). Feng et al [ 32 ] noted similar compliance between day-shift participants and night-shift participants (number of recordings day-shift: mean 44.6, SD 3.1 sessions; night-shift: mean 45, SD 20.2 sessions).

Risk of Bias

A risk of bias of assessment was completed for the 8 cohort studies and 1 cross-sectional study ( Figure 3 ). While the risk of bias was generally low across the studies, none included a comparison group of participants who did not wear a device.

To our knowledge, this is the first scoping review to investigate the use of wearable technologies for the prediction of burnout, anxiety, depression, and stress in HCPs. Among the 10 studies identified, a range of wearables collected data on HR, HRV, respiratory rate, skin temperature, sleep, and activity levels from a single shift of work and up to 14 months of data collection in relatively small samples of physicians, medical students, and nurses. In these studies, no relationships were found between collected physiological data from wearables and burnout or anxiety. One study reported a relationship between STC, time in bed, and depressive symptoms, and another between HR, HRV, and acute stress (during an examination). Identified studies had methodological limitations, including short duration which limits the capture of naturalistic variations in the workplace stressors.

In this review, 3 studies measured HRV [ 34 , 35 , 41 ] and only 1 found a significant relationship between HRV and acute stress. A previous systematic review involving non-HCPs identified 2 studies demonstrating relationships between HRV and acute stress-induced conditions and 1 study demonstrating a relationship between HRV and stress levels measured by catecholamine levels [ 31 ]. This previous systematic review also identified 1 study where in a setting of laboratory-induced stress, HRV parameters related to STAI score. These studies, however, differed substantially from the ones included in this review. For example, none of them collected physiological data longer than 24 minutes, stress was induced in a laboratory setting (vs occurring naturally in a work setting), and only 1 study compared physiological data with a self-reported stress measure (ie, STAI score).

Given these early findings, further research focusing on the following elements of rigor are warranted. First, the length of observation should be long enough (at least 2 or 3 consecutive quarters of a calendar year) to allow sufficient quanta of wearable data to capture fluctuations in and chronicity of workplace stress. Studies should systematically collect data using validated instruments measuring burnout (eg, MBI-HSS [ 43 ]), depression (eg, Center for Epidemiologic Studies Depression Scale [ 46 ] and Patient Health Questionnaire-9 [ 44 ]), and anxiety (eg, General Anxiety Disorder-7 [ 47 ]). Investigators may also want to consider designing cohorts comprising groups of HCPs defined by their type of medical specialty or practice location. For example, it is possible that workplace stressors, patient acuity, and job demand fluctuate between primary care and surgical specialties and between outpatient practices and hospital-based practices. Hence, the burnout biomarkers may vary between practices. Considering that burnout is defined as when job demands exceed job resources, it is possible that the workplace (eg, patient acuity and hospital bed size) and related staffing factors (eg, workload, shift length, and availability of support staff) impact physiological biomarkers collected from wearables. Hence, future studies should consider collecting organizational variables to better understand the systemic contributors of burnout. Additionally, given the era of decentralized health care practice (eg, nontraditional shift days/hours and remote care with augmented reality), studies engaging with HCPs may benefit from no-contact passive monitoring and a digital app interface for survey collection (ie, decentralized trail). Finally, there is a bioethics component to understand how wearables can be successfully integrated into workforces’ burnout management. Greater attention needs to be paid to participant engagement, including addressing comfort with wearing the device, resolving discrepancies in wearable-derived data versus self-reported data, and understanding factors that influence perceptions of fatigue but not recorded sleep [ 37 , 48 , 49 ].

The use of wearables to detect the functioning states of human beings is an active and rapidly evolving field. Several wearable-based studies have been shown to aid in the detection of mental health conditions or resilience in quality of life [ 50 ] through mindfulness practices including physical activity [ 51 ] and sleep [ 52 - 54 ] monitoring. Prior work has demonstrated that aspects of physical functioning when combined with data during the day could predict variations in aspects of QoL and mental well-being [ 55 - 58 ]. Work by Campbell et al [ 59 - 64 ] has demonstrated the ability of daily journaling, wearables, and mobile assessments to detect depressive symptoms and mental states in patients with schizophrenia. These prior efforts in the field of mental health and the work summarized in this scoping review demonstrate the promise of wearables in predicting states of one’s functioning, including burnout. However, a consensus is lacking on the best approaches to collecting, processing, and reporting physiological data, much like CONSORT (Consolidated Standards of Reporting Trials) [ 65 ] for reporting randomized trials and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) [ 66 ] guidelines for reporting observational studies. Standardization of variables should include the creation of a guideline for reporting the sampling frequency, device adherence, and other information regarding device parameters that impact data collection. Such standardization would assist with generalizing findings, validating predictive algorithms, informing meta-analysis, and the use of data for retraining predictive models regardless of the wearable’s make and model. Additionally, there needs to be consensus around approaches to address bioethics, privacy, and confidentiality concerns of participants [ 67 , 68 ]. Predictive technologies, informed by personal biometric or physiologic data, may help improve work conditions but could also place individuals’ privacy or perhaps even their job security at risk.

This study has limitations. Only studies that included physicians, resident physicians, medical students, and nurses and were published in English were included. Following the 2019 pandemic, physicians identifying as 2 or more races experienced the highest levels of burnout onset, according to a report by the American Medical Association [ 69 ]. Furthermore, there are known disparities in the access to, and the use of digital health technologies in underrepresented minorities [ 70 , 71 ]. Therefore, it is vital to understand the factors that cause burnout in these groups of professionals and remove barriers to access to personalized wellness technologies using wearables that may help understand and mitigate burnout. In the context of the use and access of digital health for burnout, 8 of the 10 studies reported the gender breakdown of participants, and only 1 study reported the race of their participants. With the urgent need to broaden access to digital health solutions to study and understand burnout, future efforts should (1) follow reporting guidelines (eg, set by National Institutes of Health in the Human Subjects sections) to report on participant characteristics by ethnicity, race, and gender, and (2) innovate study procedures (eg, decentralized protocols) that improve the recruitment and engagement of underrepresented minorities in digital health studies of burnout. Although we sought to include validated measures of burnout, stress, depression, and anxiety, the instruments used in the studies varied in their psychometric strengths. Finally, most studies lacked power calculations, making findings, effect sizes, or impact of dropouts difficult to interpret from the perspective of the generalizability of biomarkers.

Despite the popularity of wearable devices, only 10 studies were identified that explored relationships between physiological data and burnout, depressive symptoms, stress, or anxiety. Most of these studies had substantial methodological limitations, and nearly all reported limited data collection and processing information, participant experience with the wearable device, and device compliance. Standardizing study procedures, common data elements, and reporting of wearable data are needed to strengthen the rigor of digital health studies. Addressing these limitations will result in improvements in wearable device research, including data standardization and reporting, that will validate their use in providing early intervention for HCP wellness. Additional research is warranted to explore the potential of wearable devices, perhaps augmented with other system-level data (eg, work shift lengths and absenteeism), to predict burnout and other forms of distress, hopefully leading to meaningful action before it has an adverse impact on HCPs and patient care.

Acknowledgments

This study was partially supported by the Mayo Clinic Summer Undergraduate Research Fellowship, National Science Foundation (grant 2041339); National Institutes of Health (grant R01 NR020362); the Mayo Clinic Center for Individualized Medicine, and the Mayo Clinic Center for Clinical and Translational Science. Any opinions, findings, conclusions, or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation or National Institutes of Health.

Authors' Contributions

APA and LND contributed equally as co-Corresponding Authors. APA may be contacted at [email protected].

Conflicts of Interest

PC has received research support from the National Institutes of Health (NIH), National Science Foundation (NSF), Brain and Behavior Research Foundation, and the Mayo Clinic Foundation. PC has received research support from Pfizer, Inc. He has received equipment support from Neuronetics, Inc, and MagVenture, Inc. He received grant-in-kind supplies and genotyping from Assurex Health, Inc for an investigator-initiated study. He served as the primary investigator for a multicenter study funded by Neuronetics, Inc and a site primary investigator for a study funded by NeoSync, Inc. PC served as a paid consultant for Engrail Therapeutics, Sunovion, Procter and Gamble Company, Meta Platforms, Inc, and Myriad Neuroscience. PC is employed by the Mayo Clinic. LD is a coinventor of the Well-Being Index and its derivatives which Mayo Clinic has licensed. LD receives royalties. WB’s research has been supported by the NIMH, NINR, NSF, the Blue Gator Foundation, the Watzinger Foundation, and the Mayo Foundation for Medical Education and Research. He has contributed chapters to UpToDate concerning the pharmacological management of patients with bipolar spectrum disorders. MCs research has been supported by NSF and the Mayo Foundation for Medical Education and Research.

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PRISMA-ScR checklist.

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Abbreviations

Edited by T de Azevedo Cardoso; submitted 24.06.23; peer-reviewed by T Pipe, P Punda; comments to author 01.12.23; revised version received 01.01.24; accepted 20.03.24; published 25.06.24.

©Milica Barac, Samantha Scaletty, Leslie C Hassett, Ashley Stillwell, Paul E Croarkin, Mohit Chauhan, Sherry Chesak, William V Bobo, Arjun P Athreya, Liselotte N Dyrbye. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 25.06.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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A Study of the Effectiveness of Workplace Health and Safety Programmes in a University Setting in Canada

Zakia hoque.

Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St John's, NL, A1B 3V6, Canada

Veeresh Gadag

Atanu sarkar, introduction:.

Nearly a quarter-million people work in universities in Canada, making it one of the fastest-growing sectors. Although each university provides occupational health and safety services and training programmes to their employees, there have been no studies conducted on the impact of such programmes on employees’ knowledge, attitude and behaviour. The aim of this study was to evaluate the effectiveness of dissemination of information of workplace health and safety programmes to workers at a Canadian university.

The study compared two cross-sectional online surveys of employees of a Canadian university regarding workplace health and safety with a previously conducted cross-sectional study and thematic analysis of key informant interviews to address the issues raised in the surveys.

Participation in health and safety presentations could enhance understanding and practices of safety. Age, employment status and duration of employment were associated with the levels of knowledge, attitudes and behaviour of employees and graduate students. The key informant interviews highlighted some new initiatives such as the establishment of workplace health and safety committees in all university buildings; the development of a safety app and health and safety management system; routine annual inspections of all university building offices and laboratories; new orientation for undergraduate students where general safety rules are described.

Discussion:

University should have regular presentations on the available health and safety programmes and should increase the number of safety training programmes and keep track of the employees that have not received any training, particularly for those working in hazardous environments.

I NTRODUCTION

The labour force in the university sector in Canada is large and has considerable occupational diversity. According to Statistics Canada, out of 17 million-member workforce, 1.3 million (8%) are in educational services, and almost 20% of these individuals (~250,000) work in various universities.[ 1 ] The 2016 census shows that educational services in Canada had the fourth-highest rate of growth and more than half of this increase was in universities.[ 2 ] The working environment in universities is highly diverse, as there are a wide range of disciplines involving teaching, research, administration and maintenance. Due to this multifaceted working environment in the universities, employees encounter various types of occupational health risks. Despite the complexity of occupational risks, little has been written about occupational health and safety programmes of the university employment sector.[ 3 ]

In Canada, workers are covered by provincial or federal labour codes, depending on the sectors in which they work. While workers in mining, transportation, and the federal government are covered by the Canada Labor Codes, other workers such as employees of universities are covered by provincial health and safety legislation.[ 4 ]

Venables and Allender (2007) described the occupational health services in 93 universities in the UK by drawing on data from surveys carried out in 2002, 2003 and 2004. Most survey responses were received from universities and in-house services. The surveys requested self-completed information on occupational health services from each university. The results indicated that 50% of the universities had an in-house health service, 32% relied on a contractor, 9% used the campus student health service, and a further 9% had an ad hoc arrangement or no arrangement. On average, the service was poor, as usually only one half-day doctor with one full-time nurse and a part-time clerk were available to provide service. The wide variation among universities in staffing levels suggested that some universities might have less-adequate services than others.[ 3 ] A study examining the safety concerns of faculty members of a university campus in USA (Alabama) showed that women faculty members took more personal safety precautions than men and felt more strongly about the need for the improvement of safety features on campus. A 160-item questionnaire was distributed to the faculty members asking about socio-demographic information, daily campus activities, personal safety protection taken while on campus, awareness and attitudes about safety on campus, and reported cases of victimization on campus. A few months later, the authors examined the safety awareness of male and female staff members in the same university using the same questionnaire. The results indicated that although female staff members reported more regarding acts of violence against them than male staff members, there was not much difference in their attitudes towards improving safety features on campus. Faculty and staff members identified that they like to use avoidance strategies such as walking with a friend or using objects as a weapon rather than contacting campus security.[ 5 ]

All Canadian universities have Environmental Health and Safety (EHS) or similar departments through which Occupational Health and Safety (OHS) services are provided. All the universities follow a similar practice such as a) having health and safety committees on the campus, b) promoting health and safety and providing risk management services, c) conducting regular workplace inspections and reviewing incident investigative reports, e) creating annual reports about incidents, lessons learned, and providing recommendations to senior administrators, and e) organizing health and safety information session for the employees. The EHS unit mainly offers training on fire safety, first aid, laboratory safety, biosafety, X-ray safety, radiation and laser safety, WHMIS (Workplace Hazardous Materials Information System), contractor safety, respiratory protection, ergonomics, hazardous waste management and disposal and also provides health and safety committee representative training.[ 6 ]

Despite the existence of occupational health and safety programmes in various Canadian universities, recorded evaluation of such programmes is sparse. Considering the large workforces in universities and their unabated positive growth, it is crucial to evaluate the existing occupational health and safety programmes in Canadian university settings. The aims of this study were: a) to evaluate the effectiveness of health and safety programmes through well-designed surveys of faculty members, staff and graduate students of a Canadian university (Memorial University of Newfoundland or MUN); and b) to conduct a key informant interview of the officials of MUN responsible for the operation of the health and safety unit to address the issues raised in the surveys.

In 2013, MUN contracted a third-party consultant to conduct an impartial assessment of the safety culture at the university. The consulting group was asked to do a complete assessment of the current state of health and safety programmes offered by MUN through the Office of the Chief Risk Officer and to identify gaps in the programme. The consulting group surveyed about 10% of the permanent employees of MUN in 2013 and produced a report in 2014. The Office of the Chief Risk Officer called the report a ‘Gap Analysis (GA) survey’. In 2015, to address the identified gaps and to increase awareness about the health and safety programmes, the Office of the Chief Risk Officer organized several health and safety presentations for MUN employees. We sought to examine if these presentations had any effect on the knowledge, attitudes and behaviour of the employees and graduate students at MUN and if their level of knowledge, attitudes and behaviour are sustainable over time. As a result, in consultation with the EHS Unit in 2016, we administered two identical online surveys to employees and graduate students at MUN. The purpose of the first survey was to answer the following research questions:

• Has there been any significant improvement in the perception of the workplace health and safety of MUN employees since 2013 when the survey on gap analysis in safety culture was conducted?
• Do knowledge, attitudes, and practices regarding the health and safety of MUN employees differ with respect to demographic variables?
• Is there any significant difference in the perception of safety practices between those who attended the health and safety presentations and those who did not attend these presentations?

The purpose of the second survey (using the same questionnaires of the first survey) was to assess the retention of health and safety knowledge over the period of 6 months. The intent of conducting the surveys was to gain insight into important factors that could make MUN's health and safety programmes more effective. The study also intended to explore the responses of the officials to the issues raised in the surveys.

We used a mixed-methods approach by collecting, analysing and integrating quantitative (surveys) and qualitative (interviews) data to gain in-depth understanding and corroboration while offsetting the weaknesses inherent in using each approach by itself.[ 7 , 8 , 9 ] Approval from the ethics committee was obtained. The date of the approval 23rd August 2016.

Survey participants

The survey participants in the two surveys that we conducted, included graduate students/researchers, faculty members and staff, as they work for the MUN as employees. As the surveys were anonymous, the second survey was sent to the same entire population and not to only the respondents of the first survey. This allowed us to compare the results with those of the independent surveys to determine if there are any changes in the knowledge level of the employees on health and safety-related information.

Survey design

Two identical online surveys of MUN employees were conducted between 1) October 19, 2016 and November 30, 2016, and 2) April 10, 2017 and June 10, 2017. The purpose of the first survey was to gauge the level of uptake of the information on health and safety, disseminated by the EHS Unit to the MUN Community through their safety workshops in 2015–2016 as well as through their broader reach-out mechanisms. Further, we wanted to study the effect of the knowledge about health and safety on the attitudes and behaviour of the employees and graduate students at MUN. The second survey was conducted six months after the first survey. It targeted the same population and followed the same methodology as the first survey and aimed to understand the retention of knowledge over time and whether the knowledge, attitudes and behaviour of the employees changed over time.

Our survey was developed based on input from the EHS unit. Some questions were based on questions from the GA survey with the intent of comparing the results. We also adopted some questions from the survey questionnaire of the study ‘Montana Tech Campus Safety, Security and Safety Awareness Survey’ conducted by Kristine Witt in 2011 at Montana Tech University, USA.[ 10 ] We conducted a pilot survey of some faculty members, staff and graduate students to ensure the readability, clarity, and organization of the survey questionnaire. We sent e-mails to all faculty and departments of MUN's main campus in St. John's and affiliated Grenfell campus in Corner Brooke, detailing the nature of the survey and provided a web-link (Survey Monkey ® ) to access the survey. The questionnaire with the references is presented in a supplementary file (S1) . At the beginning of the survey, online consent was obtained. The survey instrument was prepared to capture the awareness, attitudes and behaviour of employees and graduate students toward health and safety programmes offered by MUN. The questions were divided into three groups: 1. Knowledge (refers to the awareness and perception of the participants related to health and safety); 2. Attitudes (collects information on the viewpoints and beliefs of the participants about occupational health and safety); and 3. Behaviour (collects information on participants’ day-to-day safety practices/protocols at the workplace).[ 11 ] Questions 7-18, 21, 22, 25, 29, 31 and 40 were designed to test the knowledge of the participants regarding occupational health and safety; questions 19–20, 26–27 were combined to assess their attitudes; and questions 28, 30, 32, 34, 36 and 41 were grouped under behavioural questions (please refer to the questionnaire in supplementary file S1 ). The last few questions were on the perceptions of the participants about safety in specific areas on the campuses.

In the knowledge group, there are 18 questions. For each question, we assigned a score of 1 for the answer “No” and a score of 2 for the answer “Yes”. We added the scores of these 18 questions, which ranged from 18 to 36. We divided this range of responses into halves, 18–27 representing lower score and 28–36 representing higher score, following the procedure described in.[ 12 , 13 ] we used a similar procedure with four questions representing attitudes and six questions representing behaviour groups. The purpose of creating these categories was to test for the association between the levels of the knowledge, attitude, and behaviour of the participants among themselves and with the demographic variables, using frequency analysis technique.

In order to compare with the GA survey, we selected only the Yes/No-type questions (similar to the GA survey) and divided them into three broad themes: i) Environmental Health and Safety Office-related questions, ii) Faculty/Building-related questions, and iii) Department/Division-related questions.

Key informant interviews (KII)

After completing the cross-sectional surveys, we conducted KII with eight officials who have been responsible for the development and implementation of health and safety programmes at MUN. Among them, five officials were from the Environmental Health and Safety (EHS) unit, two officials were from the Workplace Health and Safety Committee (WHSC) and one official was from Facilities Management (FM). The interviews were recorded in writing. A thematic content analysis approach was used for data analysis. Each transcript was reviewed and coded to identify key emerging themes. We then compared the coding of the transcripts. The first question of the interview is about the initiatives taken by the EHS unit to raise awareness about health and safety among MUN employees after 2013. For further analysis, we divided the rest of the questions into three groups. The first group is about knowledge and awareness of safety policies. Questions 2–6, 12 are included in this group. Questions 7–10 are in the group on laboratory safety and workplace hazards. Questions 11, and 13–15 are in the group of MUN facilities and services (please refer to the questionnaire in supplementary file S2 ). The primary motivation of the KII was to collect further information related to the survey questionnaire and to find answers to some of the comments made by the participants in the surveys. Therefore, some questions asked in the KII were based on the outcomes of the survey results.

Data analysis

Apart from descriptive statistics, Chi-square tests were conducted for correlation and P - value less than 0.05 was considered significant. For data analysis, SPSS (version 24) was used. For a detailed statistical analysis, please refer to the supplementary file (S3) .

In the first and second surveys, 148 and 103 valid independent respondents were identified, respectively. Table 1 shows demographic information of survey 1 and survey 2 participants. There was an increase in the level of the participants’ knowledge/awareness about MUN's health and safety policies, when compared to GA survey (please see detailed findings in Supplementary file (S4) ). There was an increase in the level of awareness among the employees about the presence of the EHS unit at MUN and improved communication with the Health and Safety Committee compared to GA results. On the other hand, there were lower levels of knowledge about MUN's working alone procedures, and about AED (automated external defibrillator) locations. In all three surveys, the participants demonstrated little familiarity with the OHS Act.

Demographic characteristics of the university worker participants

We have observed some association between demographic variables and knowledge, attitudes and behaviour (safety practices) of employees regarding health and safety programmes. Table 2 presents the association between the knowledge level score and demographics of the employees. In the first survey, there are associations between ‘the level of health and safety knowledge of the participants’ and their (a) ‘attendance at the safety presentations’ ( P < 0.05), b) ‘employment status’ i.e., faculty/staff/graduate student ( P < 0.05) and c) ‘age’ ( P < 0.05). For a detailed statistical analysis, please refer to supplementary file (S3) [Tables # S3.3.1 , S3.3.2 , S3.3.3 ]. In the second survey, there are associations between: ‘the level of health and safety knowledge’ and (a) ‘employment status’ ( P < 0.05), b) ‘age’ ( P < 0.05), and c) ‘duration of employment’ ( P < 0.05). For a detailed statistical analysis, please refer to supplementary file (S3) [Tables # S3.3.4 , S3.3.5 , S3.3.6 ].

Cross-tabulation between demographics and Knowledge level score

* Low score: 18-27; High score: 28-36; α significant for survey 1, β significant for survey 2

Table 3 presents the attitude level score and demographics of the participants. In the first survey, there are associations between ‘the level of attitude towards safety’ and: a) ‘employment status’ a) ( P < 0.05), and b) ‘age’ ( P < 0.05). In the second survey, no association was found between any of the demographic information and attitude towards safety. Please refer to Supplementary file S3 for a detailed statistical analysis [Tables # S3.4.1 , S3.4.2 ].

Cross-tabulation between demographics and attitude level and behaviour level scores

α significant for survey 1, β significant for survey 2

Table 4 also presents the association between ‘the behaviour (safety practice) level score’ and ‘demographic variables’ of the participants. In the first survey, there are associations between ‘behaviour level score’ and: a) ‘attendance at the safety presentation’ ( P < 0.05), and b) ‘employment status’ ( P < 0.05). In the second survey, there is an association between ‘attendance of the safety presentation’ and ‘behaviour level score’ related to health and safety ( P < 0.05). Please refer to Supplementary file S3 for a detailed statistical analysis [Tables # S3.5.1 , S3.5.2 , S3.5.3 ].

Laboratory safety related responses from different groups (in percentage)

In our two surveys, we observed that those who attended safety presentations had a better level of safety practices than those who did not attend the safety presentations. Overall, there is no significant difference in the knowledge, attitudes, and behaviour of the employees and graduate students between the two surveys. In Tables ​ Tables2 2 and ​ and3, 3 , the Chi square test results indicate that the levels of knowledge, attitudes and behaviour of the employees and graduate students have not changed much over the period of six months.

The only change we observed is a decrease in the knowledge of graduate students and researchers regarding laboratory safety in the second survey [ Table 4 ]. In both surveys, the participants reported that some places on the campus are safe [ Table 4 ]. In the first survey, 70% of the faculty/staff reported that they felt safe in the campus labs, and 51% of graduate students/researchers reported that they felt safe in the campus labs. Compared to the first survey, the difference in knowledge regarding lab safety between faculty/staff/administrators and graduate students/researchers decreased in the second survey (Please refer to Table 5 for the results). It can, therefore, be stated that the graduate students/researchers need more awareness sessions and training on laboratory safety.

Group wise health and safety ratings of different on-campus areas (except laboratories) (in percentage)

For KII, five officials from the Environmental Health and Safety (EHS) unit of MUN, two officials were from the Workplace Health and Safety Committee (WHSC) and one official was from Facilities Management (FM). During the interviews, the participants from the EHS unit highlighted several initiatives undertaken by their unit since the release of 2013 Gap Analysis (GA) results. Some important recent initiatives undertaken by EHS were: (a) Five to seven safety campus-wide presentations were organized, some of which were geared towards senior management and WHSC members; (b) MUN restructured 27 WHSCs on its campuses to provide adequate safety services and to meet the legislated requirements of CCOHS and the University OHS Act and Regulations. Each of the 27 WHSCs covered few buildings on campus; (c) In 2014, MUN implemented electronic safety reporting system (e-alert) (d) MUN Safe App was introduced in 2016; (e) Inspections of all university building offices and 350 laboratories are being conducted annually; (f) Orientation sessions for new undergraduate students each year are being organized, where general safety rules are described; (g) Established a chemical management system for labs; and (h) Created annual water sampling procedure for drinking water safety. The participants from WHSCs also mentioned some initiatives undertaken by the EHS unit such as (a) an increase in the participation of representatives from the EHS Unit to sit on the WHSC meetings and (b) more frequent laboratory inspections. The participant from FM mentioned some initiatives such as maintaining a good database to track the expiry date of the employee training; and more engagement in the weekly Toolbox Talks to discuss potential hazard assessment.

Most of the KII participants mentioned that the graduate students’ supervisors are responsible for providing information to the students on laboratory safety rules and whom to call first in the event of an incident/accident. They placed the responsibility for providing laboratory safety equipment on the Department Heads. The participants emphasized budget and manpower as the main bottlenecks for addressing workplace hazards in a timely manner. There were some suggestions from the KII participants to improve health and safety at MUN such as (i) making attendance of safety presentations mandatory and included as part of the new employee and student orientation packages, (ii) demonstrating the AED in every building, (iii) encouraging all university members to install the MUN Safe App on their phones, and (iv) constantly improving app on a regular basis.

D ISCUSSION

The survey results indicate that there are significant associations between: a) ‘attendance at the safety presentation’ and ‘participant's health and safety knowledge’, b) ‘level of attitude’ and ‘behaviour levels’, c) ‘employment status’ and ‘participant's knowledge level on health and safety’, d) ‘participant's age’ and 'safety knowledge level’, and e) ‘length of service’ and ‘participants’ level of knowledge on health and safety. In our two surveys, we observed that those who attended safety presentations had much better understanding and practices of health and safety than those who did not attend. It is clear from the results that there should be more emphasis on dissemination of the activities of the EHS unit to a larger number of MUN employees and students on a regular basis. The results of the cross-sectional surveys (our two surveys and the GA survey) show consistency in the three survey results. As presented in Table 2 , the respondents increased their awareness about the presence of the EHS unit at MUN and improved their (respondents) communication with the Health and Safety Committee over time. On the other hand, we identified some issues that need to be addressed such as less familiarity with MUN's working alone procedures, AED locations, and OHS Act. The dissemination of information on the OHS Act needs improvement, as this is the basis of all health and safety-related regulations, responsibilities, and rights.

Health and safety programmes should be evaluated periodically to ensure that best practices are being followed on a regular basis. Programme Evaluation always helps the institute to update guidelines as necessary, and to address areas of need or concern in the institute. In some of the previous studies, periodical evaluations were conducted to investigate any change or improvement in population health. Two cross-sectional surveys were conducted in1990 and in 1998 in Copenhagen, Denmark to investigate whether the prevalence of skin-prick-test (SPT)-positive allergic rhinitis had increased in an adult general population in Copenhagen, Denmark. A screening questionnaire on respiratory symptoms was distributed in random samples of 15–41-year-old people in 1990 and in 1998. Among the responders, random samples were invited to a health examination including SPT.[ 14 ] Two International Studies on Asthma and Allergies in Childhood (ISAAC) - questionnaires based surveys were carried out in 1994 and in 2001 among school children in Singapore to evaluate the hypothesis that the prevalence of asthma would further increase and approach to western figures over time.[ 15 ] A questionnaire-based survey was conducted in 1973 among 12 years old children in South Wales, Britain. In 1988, the survey was repeated in the same area among 12 years old children to again to observe whether the prevalence of asthma had increased.[ 16 ] Frequency of prescribed drugs use was assessed by a sample of elderly people 65 years and over in Nottingham in 1985 and 1989. The aim was to observe the change in numbers in the use of prescribed drugs.[ 17 ] Though in our study, we do not observe any significant difference overall in the knowledge, attitude, and behaviour of the employees between the two surveys, we observe a significant decrease in the knowledge regarding laboratory safety in the second survey. Our study is therefore, successful to investigate the change in perceptions of the employees regarding workplace health and safety over time.

This study used a mixed-methods approach as such a method allows for a more robust analysis.[ 14 , 15 , 16 , 17 ] We conducted online surveys as online survey can easily obtain large sample, it can control answer order, it required completion of answers, and online survey can ensure that respondents answer only the questions that pertain specifically to them.[ 18 ] Through the quantitative online survey analysis of MUN employees and graduate students, we learned of their perceptions regarding MUN's workplace health and safety programmes. These perceptions are a one-sided view of the survey participants, and quantitative survey analysis does not provide a detailed explanation of several issues. Through the KIIs, we collected further information related to health and safety programmes at MUN and clarified some of the issues raised by the participants in the surveys. Such as, the KII participants clarified that the graduate students’ supervisors are responsible for providing information to the students on laboratory safety rules and whom to call first in the event of an incident/accident; the Department Heads are responsibility for providing laboratory safety equipment; and budget and manpower are the two main bottlenecks for addressing workplace hazards in a timely manner. The KII participants also mentioned some recent beneficial initiatives such as, the arrangement of five to seven safety presentations campus-wide, restructuring of the WHS and EHS committees, the implementation of an electronic safety reporting system and the MUN Safe App, new orientation for undergraduate students where general safety rules are described, and development of the Health and Safety Management System. There had been a gap in understanding about health and safety matters between the employees and MUN health and safety officials. The qualitative analysis of the KII has filled this gap.

Our study is the first of this kind in the context of Health and Safety Program evaluation in Canadian university. Our study focused on the level of uptake of the information on health and safety disseminated by the university EHS unit through their safety presentations and workshops. We have also studied the effect of employee's and graduate student's knowledge about health and safety programmes at MUN on levels of their attitudes and behaviours. In addition, we have conducted KII interviews of the officials who are engaged in developing workplace health and safety programmes at MUN. As a result, improvements in the health and safety programmes have been planned by university officials. This is the practical implication of this study as the KII participants suggested some future procedures to improve health and safety at MUN such as making attending safety presentations mandatory for all employees and students; demonstrating the AED in every building; and encouraging all university residents to install the MUN Safe App on their phones.

There were some limitations of our study. The sample sizes of the surveys were small as participation was voluntary, and there was no incentive for participating in the surveys. The survey participants were not equally distributed across the disciplines, as the numbers of respondents from some faculties were much higher (Engineering faculty) than the number of respondents from other faculties (Arts and Education faculties). The survey data were anonymous, so our assertion on sustenance of the perceptions of the health and safety of respondents over the six-month period of time is not stronger.

In future surveys, undergraduate students should be included, as they are also exposed to similar risks as graduate students, and they outnumber graduate students. There is a sizable workforce involved in post-secondary university institutions in Canada, and this sector is growing. Varying ranges of working environments in the universities expose employees to multiple occupational risks. Safety training in a university is often not mandatory, and the survey analysis clearly indicates that there is need to increase the level of uptake on the information on health and safety programmes of university by employees and graduate students. Therefore, the universities should increase the number of safety training programmes and keep track of the employees that have not received training, particularly for those working in hazardous environments. Assured provision of financial resources is the key to maintaining a safe work environment and practices.

Key Messages

Universities should make safety training mandatory for all employees and graduate students. Therefore, there is a need to increase the number of training sessions to accommodate all eligible persons. Also, the universities should keep track of the employees and students that have not received training, particularly for those working in hazardous working conditions. The universities have to set aside financial resources for such regular trainings.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgements

We would like to thank the Associate Director of the EHS Unit of the Office of the Chief Risk Officer, Memorial University, Ms. Barbara Battcock, for her valuable suggestions throughout the survey. We would also like to thank all the anonymous participants who volunteered for the surveys and for the key informant interviews.

Supplementary File S1

Memorial University-Workplace Health and Safety Survey .

1. Did you attend the Safety-Presentation provided by Environmental Health and Safety Unit at Memorial University?

[ ] I don’t remember.

2. Employment Status

[ ]Faculty.

[ ]Researcher/Graduate student.

[ ]Administrator.

4. Which faculty/office do you belong to?

[ ] Medicine

[ ]Pharmacy

[ ]Engineering

[ ]Business

[ ]Education

[ ]Administrative office

[ ]Other (Please specify)

5. In which age group do you fall?

[ ] Less than 30

[ ] 60 or more

6. How long have you been on the Campus as an employee?

[ ] less than 5 years

[ ] 5-9 years.

[ ] 10 -14 years

[ ] 15-19 years

[ ] 20-24 years

[ ] 25 years or more

7. Are you aware of the presence of the Environmental Health and Safety Unit at Memorial University? (GA Survey, 2013)

8. Are you aware of Workplace Health and Safety Committees (WHSC- formerly known as Occupational Health and Safety Committees) of the building you work in? (GA Survey, 2013)

9. Does the WHSC in your building communicate with you? (GA Survey, 2013)

10. Do you read newsletters, brochures, bulletins, etc., relating to health and safety e-mailed by Environmental Health and Safety Unit? (GA Survey, 2013)

[ ] I don’t receive any of them.

11. Were you informed about the Occupational Health and Safety Act? (GA Survey, 2013)

12 Do you know where to report a safety concern, a safety hazard or accident? (GA Survey, 2013)

13 Do you know your role in the event of an emergency? (GA Survey, 2013)

14) Do you know the campus emergency telephone number? (GA Survey, 2013)

15. Do you know the shortest exit route from your work area (s)? (GA Survey, 2013)

16. Do you know whom you call first if you get injured at work? (GA Survey, 2013)

17. Are you aware that there are Automated External Defibrillators (AED) available in campus buildings? (GA Survey, 2013)

18. Do you know where the AEDs are located in the buildings you work? (GA Survey, 2013)

19. If AED training is made available through MUN, would you be interested in participating in the training? (GA Survey, 2013)

[ ] I am already trained in using AED.

20. In your experience, do you think that safety is a priority within your department/division/faculty/office? (GA Survey, 2013)

21. Do you understand your responsibilities for your and your colleagues’ health and safety? (GA Survey, 2013)

22. Are you familiar with MUN's health and safety policies? (GA Survey, 2013)

23. Please rate how safe you feel in the following areas on campus. (Montana Tech Safety Awareness Survey, 2011).

Please elaborate on any other particular areas you feel unsafe.

24. What precautions do you think you should take to increase your safety on campus? (Check all that apply). (Montana Tech Safety Awareness Survey, 2011).

• i) Carry a cellular phone.
• ii) Let others know where I will be.
• iii Take safety- training classes.
• iv Other, please specify.

25. Are you aware of Memorial's online reporting system for the health and safety issues/concerns? (GA Survey, 2013)

26. Do you report unsafe acts/conditions if you see them? (GA Survey, 2013)

’Toolbox Talks’ is the name of a meeting, which gives opportunity to Memorial University workers, supervisors and Department Heads a means of communicating health, safety and environmental initiatives as well as accident/incident ‘Lessons learned’ and expressing concerns, obtaining information, and resolving issues related to safety in the workplace.

27. Are toolbox talks/safety meetings relevant to your task? (GA Survey, 2013)

[ ] I do not know.

28. Have you participated in a toolbox talk/safety meeting? (GA Survey, 2013)

29. Are you aware of MUN's working alone procedures? (GA Survey, 2013)

30. Do you work after hours at least some times? (GA Survey, 2013)

31. Are you aware of MUN's safety escort service? (GA Survey, 2013)

32. Do you work at a lab or visit one frequently?

33. Please rate the following regarding laboratories on campus.

34. Is safety discussed in your workplace? (GA Survey, 2013)

35. Were you provided information/training on the safe use and maintenance of tools and equipment necessary for your job? (GA Survey, 2013)

36. Have you requested specific safety training appropriate to your position? (GA Survey, 2013)

37. Were you informed about the hazardous materials that are present in your workplace? (GA Survey, 2013)

For the purpose of this survey a hazard is defined as: ‘Any source of potential damage, harm or adverse health effects on something or someone under certain conditions at work’.

38. How many hazards have you identified in your work place in the last one year.

0 1 2 3 4 or more.

In the above question if your answer is 1 or more than 1 go to question 34 or else go to question 35.

39. How many of them have been corrected in a timely manner?

40. Are Employees given feedback on accidents that occur in your workplace? (GA Survey, 2013)

41. Do you have any concerns regarding your safety and/or security in your faculty or department?

If you answered yes please specify.

42. Which of the following do you think MUN should provide to help increase the safety of the campus community? (Check all that apply). (Montana Tech Safety Awareness Survey, 2011)

• Improve safety escort service.
• More emergency call boxes.
• Additional lighting.
• More security guards.
• More safety presentations.
• Self-defence classes.
• Other, please specify

Supplementary File S2

Key Informant Interview Questions

Q1. After the 2013 Gap Analysis survey on safety culture, can you recall any additional initiatives that EHS Unit has initiated to create awareness on health and safety among MUN employees?

Q2. In the surveys less than 50% respondents (first survey 46.6%, second survey 40.8%) notified that they had participated in the safety presentation/workshop in 2015. Is this level of participation satisfactory? If not what additional steps can be taken to reach out to more people at MUN?

Q3. The survey results indicate that, the graduate students and researchers have low level of knowledge/awareness on occupational health and safety programmes compared to the faculty and staff. Knowing that the graduate students and researchers are more exposed group to different safety critical scenarios,

• i Does this appear as a concern?
• ii How do you think the safety awareness of graduate students and researchers can be improved?

Q4. In the surveys less than 65% of the participants know whom to call first if they get injured at work. Is this level of awareness acceptable? What are the current mechanisms to educate researchers/employees about this information? How do you think this information can be disseminated more effectively?

Q5. The respondents have suggested to improve communication and implementation of the policies and to provide more auditing of safety policies by EHS department to ensure compliance, do you have a similar observation? Is there any continuing effort to improve this concern?

Q6. The surveys indicate that, among the people who said Tool Box Talk is relevant to them, the level of participation in toolbox talk decreased over time. Does your observation support this finding? If so, what can be done to increase the participation?

Q7. The survey analysis indicates that, the graduate students and researchers need more training on eyewash station and safety shower, can you explain the current mechanisms for training graduate students on these basic safety practices? Do you see any way to improve the provision of training and increase the level of participation?

Q8. The respondents suggested to install more flammable gas detectors and improve the splash proof safety goggles. In your opinion are the units/labs equipped with adequate gas detectors and splash proof safety goggles?

Q9. The respondents commented on shortage of lab space and shortage of PPE (Personal Protective Equipment).

• i) Is there any continuing effort to create more lab space?
• ii) Who is normally responsible to provide the PPE to the researchers/graduate students? How can one address the shortage of PPE in labs at MUN?

Q10. In the surveys over 50% of the respondents mentioned that, none of the hazards at their workplaces had been addressed in a timely manner.

• (i) What are the current practices for reporting, follow-up and correction of hazards?
• (ii) Do you see any bottleneck in the addressing the hazards in a timely fashion?

Q11. The survey results show that over 70% of the respondents want to participate in AED training. Is there any continuing effort to provide AED training to the employees and students at MUN?

Q12. The surveys indicate that a significant portion of the employees is not aware of MUN's working alone procedure though most of the employees are working after hours at the office. Is this a concern? If so what can be done to increase awareness on working alone procedure among the employees?

Q13. The participants have suggested repair of walkways and parking lots and removal of thick layer of ice from the parking lots to prevent slips and falls. Does this come under the purview of EHS Unit? If yes how can one address this issue?

Q14. Many respondents showed their concern about the design and usage of MUN Safe App. Is there a continuing effort to improve the App and make it user friendly?

Q15. In the surveys many of the participants have suggested the improvement of the on-campus safety escort service. How is the current safety escort service implemented and what additional steps can be taken to improve it?

Supplementary File S3

Table s3.3.1.

Chi-Square Tests for table 3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 14.02, * p-value < 0.05 considered significant

Table S3.3.2

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 6.89

Table S3.3.3

Chi-Square Tests for Table 3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 17.08

Table S3.3.4

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 6.67

Table S3.3.5

Chi Square Tests for Table 3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 12.53

Table S3.3.6

a. 1cells (25.0%) have expected count less than 5. The minimum expected count is 3.67

Table S3.4.1

Chi-Square Tests for table 4

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 8.71

Table S3.4.2

Chi-Square Tests for Table 4

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 21.79

Table S3.5.1

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 14.75

Table S3.5.2

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 6.94

Table S3.5.3

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 8.87

Supplementary File S4

Comparison of surveys

R EFERENCES

Who Pays for Rising Health Care Prices? Evidence from Hospital Mergers

We analyze the economic consequences of rising health care prices in the US. Using exposure to price increases caused by horizontal hospital mergers as an instrument, we show that rising prices raise the cost of labor by increasing employer-sponsored health insurance premiums. A 1% increase in health care prices lowers both payroll and employment at firms outside the health sector by approximately 0.4%. At the county level, a 1% increase in health care prices reduces per capita labor income by 0.27%, increases flows into unemployment by approximately 0.1 percentage points (1%), lowers federal income tax receipts by 0.4%, and increases unemployment insurance payments by 2.5%. The increases in unemployment we observe are concentrated among workers earning between $20,000 and $100,000 annually. Finally, we estimate that a 1% increase in health care prices leads to a 1 per 100,000 population (2.7%) increase in deaths from suicides and overdoses. This implies that approximately 1 in 140 of the individuals who become fully separated from the labor market after health care prices increase die from a suicide or drug overdose.

We thank Joseph Altonji, Steven Berry, Zachary Bleemer, Anne Case, Angus Deaton, Amy Finkelstein, Joshua Gottlieb, Jason Hockenberry, Anders Humlum, Dmitri Koustas, Neale Mahoney, Alex Mas, Costas Meghir, Fiona Scott Morton, Chima Ndumele, Seth Zimmerman, and many seminar participants for extremely valuable feedback. We benefited enormously from excellent research assistance provided by Felix Aidala, Krista Duncan, James Han, Mirko De Maria, Kelly Qiu, Shambhavi Tiwari, and Mai-Anh Tran. This project received financial support from Arnold Ventures and the National Institute on Aging (Grant P01-AG019783). We acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study. HCCI had a right to review this research to guarantee we adhered to reporting requirements for the data related to patient confidentiality and the ban on identifying individual providers. Neither HCCI nor the data contributors could limit publication for reasons other than the violation of confidentiality requirements around patients and providers, nor could they require edits to the manuscript as a condition of publication. The opinions expressed in this article and any errors are those of the authors alone. This research was conducted while some of the authors were employees at the U.S. Department of the Treasury. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and do not necessarily reflect the views or the official positions of the U.S. Department of the Treasury. Any taxpayer data used in this research was kept in a secured Treasury or IRS data repository, and all results have been reviewed to ensure that no confidential information has been disclosed. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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