Ethical analysis of the decision-making process in occupational health practice

BACKGROUND: Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society. OBJECTIVES AND METHODS: The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders. RESULTS: Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered. CONCLUSION: Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.     

Experimental validation of the Evidence-Based Occupational Health paradigm and of the PICO model in the decision making process applied by occupational health physicians

BACKGROUND: Health care organizations are increasingly aware of the need to apply quality assurance principles to serve their mission and there is an increasing pressure on health professionals to ensure that the practice is based on evidence of appropriateness. Medical specialists of different disciplines, including occupational health, are presently required to shift from habitual practices to evidence-based practices, and have began to use an approach based on the paradigm of Evidence-Based Medicine and of Evidence-Based Occupational Health (EBOH). OBJECTIVE AND METHODS: The study was carried out to analyse how the paradigm of the EBOH could be implemented in the search, analysis and synthesis of the best available evidence to apply in the decision-making process in occupational health practice. Out of 464 medical examinations consecutively performed by 4 occupational health physicians, 6 cases were selected on the basis of their complexity and the need for further investigation. Each case was submitted to each of the 4 physicians, who were asked to make a decision according to the EBOH paradigm: i.e., (i) identification of the problem according to the PICO model, (ii) solution of the problem according to his/her internal evidence or experience (iii) search for scientific external evidence, (iv) critical appraisal of such evidence, (v) application of the evidence in the decision-making process, (vi) comparison between internal evidence and external evidence. Outcome measurements, including satisfaction of the physicians, were collected. RESULTS: No differences were found between the decisions based on external evidence or on internal evidence in about 50% of the cases (13/24). In about 1/3 of the cases (7/24) no agreement was observed between the decisions taken on the basis of internal and external evidence. In some cases (5/24) no useful information was added for the purposes of decision-making. In about 50% of the cases the professionals were satisfied with the information found in databases, due to its usefulness both in increasing their knowledge and in improving their practice. CONCLUSIONS: Due to their involvement in a corporate system, the participants were aware of the need to practice according to quality assurance principles and to relinquish ineffective and obsolete practices. They agreed with the need to search for the best available evidence with the aim of guaranteeing efficacious interventions. In spite of a number of obstacles to the application of the EBOH paradigm to occupational health practice, the study demonstrated that such approach can be successfully applied in this field and that it can be proposed for the search of appropriate solutions to the problems usually encountered in professional practice.     

The evidence-based occupational health paradigm in managing back pain: identifying the problem and evaluation of the decision

BACKGROUND: Occupational health professionals must rely on the best available evidence in support of the appropriateness of diagnostic tests and preventive or clinical interventions. This study aims at comparing the decisions made in respect of health care personnel with the decisions made on the basis of the evidence and evaluating the effectiveness of these decisions. MATERIALS AND METHODS: Five female nurses with back problems exposed to health risk mostly associated with patient handling and movement were considered. The diagnostic results and the interventions following the decisions made in 2002 were evaluated and compared with the medical data during the years 2004-2005. To assess health changes occurring after the intervention, an indicator of impact was used. During 2006 the health problems were reviewed by means of the multi-step evidence-based occupational health paradigm: starting from identification of the problem and search for evidence (with a new and validated search string and the database Medline) followed by evaluation of performance. Professional performance was assessed by comparing the medical decisions made in 2002 with the decision supported by the evidence. RESULTS: All the medical decisions were in agreement with the decisions inferred from scientific evidence. Furthermore, all subjects showed an improvement in both perceived and objective health conditions after the intervention, together with increased acceptability of working conditions. CONCLUSION: Given that no gold standard exists and that guidelines for the management of back pain need to be assessed for their effectiveness, this study shows that the occupational health professional should be aware of the availability of up-to-date scientific evidence which can provide appropriate solutions to the commonly encountered problems. This perspective will be a challenge for professionals aware of the need to adopt practices related to the concept of quality in occupational health care.     

Evidence-based practice: a review of theoretical assumptions and effectiveness of teaching and assessment interventions in health professions

Health care professionals are expected to use a systematic approach based on evidence, professional reasoning and client preferences in order to improve client outcomes. In other words, they are expected to work within an evidence-based practice (EBP) context. This expectation has had an impact on occupational therapy academic programs’ mandates to prepare entry-level clinicians who demonstrate competence in the knowledge, skills and behaviors for the practice of evidence-based occupational therapy. If the EBP approach is to be entrenched in the day to day practice of future clinicians, a pedagogically sound approach would be to incorporate EBP in every aspect of the curriculum. This, however, would require a comprehensive understanding of EBP: its basis, the principles that underpin it and its effectiveness in promoting core professional competencies. The existing literature does not elucidate these details nor does it shed light on how requisite competencies for EBP are acquired in professional education in general and in occupational therapy education in particular. Drawing from educational psychology and EBP in the health professions, this paper provides a critical review of the evidence that supports EBP and the effectiveness of EBP teaching and assessment interventions in professional heath sciences programs and offers suggestions for the design of EBP instruction, grounding recommendations in educational theory for the health professions.     

Dual loyalties and the ethical and human rights obligations of occupational health professionals

BACKGROUND: Underlying most ethical dilemmas in occupational health practice is the problem of Dual Loyalties where health professionals have simultaneous obligations, explicit or implicit, to a third party, usually a private employer. METHODS: A literature review was undertaken of case studies of workplace occupational health conflicts, international human rights and ethical codes and strategies for managing dual loyalties, complemented by iterative discussions in an international working group convened to address the problem of Dual Loyalties. RESULTS: Violations of the worker-patient's human rights may arise from: (1) the incompatibility of simultaneous obligations; (2) pressure on the professional from the third party; and (3) separation of the health professional's clinical role from that of a social agent. The practitioner's contractual relationship with the third party is often the underlying problem, being far more explicit than their moral obligation to patients, and encouraging a social identification at the expense of a practitioner's professional identity. CONCLUSIONS: Because existing ethical guidelines lack specificity on managing Dual Loyalties in occupational health, guidelines that draw on human rights standards have been developed by the working group. These guidelines propose standards for individual professional conduct and complementary institutional mechanisms to address the problem.     

From scientific evidence to operative practice: towards a model of occupational medicine based on on efficacy evidence

There is increasing interest in improving health care practice and in providing evidence-based health care, that is, care in which different stakeholders consistently consider research evidence when making decisions. Quality of health care is presently viewed as a goal towards which different health care settings are geared. In comparison with this approach and in spite of the large development potentialities, occupational health practice is only at the beginning of the process. ILO convention No. 161 already pointed out the need to provide customers with quality-oriented services and evidence-based services. Occupational health practice can be analysed by means of a general system model already established for health care systems including input (structure, management, personnel, equipment), process (activities, performance), output (advice, recommendation), outcome (good life quality, sickness absence, work ability). All these elements can be critically measured with appropriate indicators to evaluate their efficacy. Despite general agreement about the importance of such analysis, there is a lack of data on the efficacy of prevention programmes. According to the evidence-based medicine model, which is commonly used by many other medical specialties, occupational health physicians could adopt a similar approach in order to implement more efficacious interventions. The evidence-based paradigm consists in the conscientious, explicit and judicious use of available best evidence in making decisions about health care problems. The practice of evidence-based medicine means integrating individual expertise with the best current evidence from systematic research. Evidence-based occupational health should implement this innovative approach to evaluate and to improve the efficiency of prevention services by means of the ability to (i) formulate the questions on the problem; (ii) search for scientific evidence; (iii) critically evaluate scientific evidence; (iv) use evidence as a key element for the decision process.     

Putting the public back into public health. Part I. A re-definition of public health

The practice of public health has been criticized as being too involved with a narrow, managerial agenda focused on health care rather than the wider horizons of public good. Public accountability is central to the practice of public health, but is not mentioned in current definitions. We offer a new definition that recognizes the centrality of the public, and which should help public health professionals interpret their own role: 'Use of theory, experience and evidence derived through the population sciences to improve the health of the population, in a way that best meets the implicit and explicit needs of the community (the public)'.     

Quality assurance and quality improvement in medical practice - Part 2. Evidence-based medicine

For assuring and improving quality of healthcare, everyday medical practice should be based on appropriate scientific evidence and results of health technology assessment. Evidence-based medicine is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care, when health technologies are used. On one hand health technologies which proved to be effective should be available for all patients, on the other hand, because of the limited financial resources of the health care system, they should be cost-effective, not to spend on interventions proved to be ineffective or even harmful. For effective implementation of evidence-based practice, development of more clinical guidelines, that contain explicit recommendations, and improvement of quality approach are necessary in Hungary.     

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.     

Supporting and resourcing treatment decision‐making: some policy considerations

This paper considers some of the policy implications of issues raised during a conference about treatment decision‐making in the clinical encounter held in Hamilton, Ontario in May 1999. Policies promoting patient participation in treatment decision‐making need to be flexible enough to ensure that they are appropriate across the range of contexts in which health care decisions are made and acceptable to people with diverse preferences and abilities. They should also be formulated in consideration of other health policies and of available resources. Policies of informing people and involving them in decisions about their care are unlikely to be simple to implement. Various strategies might be needed to support them. These include the development of appropriate skills among health professionals and in the general population, the use of interventions to encourage people to play more active roles in decisions about their health care, the provision of decision aids for people facing specific decisions and the provision and accreditation of more general information resources and services. If information and other facilitators of patient participation in decision‐making are seen as integral to good quality health care, then funding should be made available for them. This will, however, have opportunity costs. Policy makers’ decisions about how much health care funding should be invested in which strategies should be underpinned by good research evidence about the effects that different types of intervention have on a range of outcomes for individuals, health care systems and populations. The knowledge on which current policies are based is limited. The development of future policies will be enhanced if policy makers invest in critical conceptual thinking, reflective practice, imaginative development work and good quality evaluative research.     

Beyond evidence--to ethics: a decision-making framework for health promotion, public health and health improvement

Echoing the rise of 'evidence-based medicine', the concept of evidence-based policy and practice in the inter-related fields of health promotion, public health and health improvement has attracted increasing attention over the past two decades. More recently, again with roots traceable to biomedical thinking, there has been growing interest in ethics in relation to these fields. This paper links these two topical themes in a practical way. It explores the extent to which policies and activities 'on the ground' can and should be based on evidence, and considers the relative places of evidence and ethics in decision-making. It goes on to present the 'decision-making triangle', a framework that gives primacy to a set of ethical principles--with available evidence and plausible theory being used to inform the application of these. After introducing the concept of 'ethical logic modelling', the paper concludes by suggesting an 'ethical imperative' for health promotion, public health and health improvement: to make decisions based on the explicit application of ethical principles, using available evidence and theory appropriately.     

Ethical preferences for the clinical practice of empowerment social work

Social workers in health care and mental health benefit from interventions that integrate principles of contextual social work practice with standards for clinical practice. The authors articulate a conceptual framework for the ethical practice of social work that complements the social justice purpose. The sixteen ethical preferences in this framework are the ethics of care, autonomy, power, change, respect, critical thinking, praxis, discourse, critique, justice, contextual practice, inclusion, anti-oppression, advocacy, collaboration, and politicized practice.     

Inaccessible information is useless information: addressing the knowledge gap

The burdens of increasing information overload, time constraints, and the high human and financial costs of medical error, mean that doctors cannot practice high quality evidence-based medicine without the aid of decision support systems at the point of care. The physician's role is to formulate a management plan based on clinical judgment, the patient's unique circumstances and preferences, and the best available evidence. Clineguide is a clinical knowledge system that will integrate into the workflow to improve patient outcomes, reduce variability of care, and promote efficiency in the health care process. This article discusses some of the issues surrounding the provision of rapid, accurate, and accessible information to health care professionals.     

Professional ethics in occupational health--Western European perspectives

In this paper, the foundations of professional ethics in occupational health care is described and discussed. After an introduction reminding of the global developments of world economy, communications and trade and reference to cultural and social developments, reference is given the four basic ethical criteria of biomedical ethics of beneficence ("doing good"), non-malfeasance (avoidance of harm), autonomy (integrity) and Justice/Equity-The "Appletown consensus" of 1989. These criteria provide the basis for current thinking and practice in health professions of Western Europe. The principles of ethical analysis, as currently practiced is described using a practical case scenario drawn from experience of challenging tasks for Occupational Health Services in Western Europe. Specific challenges to professional ethics are discussed-the growth of knowledge in subjects and academic disciplines relevant to occupational health and the multiple loyalties of occupational health professionals. The principles of ethical codes and their implementation are touched on. In conclusion, the universality of professional ethical principles of bioethics-including occupational health-is discussed in observing global inter-cultural commonalities and convergence on ethical criteria of central importance. Emphatic recommendation is given to continue inter-cultural exchanges with a view to improve understanding of impact of contextual and cultural factors on ethics in professional occupational health practice.     

The effectiveness of inter‐professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter‐professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990–31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user‐relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost‐effectiveness for IPW, although well‐integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user‐defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.     

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment

We sought to evaluate whether health care professionals’ viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108—tertiary care center, 92—large community hospitals, 40—small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.     

Consensus Document. Update on latex exposure and use of gloves in Italian health care settings

This consensus document was prepared by an Italian working group including occupational health professionals involved for many years in the management of glove- and latex-related problems in health care settings. The aim of this document was to address the most significant technical, epidemiological, clinical, environmental and prevention problems related to the use of gloves and latex. The group's recommendations are based on scientific evidence and practical experience but they cannot be considered as final. These topics need to be periodically revised. The following points should be taken into account: glove quality seems to have improved considerably but the information on glove features provided by the manufacturers is often still inaccurate or incomplete; the regulations in force provide that the manufacturers perform tests to supply evidence for the quality of the products but they do not indicate which analytical method should be used and they do not require that the results be reported in the technical data sheets. Thus the manufacturers have only to declare that their products are "in accordance with the rules"; therefore, purchasers should require the manufacturing companies to supply detailed information and verify their reliability. Moreover, the rules should be adapted to higher quality standards; occupational physicians must be involved for the correct choice and purchase of protective gloves; the use of gloves (in particular latex gloves) and latex devices in health care settings should be based on specific criteria: procedures must be available stating which kind of gloves are suitable for specific tasks. When exposure to latex cannot be avoided it is necessary to choose products that have good biocompatibility (e.g., powder free-gloves with low allergen content); once and for all latex powdered gloves should no longer be commercially available! labels for latex devices (including gloves) should report the extractable latex allergen content. Limit values for extractable latex allergens should be established; the use of synthetic rubber gloves should be encouraged since some materials (e.g., neoprene and nitrile rubber) appear to have physical properties and protective efficacy similar to latex, plus good biocompatibility; more studies should be promoted to verify the protective efficacy of new synthetic materials; health care workers should be informed about the advisability and usefulness of using materials other than latex; health care services should not cause additional risks but rather highlight the advantages for workers and patients if the use of latex gloves and devices is minimized.     

Finding toxicological information: An approach for occupational health professionals

Background

It can be difficult for occupational health professionals to assess which toxicological databases available on the Internet are the most useful for answering their questions. Therefore we evaluated toxicological databases for their ability to answer practical questions about exposure and prevention. We also propose recommended practices for searching for toxicological properties of chemicals.

Methods

We used a systematic search to find databases available on the Internet. Our criteria for the databases were the following: has a search engine, includes factual information on toxic and hazardous chemicals harmful for human health, and is free of charge. We developed both a qualitative and a quantitative rating method, which was used by four independent assessors to determine appropriateness, the quality of content, and ease of use of the database. Final ratings were based on a consensus of at least two evaluators.

Results

Out of 822 results we found 21 databases that met our inclusion criteria. Out of these 21 databases 14 are administered in the US, five in Europe, one in Australia, and one in Canada. Nine are administered by a governmental organization. No database achieved the maximum score of 27. The databases GESTIS, ESIS, Hazardous Substances Data Bank, TOXNET and NIOSH Pocket Guide to Chemical Hazards all scored more than 20 points. The following approach was developed for occupational health professionals searching for the toxicological properties of chemicals: start with the identity of the chemical; then search for health hazards, exposure route and measurement; next the limit values; and finally look for the preventive measures.

Conclusion

A rating system of toxicological databases to assess their value for occupational health professionals discriminated well between databases in terms of their appropriateness, quality of information, and ease of use. Several American and European databases yielded high scores and provide a valuable source for occupational health professionals.     

Recent changes in occupational medicine in The Netherlands

 In some respects, the Dutch seem to be forerunners in Europe. Occupational health care for all workers can be considered as a substantial progress. Nonetheless, The Netherlands has taken the lead in Europe regarding high work pressure, sickness absence and disability for work. The resulting focus on sickness absence management in many companies is associated with changes in the tasks and position of the occupational physician. Quality of occupational health care is not always as high as it should be, partly as a result of the commercial approach occupational health services have to adopt nowadays. However, the post-academic education programme, with special attention for training of skills, is increasingly adapted to occupational physicians working in a commercial environment. Moreover, a basis has been laid for a better infrastructure and occupational physicians show an increase in professional enthusiasm. Furthermore, co-operation between different professionals has become increasingly common, resulting in a more comprehensive support for companies. Efforts are being made for better co-operation with general practitioners and medical specialists. Finally, the priorities for future research have been clearly outlined by a programming study. Experts are in demand for studies regarding implementation and evaluation of interventions, especially cost-benefit analysis. Furthermore, work stress and musculoskeletal disorders remain on the research agenda. Received: 8 April 1999 / Accepted: 24 April 1999