Secondary Prevention

Responding to Workers' Signs and Symptoms of OSIs/PTSD

It is important for managers and supervisors to understand how to appropriately respond to signs and symptoms of OSI and PTSD. As part of the workplace Prevention Plan, you need to specifically outline the expectations of managers and supervisors when these signs and symptoms present themselves in the workplace. Some tips on how Managers and Supervisors can respond to a worker in distress include:

• Deal with signs and symptoms directly and as soon as possible. If you recognize signs and symptoms it is best to open the dialogue and keep these communication lines open. Let them know that they can come talk to you and ask how you or other team members can provide support.
• It may be difficult for the worker to open up. If the worker is not ready to talk, wait for them. Encourage the worker to talk to someone they trust about what has happened. This could be team members identified in the workplace to provide peer support, family members, friends or a manager/supervisor.
• If they do start to share, do not interrupt; it is often difficult for people to ask for help, particularly if they feel that they will be stigmatized.
• Share with the worker that what they are experiencing is a normal reaction. Provide information about signs and symptoms and when they should speak to a professional or seek additional help.
• Provide information about the options the worker has to address OSI/PTSD. Help the worker access support and resources if they request assistance.

Providing Support to Workers

Increasing Benefits Coverage for Psychological Support

OSI and PTSD in healthcare workers can have a significant impact on work productivity and working relationships and can result in substantial costs to employers in absenteeism (i.e. sick days) and presenteeism (i.e. an employee coming to work when they are unable to perform the work well).

Early recognition of mental health concerns and access to the right resources and adequate treatment can help people get on the path to recovery and return to work quickly. In addition to providing supportive resources like peer support teams, Employee Assistance Programs (EAP) and community-based mental health services, you should consider increasing health benefits coverage for psychological support in order to prevent the onset of mental illness, including PTSD, more effectively and promote a healthier and quicker return to work.

Many extended healthcare benefits offered through organizations provide coverage for the use of psychologists. Organizationally, it is considered a best practice to provide additional coverage for treatment of PTSD or other occupational stress injuries.

Benefits of Internal Support

In addition to increased psychological benefits, internal or integrated psychological support and referral should also be considered. An early intervention is important for the effective treatment and prevention of OSIs, internal support is ideal as it will allow healthcare workers to seek help directly after an exposure to a traumatic event. Moreover, internal psychological support will allow employees to take appropriate steps after completing self-screening and self-care assessments, which will ensure symptomatic workers have timely access and referral to mental health treatment. Furthermore, internal support is advantageous as the clinician will have experience with both occupational stress injuries and healthcare workers, and a nuanced understanding of the employer in order to help navigate place of employment. This will allow for ease of transition or return to work for employees. As a result, internal psychological support will often lead to increased job commitment, job satisfaction, involvement, positivity and job performance.

Understanding the Strengths & Limitations of your Organization’s EAP

An important part of developing your prevention plan is understanding the strengths and weaknesses of your organization’s Employee Assistance Program (EAP). While many organizations offer this to their workers, employees are not always equipped to deal with the potential OSIs or traumatic events that healthcare workers are exposed to and therefore the EAP program may not be the recommended portal for workers who are experiencing PTSD, as an example.

It is important that you understand the strengths and limitations so that you can address any gaps in your prevention plan. You need to find out about the specific provision of service for your workers with regards to OSI and PTSD. Remember, it is best for workers to receive treatment by a qualified mental health professional who has received training to address PTSD. Under the presumptive legislation, diagnosis of PTSD must be made by a psychologist or psychiatrist.

Some of the items that you will want to check include:

• How does the EAP provider screen calls and are they are equipped to provide service in this area?
• How many hours of counseling they workers receive and can this be increased for OSI cases?
• What qualifications do available counselors have to address OSI/PTSD symptoms?
• What knowledge and experience or training has been provided to the people who are taking employee calls with regards to the signs and symptoms of OSI/PTSD, and how is the employee properly referred to a mental health professional with training and experience addressing OSI/PTSD?
• Is the service available 24/7?
• What type of assistance is available to help you manage a critical incident?
• Does the provider provide training for managers on how to spot an employee in crisis and is this included in the package? If not, can we pay for it as needed?
• Does the provider provide peer support training or training for peer support mentors? Is this included in the package, or can we pay for this as needed?
• Does the EAP have other clients in the healthcare worker community?
• Is there an opportunity to improve the level of service if other members in the healthcare worker were to access the EAP as a single account/client?

Once you understand the strengths and limitations of your Employee Assistance Program provider, you will be able to identify the next steps you need to take to provide additional support to your workers. In some cases you may want to contact colleagues and peers within the healthcare worker community to establish a more robust program.

Communicate the strengths and limitations of your EAP program to your workers so that they are aware of the services and/or processes they will have to go through if they utilize this as a support resource. Remind your workers that is important that if they think they are experiencing OSI/PTSD they should see help from a mental health professional.

Understanding other available Support within your Community

There are community supports available to your workers and these resources can be a valuable first step when you are just getting started in developing your plan. There are a number of distress and crisis centres throughout Ontario which offer beneficial services to workers. Some of the services provided include suicide and crisis intervention, suicide prevention training, community education and suicide survivor support.

You should reach out to your local distress centre and identify the services that they provide. Most of the centres are open 24 hours a day, 7 days a week. Some of the questions you can ask your local distress centre include:

• What specific services are provided through your local distress or crisis centre(s)?
• What are the qualifications of the service providers?
• Are the help line staff equipped to recognize the signs and symptoms of OSI/PTSD and provide appropriate support and direction for the worker?
• Do they provide training or resources for managers on how to spot an employee in crisis?
• Do they provide peer support training or training for peer support mentors?

As part of your prevention plan you should communicate the services available through your local distress centre. To find your local distress centre contact information visit: dcontario.org

The Government of Canada also has a Mental Health Helpline. Information about this service can be found on their website: mentalhealthhelpline.ca.

Setting up Peer Support

Having an organizational peer support program in place is a recognized evidence-based practice. However, it is important to remember that while peer support is an key component of dealing with occupational stress injuries and PTSD, it is not a substitute for professional support.

Peer support is an intervention that leverages shared experience to foster trust, reduce stigma and create open channels of communication for seeking help and sharing information and support resources. The focus of a peer support program is to establish positive coping strategies using common language which fosters trust and credibility between team members.

If you are just getting started, here are some approaches you may want to consider:

1. Utilizing the Service Chaplain as a source of Peer Support.
2. Utilizing a volunteer Peer Support Mentor from the Joint Health and Safety Committee. This person should be provided training to help them fulfill their duties which includes:
   • Basic skills to be a peer support mentor
   • Listening skills
   • Psychological first aid training
   • Referral options for workers within the organization

The benefit of utilizing this approach is that this person is already familiar with your health and safety program and they are a member of the team. This person should be viewed as being a credible resource and respected by peers. This person should also undergo a selection process.

It is important that the peer supporters are monitored so that they feel supported in their role and can get help they need to deal with trauma-related experiences. This could include the provision of access to a behavioural health expert, opportunities to improve peer supporting skills and monitoring of their own health and wellbeing.

The Mental Health Commission of Canada has established Guidelines for Practice and Training of Peer Support which may be helpful for your organization.

Engagement of Families and Friends

Engagement with families and friends of workers suffering from OSI increases awareness, reduces the stigma and allows for a community of support. Some examples of how family and/or friends can be engaged include:

• Open houses, barbeques, family nights and other social events which also provide information about:
  • The job(s) that the employees do.
  • Potential impact of critical incident exposures in the short and long-term.
  • Signs and symptoms of OSI and potential triggers.
  • Available organizational supports, including contact information.
  • How to support someone with OSI, including communication, social support and anger management.
  • How to take care of yourself and your family.
• Providing family-based peer support that allows family members and caregivers to speak to others who have had similar experiences in an effort to support themselves and their loved one through recovery. Such a program would address:
  • Understanding of the illness.
  • Understanding the role of the caregiver.
  • How to support their loved one and balance their need to do what they feel is best while honoring his/her right to make decisions.
  • Managing stress, self-care and wellness.
  • The special circumstances that may arise within a family or through care.
  • How to encourage seeking assistance and help, available services and supports.
• Offering and funding for time-limited family counselling if required. This can be made available by the employer as part of an insurance benefits package, though an EAP or under circumstances where it is deemed necessary for the well-being and recovery of the worker and their family.

Establishing a Screening Protocol

Healthcare workers, as part of their job, may be exposed to traumatic events. Many individuals in these environments may suffer both short and long-term effects as a result of their exposure to the traumatic event. While some people may recover from an exposure to a traumatic event, others may develop chronic problems over many years. Your workplace may want to implement regular screening protocols, based on the type of work or exposures your workers may be experiencing, to help employers identify workers who are potentially at risk of developing occupational stress injuries.

Mental health screening is a well-established strategy to promote early detection of illness in at risk groups. Screening for common psychiatric disorders, such as PTSD, can significantly improve rates of diagnosis and reduce time to appropriate treatment, thus improving overall outcomes. Considering the risk for repeated traumatic exposures with healthcare workers, screening for signs of psychological injury is strongly supported. Those at risk for suicide and other serious mental disorders would also benefit from early and sometimes urgent intervention.

The following protocol is recommended for employers and occupational health departments:

• Identify employees that have been exposed to serious incidents, a repeat number of events or who are distressed as a result of any traumatic incident.
• Once identified, occupational health or other trained staff can deliver a screening instrument or protocol by phone or in-person. This would serve to identify symptomatic individuals early and those who develop progressive symptoms of PTSD.
• Those individuals who screen positive based on a fixed cut-off score would be referred for further assessment and treatment if indicated. A positive response to a screen does not necessarily indicate that an employee has PTSD. However, a positive response does indicate that an employee may have PTSD or trauma-related problems and further investigation of trauma symptoms by a mental-health professional may be warranted.
• For individuals who are exposed to a traumatic event, some evidence suggests that screening should be conducted within 1 month and again at 3 and 6 months after serious or repeated exposures. following the event.
• Screening should be available to all staff who have been exposed to traumatic incidents and may be suffering from work-related occupational stress injuries or PTSD. Early intervention is important for effective treatment and the severity of the initial traumatic event should be considered when determining the need for early intervention.

Several screening methods have been developed specifically for PTSD. In general, a good screening instrument for PTSD would be brief, sensitive and reliable, consistently identifying those with potential symptoms. Screening tools are not intended to provide a diagnosis, but will help identify those who may require further assessment.

Occupational health professionals should be aware of and have access to validated screening tools for PTSD and other mental disorders and should be trained in how to identify those at increased risk for PTSD, suicide and other mental disorders, and how to refer workers to the appropriate mental health professionals in a timely manner. Screening models such as online mental health screening, in-depth mental health screening or routine mental health “check-ups”, or Primary Care (PC-PTSD) screening may be used. The screens do not include a list of potentially traumatic events, which should be tracked, conducted, and maintained by your organization’s Occupational Health and Safety Department.

The Screening Program should also be re-evaluated annually by occupational health professionals and your JHSC to ensure screening is being consistently performed and those screening positive are seeking assessment and treatment.

Below is a sample screening protocol that you may want to consider for your organization:

Stay at Work/Return to Work Plan

It may seem strange to include Recovery and Return to Work in your organization’s OSI management process, however there are some benefits to understanding more about this process and including it upfront when you are thinking about prevention. This is an important aspect of being prepared to support a worker and help them stay at work, recover and/or return to work. This guide intends to provide a holistic health and safety management approach and therefore includes Recovery and Return to Work.  

Minimizing Worker Stress After the Event

An important part of managing the crisis is helping workers minimize their stress when they return to work. You may want to consider the following actions when developing your Prevention Plan.

• Allow time off for workers who have been involved in a traumatic event.
• Transition workers back into the workplace by initially assigning them to less-demanding jobs.
• Develop protocols to provide workers with stigma free counselling so that workers can address the emotional aspects of what they have experienced.
• Institute debriefing sessions that focus on helping workers put their experiences in perspective and validate what they have seen, done, thought and felt.
• Provide ongoing education or workshops that provide information on PTSD, stress management and actions workers can take to take care of themselves.
• Offer group peer support activities.

Tips for Accommodations

Research has found that OSI and PTSD do have an impact on impaired occupational functioning, particularly as it relates to reduced productivity, presenteeism and absenteeism. Below are some questions to consider when accommodating work. This is not an exhaustive list of accommodations, there may be other ideas or options you may wish to use.  

• What is the worker experiencing (signs and symptoms) and what are the limitations?
• How will these limitations impact the work that the worker needs to do?
• Are there specific job tasks that will be problematic as a result of these limitations?
• What accommodations can help address or eliminate these limitations?
• Has the worker been asked about possible accommodations? Can they help identify specifically how the organization can assist?
• Does the worker’s senior leadership team, supervisor/manager or coworkers need training on OSI and PTSD to help facilitate a successful return?  
• Is the worker currently receiving care or treatment and, if so, are they continuing to follow a treatment plan (if this is known)?

Supportive Management Techniques

When you are planning how to manage Recovery and Return to Work for your workers, it is also important to provide support to your managers and supervisors so that they can utilize effective techniques to help keep the worker on track to recovery. Below is a list of tips that may help managers and supervisors implement an individual Return to Work plan:

• Be prepared to provide day-to-day guidance and feedback, focused on tasks.
• Provide both written and verbal instructions.
• Provide positive praise and reinforcement.
• Recognize when the worker is experiencing hyper‐arousal symptoms, stress or withdrawal, and provide necessary support. Remind the worker of mechanisms they can use, such as utilizing quiet space and strategies to deal with conflict.
• Establish long term and short term goals, breaking down complex tasks.
• Provide clear expectations of responsibilities and outline the consequences of not meeting those performance standards.
• Plan how to evaluate the effectiveness of the accommodations.

7 Principles for Effective Return to Work

The Institute for Work and Health did a comprehensive systematic review on the most effective workplace‐based Return to Work practices in 2007 and identified 7 Principles for Return to Work. This review found that workplace-based Return to Work interventions can have positive impacts on duration and costs of work disability. Another study done by the Occupational Health and Safety Agency for Healthcare in British Columbia – Best Practices for Return to Work/Stay at Work Interventions for Workers with Medical Conditions – highlighted similar principles. The majority of interventions in this systematic review focused on the individuals and the researchers highlighted the need to study more workplace-based interventions. There is a belief that more effective workplace-based interventions could improve the length of time the worker is away from work and support positive outcomes for the workers who are still working.  

The principles outlined below come from both of these systematic reviews and provide a good starting place to establish Recovery and Return to Work procedures. For each of the items listed below, you may want to review how your current organization approaches Return to Work and identify if there are opportunities to include some or all of these practices.

1. The workplace needs to have a strong commitment to health and safety which is demonstrated by the behaviours of the workplace parties.

• This is demonstrated by senior leadership’s investment in resources and time to promote safety and coordinate Return to Work and labour’s support of safety policies and Return to Work programming. A commitment to safety issues is the norm across the organization.
• This includes having a clear, detailed and well-communicated organizational workplace mental health policy that supports the Return to Work and Stay at Work process.

2. The employer makes an offer of modified work to the injured/ill workers so they can return early and safely to work activities suitable to their abilities.

• The literature highlights that work accommodations are an integral part of the Return to Work process and the context of their implementation determines their effectiveness.

3. Those planning Return to Work need to ensure that the plan supports the returning worker without disadvantaging co-workers and supervisors.

• The systematic reviewed highlights that the Return to Work process is a “socially fragile process.” To reduce resentment towards the returning worker, steps must be taken to anticipate and address concerns that co-workers and supervisors have to ensure better outcomes. This can include education and encouraging cooperation with the process.
• Offering training on OSI, PTSD and other mental health conditions is important. Raising awareness can address issues around stigma about mental health conditions and facilitate Return to Work.
• Disclosure needs to remain in the hands of the worker. Yet, regardless of disclosure, evidence suggests that reducing stigma and silence around mental health injuries can facilitate successful accommodation and Return to Work.

4. Supervisors are trained in work disability prevention and are included in Return to Work planning.

• Supervisors are important to the success of the Return to Work program because they are closest to the worker and they manage the immediate Return to Work environment. Supervisors and managers need to understand how to accommodate a worker suffering from an OSI or PTSD which may involve training and education.
• It may be important to train the supervisor on how they can assist the worker when they return to work, specifically how to listen to the worker’s limitations, help identify tasks which may be challenging and evaluate the effectiveness of the interventions and the environment.
• Involving the supervisor or manager in the Return to Work process also helps them feel more equipped to accommodate the worker when they come back to work.

5. The employer makes early and considerate contact with the injured/ill worker.

• The literature suggests that early contact is core to successful Return to Work programs, but it should consider the worker’s specific situation. This contact should be made by the immediate supervisor and focus on the worker’s well-being and mental health.
• The supervisor may want to refer back to Important Messaging for Workers about What to Expect which provides tips on how to communicate with workers who have experienced traumatic events, including reminding them that:
  • No one who sees a traumatic event is untouched by it.
  • It is normal to feel sadness, grief and anger about what happened and what you saw.
  • It is natural to feel anxious about your safety or the safety of those who are important to you.
  • It is important to acknowledge your feelings as it will help you move forward more quickly.
  • Everyone have different needs and different ways of coping. This is normal.
  • It is healthy to reach out for and accept help if you need it.
• The literature highlights that for this to be successful the workplace environment should be characterized by a shared sense of goodwill and confidence.

6. There is a person in the workplace who is responsible for coordinating Return to Work and this person can help provide an individualized plan that focuses on the worker’s initial and ongoing needs.

• It is important that the person coordinating Return to Work has clear mandates and feels empowered to be flexible with creating different work accommodations.
• This person should help the worker return to the workplace post-injury or assist the injured worker to remain at work while they recover.
• This person should ensure that the worker’s return to work date is sensible, flexible and safe.
• It is important to connect and consult with the injured worker, treating health professional and WSIB representative to ensure everyone understands what to expect and what is expected of them.
• This person needs to monitor the worker’s progress towards returning to work. They should help resolve issues or disputes related to the Return to work and take steps to prevent further injury/illness to the worker.

7. Employers and healthcare providers communicate with each other about the workplace demands, as needed, and with the worker’s consent.

• The literature highlights the importance of the workplace facilitating access to evidence-based treatment.
• Healthcare providers can play a significant role in the process as the injured worker often looks to them for advice and guidance on Return to Work.
• It is important that all of the parties understand the worker’s job and the ability to accommodate.
• Permission must be provided by the worker for this type of contact to take place and the type of contact will vary based on individual circumstances and healthcare providers.