Primary Prevention

Understanding Operational Stress Injuries & Post-Traumatic Stress Disorder

An Operational Stress Injury (OSI) is any persistent psychological difficulty resulting from operational duties. Workers experiencing high levels of operational stress injury are at greater risk of suffering from depression, anxiety or post-traumatic stress disorder (Canadian Mental Health Association, 2019).

Post-Traumatic Stress Disorder, also referred to as PTSD, is one type of operational stress injury. It is a mental illness that results from exposure to trauma from single or multiple events that involve death or the threat of death or serious injury. PTSD may also be linked to ongoing emotional trauma, such as abuse in a relationship (Canadian Mental Health Association).

What is Trauma?

According to the Centre for Addiction and Mental Health (CAMH), trauma is “a term used to describe the challenging emotional consequences that living through a distressing event can have for an individual.” Each person can experience trauma differently and what might be traumatic for one person, may not be as traumatic for someone else.  The Workplace Safety and Insurance Board (WSIB) outlines some examples of trauma:

• Witnessing a fatality or horrific accident.
• A traumatic event that occurred in the past (e.g. sexual assault, death of a spouse or child, living through a natural disaster).
• Witnessing or being the object of an armed robbery.
• Witnessing or being the object of a hostage taking.
• Being the object of physical violence.
• Being the object of death threats or threats of physical violence.
• Workplace harassment that includes physical violence, life threatening or potentially life threatening situations (e.g. tampering with safety equipment).

Causes of OSI/PTSD and Risk Factors

OSI/PTSD is caused by a complex mix of:

• Life experiences, including the amount of and severity of trauma experienced since early childhood.
• The way the brain regulates and releases chemicals and hormones in response to stress.
• Genetically inherited mental health risks, such as an increased risk of anxiety or depression and aspects of personality or temperament.

Several factors can impact whether a worker develops an OSI/PTSD as a result of their job or situations that occur in their workplace, such as:

• A job that increases the risk of being exposed to traumatic events (e.g. frontline healthcare workers, first responders, corrections and military personnel).
• Experiencing intense or long-lasting trauma.
• Seeing people get killed or hurt.
• Having experienced other trauma earlier in life, including childhood abuse and or neglect.
• Having other mental health problems, such as anxiety or depression.
• Lacking a good support system of family and friends.
• Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home.
• Having biological relatives with mental health problems, including PTSD or depression.

Signs and Symptoms

OSI/PTSD symptoms often start within one month of an event or repeated events. In some cases, symptoms may not appear until months or years later. Symptoms can make it hard for a worker to function at work and in their everyday life. PTSD can increase the risk of other mental health problems, such as depression and anxiety, substance abuse and suicidal thoughts and behaviours.

There are three types of symptoms associated with PTSD:

1. Intrusive Memories

Intrusive memories, also known as re-experiencing symptoms, can begin from your thoughts or be triggered by words, objects or situations that are reminders of the traumatic event. Intrusive memories include:

• Recurring, unwanted distressing memories of the traumatic event.
• Reliving the event as if it were happening again.
• Upsetting dreams about the event.
• Severe emotional distress or physical reactions to a reminder of the event (e.g. heart racing, hands sweating).

2. Avoidance

Avoidance symptoms may cause a worker to change their routine, including avoiding things that remind them of the event as well as negative changes in thinking and mood. Avoidance symptoms include:

• Trying to avoid thinking about the event.
• Avoiding places, objects, activities or people that are reminders of the event.
• Increased negative feelings about oneself or others.
• Feeling emotionally numb or unable to experience positive or negative emotions.
• Feeling hopeless about the future.
• Losing interest in activities that were enjoyable in the past.
• Feeling intense guilt, depression or worry.
• Memory problems, including not remembering important aspects of the traumatic event.
• Difficulty maintaining close relationships.

3. Hyper-Arousal Symptoms

Hyper-arousal symptoms are changes in emotional reactions that can make you feel stressed, angry, and overwhelmed. They are usually constant. Symptoms include:

• Irritability, feeling tense or “on guard”.
• Difficulty sleeping.
• Angry outbursts or aggressive behaviours.
• Feelings of overwhelming guilt or shame.
• Self-destructive behaviours.
• Trouble concentrating or sleeping.
• Being easily startled or frightened.

When Workers Should Seek Help for OSI or PTSD

As an employer or supervisor, you should encourage open conversations about signs and symptoms of OSI/PTSD with workers. In particular you should encourage workers to seek help if they are feeling as though they are not able to function as before in their work and everyday life and continue to experience psychological changes (e.g., heightened anxiety, depression, inability to concentrate).

Workers should be encouraged to seek help from a mental healthcare professional (e.g. psychiatrist, psychologist, or counsellor specializing in anxiety disorders) if their symptoms last for more than one month and include experiencing at least:

• 1 Intrusive Memory symptom
• 2 Hyper-Arousal symptoms
• 3 Avoidance symptoms

A trained mental health professional will conduct a comprehensive assessment and provide a medical diagnosis. Additionally you should encourage communications with labour unions (if applicable), and/or family and friends who can also support a worker suffering from PTSD-type symptoms.

Understanding the Legal Requirements

Occupational Health and Safety Act

Under the Occupational Health and Safety Act, employers and supervisors are required to take every reasonable precaution to protect workers from harm. You are also required to inform all workers about psychological hazards on the job and train employees how to prevent these hazards and protect themselves. Workers are required to follow policies and procedures set out by the employer.

Workplace Safety and Insurance Act (WSIA)

The WSIA is monitored and enforced by the Workplace Safety and Insurance Board. It establishes a system which ensures that workers are compensated for work-related injuries and occupational diseases. Participating employers, in return, are given immunity from civil suits for worker injury/disablement. The purpose of the WSIA is to accomplish the following in a financially responsible and accountable manner:

• Promotion of health and safety in workplaces.
• Ensuring wherever possible the successful return to work of employees following workrelated injuries or occupational illnesses.
• To facilitate reentry into the labour market of workers and spouses of deceased workers.
• To provide compensation and other benefits to workers and to the survivors of deceased workers.

The employer has the duty to modify the work or the workplace to accommodate the needs of workers to the extent of undue hardship. The employer must re-employ an injured worker if they have worked continuously for the employer for one year and the employer normally employs 20 or more workers. If possible, and the worker is medically able to perform the essential duties of the job, the worker must be returned to their pre-injury position. If the worker is unable to perform essential duties of their job, but is able to work, they must be offered work appropriate to their functional abilities within the terms set out in the Act s. 40(1-2) and s. 41 (5-6).

Ontario Human Rights Code (OHRC)

The OHRC is the overarching legislation that requires employers to accommodate employees who are seeking accommodation due to disability up to the point of undue hardship.

Accessibility for Ontarians with Disabilities Act (AODA)

This legislation establishes mandatory accessibility standards in order to achieve accessibility for all people with disabilities by removing and preventing barriers for people with respect to goods, services, facilities, accommodation, employment, buildings and structures. The AODA adopts the broad definition of disability found in the OHRC. Specific to accommodation of a worker, this standard applies to those who employ workers and offer accommodation (Section 3).

Roles and Responsibilities for Positive Mental Health Culture in the Workplace

All workplace parties have roles and responsibilities for establishing a culture of positive mental health in the workplace.

Employers and Supervisors

Employers and supervisors have responsibilities under the OHSA to protect workers from an operational stress injury such as PTSD. Under the law, employers and supervisors must:

• Take every precaution reasonable to protect workers. In the case of creating a psychologically healthy workplace, it is important that employers and supervisors ensure that the workplace is civil and respectful, and that they are doing all they can to make the workplace psychologically safe and healthy for all workers.
• Assess risks for actual or potential occupational hazards. This means that employers and supervisors should understand the psychological demands of the job as well as the workload experienced by workers and as it relates to OSI. Employers and supervisors should understand the exposures to traumatic events or cumulative effects of exposure to trauma in the workplace.  To help understand psychological risks, organizations can use tools like www.stressassess.ca or the Mental Injury Toolkit.
• Provide appropriate personal protective equipment.
• Provide instruction, information and supervision to workers, which may include the provision of mental health literacy training, resilience training or suicide prevention training.
• Appoint a competent person in the role of a supervisor. To support supervisor competency, the employer should establish clear leadership and expectations which means supervisors understand core functions, how work is organized and measured and what needs to be done to be successful.
• Inform workers about actual or potential hazards.
• Give workers written instructions on how to work safely, including information about policies and procedures that have been implemented for the protection of workers’ psychological and physical safety in the workplace.

Joint Health & Safety Committee (JHSC) and Union Representatives

As leaders in the organization, it is important that you engage your health and safety committee and union representatives during the development of your OSI/PTSD Prevention Program.  A strong and healthy partnership between your committee and union representatives will contribute to the development of a positive workplace culture which is a key factor in psychologically healthy and safe workplaces.

To be an active part of the prevention of psychological injuries, the committee and union representatives should:

• Understand the factors of the job that impact psychological health and safety, in particular, OSI and PTSD.
• Be involved in workplace assessments.
• Assist the organization in developing policies and procedures, in particular, a process for identifying workplace mental health and wellbeing issues.
• Help identify controls that can be put in place to address psychological health and safety risks.
• Help reduce stigma related to mental illness by participating in identifying needs for education, training and resources to address OSI/PTSD, and participate in delivering these to the organization.
• Participate in the development of a communications plan and strategies.
• Reduce stigma by participating in positive conversations.

Healthcare Workers

Under the Occupational Health and Safety Act (OHSA), workers also have responsibilities when it comes to workplace hazards, including psychosocial hazards. The law requires all workers to:

• Comply with the OHSA and its regulations.
• Comply with workplace policies and procedures.
• Use and wear the personal protective equipment, protective devices or clothing required by the employer.
• Report actual or potential hazards to the supervisor.
• Participate in training and education about OSI/PTSD awareness and prevention, mental health literacy and other programs identified by the employer.

Additionally, to support positive mental health, workers should be encouraged to:

• Listen to co-workers and encourage engagement in mental health programing.
• Reduce stigma by participating in positive conversations.

Developing a Psychologically Healthy and Safe Workplace

CAN/CSA-Z1003-13/BNQ 9700-803/2013 Psychological health and safety in the workplace – Prevention, promotion, and guidance to staged implementation is an excellent resource for workplaces who are developing and integrating a psychological health and safety management system in their workplace.  Reviewing this free standard may be a great starting point for your organization.

A Psychological Health and Safety Management System includes the following elements which appear throughout this document:

1. Leadership Commitment and Participation
2. Planning
3. Implementation
4. Evaluation and Continuous Improvement (or Corrective Action)
5. Management Review

This website will also walk you through steps that you can take, which align with the above elements found in the standard.

Taking Steps to Prevent OSI/PTSD

As organizational leaders, you are required to take action to prevent injury, including occupational stress injuries. To start, it is essential that employers understand the impact these injuries have on the organization and how often workers are exposed to potentially traumatic events. Instead of reinventing the wheel, employers can use psychological health and safety programs that already exist, adapt them to the workplace and integrate into your organization’s health and safety program.

Here are some specific steps that employers and supervisors can take to prevent occupational stress injuries.  

Employers should:

• Consult unions and association members to provide input on policies, procedures, initiatives and services that will be offered to workers.
• Set the tone and take the lead on reducing stigma by encouraging conversations about mental health, the importance of self-care and early treatment when signs and symptoms are observed among workers and management.
• Develop policies, procedures, initiatives and services that support the organization’s mental health plan and program.
• Positively enforce the policies, procedures and mental health program in the workplace.
• Ensure all staff know and understand all of the components of the mental health program, policies and procedures within your organization.
• Review if the policies, procedures and program for mental health are working and take action on any gaps that are identified.
• Provide training for supervisors and managers such as anti-stigma awareness training, communications strategies, civility and respect and mental health literacy.
• Provide training to workers on mental health literacy, anti-stigma awareness, civility and respect.
• Establish supports for workers in the form of an Employee Assistance Program (EAP) or other benefits that offer mental health and wellness programing.
• Provide enhanced benefits to ensure workers can access the right type of care for occupational stress injuries, in particular PTSD.
• Provide supportive programs to help workers understand and know how to access available resources to improve resilience and health and wellness behaviours.

Supervisors should:

• Understand the risk factors and know how to recognize the signs and symptoms of OSI/PTSD.
• Support workers who are showing signs and symptoms of OSI/PTSD.
• Contribute to the development of the organization’s mental health program, including taking part in workplace assessments and assisting in the development of policies, procedures, initiatives and services.
• Understand the organization’s mental health program and how to implement it in the workplace.
• Ensure workers are aware of the organization’s mental health program, and enforce these policies and procedures.
• Help the employer by identifying strategies that support OSI/PTSD prevention in the workplace, such as rotations for workers who are highly exposed to trauma.
• Provide advice on how to monitor and screen for traumatic exposures.
• Encourage and engage in discussions about stigmatizing behaviours and how to improve mental health and psychological safety in the workplace.
• Be a positive role model.

Developing an Organizational OSI/PTSD Prevention Program

It is the employer’s responsibility to take every reasonable precaution to protect the health and safety of workers in the workplace. Psychological support and the protection of health and safety in the workplace through the establishment of policies, provision of training and the monitoring of psychological health and safety are important organizational factors that set the foundation for a psychologically healthy and safe workplace.

Policies and Procedures

Some organizations may already have policies that psychological health and safety can be added to. However, if your organization is just starting out on the OSI/PTSD prevention path, some policies and procedures you may want to consider include:

A policy statement outlines the organization’s commitment to addressing OSI/PTSD in the workplace and its support of workers. Ideally it should be signed and dated by the organization’s leaders. The policy statement should outline the following:

• A commitment by senior leadership to provide workers with psychological support that is in line with emerging best practices or known to be effective.
• An understanding of how OSI/PTSD fits into the organization’s overall workplace psychological health and how the policy will contribute to a mentally healthy and psychologically safe workplace.
• Required resources will be committed to establish, implement and maintain the prevention plan and related procedures and programs addressing OSI/PTSD in the workplace.
• The importance of worker participation in the development, implementation and improvement of the prevention plan and program.

Establishing Organizational Commitment

As leaders, it is important that you demonstrate your commitment to the prevention of OSI/PTSD and fostering a culture of support of psychological and physical safety. You also need to demonstrate clear anti-stigma practices. To demonstrate commitment, leadership should be actively involved in the organization’s mental health, wellbeing and psychological safety policies, programs and services. Leadership should also express that the OSI/PTSD prevention plan is a vital component of the organization’s Occupational Health and Safety Program across all operations, processes and procedures. Part of creating a supportive culture also includes allowing for open dialogue between all employees, peers and management. Information should be shared from both the top down and throughout the organization.

Creating a Culture of Support

It is important that organizations establish procedures that create a culture that promotes fairness, caring, honesty and trust. This is done by establishing a collective set of assumptions, expectations and beliefs which foster employee trust in their employers’ and supervisors’ intentions and motivations.

PSHSA’s survey of workers found that, when trust is broken, it can create a barrier to help seeking because, even if supports are offered, workers feel that management is not supportive and there is a sense that workers are stigmatized, not supported, believed, respected or listened to. 

Some actions organizations can take to create a culture of support include:

• Engaging in conversations about psychological well-being to understand workers’ needs and how the employer and supervisors can support them.
• Offering skill building sessions to increase awareness of psychological health and safety at work.
• Establishing, communicating and monitoring workplace civility and respect in the workplace.
• Defining employers’, supervisors’ and workers’ roles and responsibilities.
• Promoting work-life balance.
• Implementing conflict resolution procedures.
• Stopping stigmatizing behaviours by using person-first language, educating everyone about stigma, being kind to one another, listening and asking how you can help and talking about mental health in the workplace.
• Ensuring that workers can advocate for themselves and have confidence in their ability to communicate with their supervisors or managers. In order to feel psychological protection in the workplace, workers need to feel confident and safe to ask questions and report mistakes without fear that they will be judged or their current or future career will be put at risk.
• Consistently applying policies, procedures and programs, and quickly responding to workers’ requests for support.

Zero Tolerance for Harassment and Discriminatory Practices

A zero-tolerance policy for harassment and discriminatory practices should be enforced at all levels to demonstrate commitment and support of OSI/PTSD prevention. Enhanced benefits and wellness may also be considered as they relate to incidents of traumatic mental stress and PTSD.

Engaging the Joint Health and Safety Committee

The Joint Health and Safety Committee (JHSC) or Health and Safety Representative (HSR) can play an important part of your OSI/PTSD Prevention Program. The JHSC should be engaged in continuous improvement and evaluate the policies and programs at planned intervals. These engagement procedures should be aligned to the role that the committee members or representative play in your existing health and safety program and include:

• Consulting the JHSC when assessing or modifying the existing program.
• Reviewing the OSI/PTSD Prevention Program with the JHSC to make recommendations for improvements to the program.
• Reviewing training programs for staff with the JHSC.
• Identifying and/or tracking of trauma exposures, injury/illness reports.
• Training JHSC members to ensure they understand OSI/PTSD risk factors and symptoms, including organizational and job factors that impact this.
• Sharing the results of any organizational assessments with the JHSC.
• Consulting and including the JHSC when new programs or resources are created, as they relate to OSI/PTSD prevention.
• Involving the JHSC in the communication strategy of programs and resources to employees across the organization.

It is important your committee or representative be familiar with what internal and external resources are available as well as they may be asked by peers. In some instances, the JHSC or HSR may also be used as a resource for any concerns or complaints regarding the OSI/PTSD prevention program from fellow staff or peers. The JHSC or HSR may be helpful or required in investigations as well.

Orientation and Training

Your OSI/PTSD Prevention Program should incorporate training to help increase awareness about mental health and OSI, anti-stigma practices, and PTSD awareness and prevention. Employers should also provide supervisors with specific training on how to support workers, improve psychological health and safety in the workplace and how to support stay at work and return to work.

At a minimum, training should include general mental health information for employees about signs and symptoms of mental health injury, distress, and reduced coping, what to do if they recognize these signs and symptoms in themselves or a coworker, and how to seek help, both internally and externally. Post-exposure education is significant as it may include techniques to manage OSI/PTSD, organization-specific return-to-work policies and procedures, roles and responsibilities, and other peer support or counselling options that are available. Additionally, your training program should include anti-stigma training, such as how to support open dialogue, dispel myths about OSI/PTSD, frame help seeking as adaptive, and increase awareness in order to decrease the amount of negativity and prejudice.

You may also want to consider additional training for all managers and supervisors so that they are able to support their staff and answer any questions when implementing the Prevention Plan. Other aspects to consider when developing OSI/PTSD Awareness training include the frequency of training, type of delivery and timelines for completion.

Risk Management, Exposure Reporting and Tracking

There is limited research on the sensitivity and specificity of using any potential approach for identifying individuals at risk for OSI/PTSD, and there is no guide for the employer to reliably identify an employee as high risk.

According to research, the most appropriate way to identify risk is to focus on those individuals who have risk factors (prior history, repeated exposures to trauma, observed changes in performance or an increase in difficult interpersonal reactions) (Alexander & Richard, 2007). Procedures should be established for monitoring and offering the opportunity for mental health assistance.

The organization should establish procedures to collect objective information on exposures to traumatic events so that staff can be appropriately supported should they begin to develop symptoms acutely or in the months post exposure. In many cases, symptoms may arise as a result of multiple or cumulative exposure emphasizing the need for proper tracking

Screening Protocols

In addition to collecting objective information on exposures, it is recommended that organizations establish some form of screening protocols for frontline healthcare workers who experience high exposure to traumatic events. Establishing routine screening protocols, rather than voluntary screening, is extremely important. This allows supervisors to have ongoing conversations with employees about the importance of self-care and encourages open dialogue. For those in high distress, it is recommended that formal screening take place immediately. For those who are not at high distress, it is recommended that formal screening take place one month following the exposure to the traumatic event and again at six months following the exposure. Those found to be symptomatic should be referred to appropriate mental health resources.

Recovery and Return-to-Work

The organization should identify roles and responsibilities related to recovery and return-to-work. This could include mechanisms for referral to psychological support, Employee Assistance Programs or community supports.

Recommended OSI/PTSD Prevention Program Elements

PSHSA held a focus group with various stakeholders from the healthcare sector, including employers, union association members, health and safety experts, psychologists and psychiatrists, who determined the following list of recommended OSI/PTSD prevention program elements:

• Leadership engagement, recognition and demonstrated commitment that the prevention of mental injury and the creation of a psychologically safe work environment is a vital component of the workplace’s health and safety program.
• Active engagement of all workplace parties in the development of the OSI/PTSD Prevention Program, including workers, management, JHSC/HSR and the union (where applicable).
• Leadership takes every reasonable precaution for preventing mental injury, including identifying and preventing organizational factors causing or contributing to mental distress, such as considering job stress, work autonomy, work-life balance, justice and respect treatment in the workplace, and workload, as well as organizational communication, transparency and support.
• The employer fosters a work environment where workers and supervisors feel safe talking about mental injury/illness exposures, are supportive of employees’ mental health concerns and are able to respond appropriately.
• All staff talk openly and regularly about the importance of self-care and self-assessment as it relates to OSI/PTSD risk.
• Management knows how to identify, prevent and respond to mental health injuries/illnesses and exposures, and is ready for challenging scenarios such as responding to reports of mental injury/illness or a loss due to suicide.
• Workers know how to report mental health hazards/injuries/illnesses and are supported in doing so.
• There are employer-provided health benefits to support early treatment of OSI/PTSD.
• Effective mechanisms are in place to support workers who are experiencing OSI/PTSD and may be at risk for suicide or substance abuse.
• Workers are aware of and know how to access internal and external mental illness/injury treatment and supports for OSI/PTSD (e.g. peer support, relapse prevention programs, family/friend focused programming to support recognition and open dialogue about the importance of early treatment).
• Managers understand how to support and accommodate a worker returning to work following an absence due to OSI/PTSD.
• The employer involves the union in supporting and accommodating a worker returning to work following an absence due to OSI/PTSD.
• The employer has a continuous improvement mindset and is monitoring its prevention/response performance and data trends in consultation with the JHSC.
• The employer is actively working with the Joint Health and Safety Committee to implement changes.