Facilitators and obstacles to help

This section describes briefly the various factors that can improve or limit access to and use of support and care strategies by crew members before and after a critical incident. These factors should be considered when designing and implementing a support strategy.

Improving access to various forms of support

-          A proactive offer of support and care is likely to have positive effects on the actual use of help by crew members

-          We know from interviews and from research on men’s relationships with health services, that when a man tries and fails once to obtain the help he needs, he is less likely to try again. Therefore, improving first time access to services is very important.

Promoting use of resources

-          Railway companies (at all levels: top management, Claims Department, Human Resources Department, operation managers, Safety and Police Department, local management, team leaders, employees), the union, the Railway Association of Canada and Operation Lifesaver should promote help seeking, be aware of existing stereotypes and advertise resources (present, describe and explain those resources).

Involvement of peers inthe promotion of help seeking

-          Peers play a key role in changing values and behaviours. Peer support programmes are an important medium to promote existing resources and their use in a time of crisis.

-          Peers who successfully used available help become good advocates for help seeking

Clearly defined training, support and care protocols

-          Accurate and unbiased information is important. The use of resources will depend upon the trust people place in these resources, their usefulness and the absence of negative consequences of their work. When people are well informed about the various resources and their impact, they can make the right decisions for themselves.

-          In times of intense crisis, reducing uncertainties by clearly describing resources and available support helps people regain a sense of control, feeling supported by their employer and it reduces tension.

Fear for loss of income

-          Some crew members do not “book on trauma” because they fear the 3 month delay it automatically induces before they can return to work (see medical rules[t1] ). They feel forced off work and feel doubly victimized by the loss of income that comes with time off work.

Masculine stereotypes

-          Even if it is changing, there is still a strong masculine culture within the railway industry. Men who strongly adhere to strong masculine values and stereotypes tend to “bottle it up”, repress their feelings and deny their difficulties.

-          These men do not tend to use available resources to help them cope with critical events. The railway industry can play a role in promoting help seeking in it values and codes of conduct, encouraging their employees’ perspectives to evolve.

Fear for negative consequences in work relations

-          Some people fear that if they take time off work, use medication, consult with a therapist or express emotional difficulties, they will be judged by their peers, by their managers and that this  will have a negative on their work relationships.

Pre-existing difficult work relations

-          Seeking help implies that people admit to experiencing difficulties. This can only be done in a context of trust. Difficult relations with colleagues or especially with managers may prevent crew members from expressing a need for support and care.

Misunderstanding the roles of various actors

-          People do not always understand the role of the professionals they meet. There are misunderstandings leading to frustrations, unexpected consequences and grievances.

-          The role of the company medical officer appears to be particularly ambiguous to employees.

-          People do not always understand the difference between a doctor, a psychiatrist, a psychologist, a social worker and a therapist. They do not always contact the right professional and may feel frustrated by the response.

-          These misunderstandings may lead to multiple referrals and an increased riss of discontinuing care seeking.

Unmet expectations in previous experiences

-          The desire to seek support depends largely upon previous experiences. Negative experiences in the past will discourage people to seek help again.

-          Having had arguments with the employer about a previous leave of absence will increase pressure when the time comes to take some more time off work

-          Having a poor experience with a mental health professional can lead people to think that these resources are useless

On-train duties are regulated by the Safety Critical Position rules within the Railway Safety Act.

RAILWAY MEDICAL RULES

FOR POSITIONS CRITICAL TO SAFE RAILWAY OPERATIONS

http://www.railcan.ca/assets/images/regulations/rules/2006_10_19_TC_O_17B_eng.pdf

A safety critical position involves mandatory mental and physical fitness requirements in order to guarantee proper alertness, judgment, sensory and motor functions. In order to make certain that safety critical position holders have the required fitness, the Railway Medical Rules Handbook has prescribed specific guidelines. These guidelines address some of the mental health issues that may arise from experiencing critical incidents.

Diagnosis

Ability to work in safety critical position

Condition for returning to work

Elements that need to be assessed in the context of a safety critical position

Acute Stress Disorder

no

1 month symptom free

Recurrence

Hyper-arousal

Affective problems

Judgement

Attention

Alertness

Predictability

Side effects of medications

Post Traumatic Stress Disorder

no

3 months symptom free

Recurrence

Hype-rarousal

Affective problems

Judgement

Attention

Alertness

Predictability

Side effects medications

Panic Disorder

no

6 months symptom free

Judgement

Attention

Alertness

Side effects of medications

Depressive Disorder

no

Being asymptomatic (no delays)

Judgement

Attention

Alertness

Insight

Side effects of medications

These rules have a strong impact on the willingness of crew members to seek help after they had a critical incident because they often feel that they will be trapped in long procedures before they can come back to working normally. They often also fear the loss of income from a long period of time off. Finally, most of the time, they feel they do not need so long to get better and do not see other alternatives: either they come back too soon, or they stay off too long. The medical rules, based upon diagnostic manuals and the practices of Workers Compensation Boards seem to dichotomise the possibilities, either:

-          The worker is fit to work within 72 hours after incident, or

-          The worker is diagnosed with a traumatic reaction and is off work for at least one month, with the responsibility to prove themselves fit in order to return to work

As we can see in our analysis of the impact of critical incidents[t2] , most crew members find themselves in situations that are “in-between”. Taking these variations into account within the medical rules would increase the use of support and decrease recovery delays and difficulties.

Recommendations to Medical Doctors:

When evaluating and diagnosing a railway worker who has experienced a critical incident, it isimportant to assess with him the consequences of various diagnoses and the likelihood of him following your recommendations, when considering the consequences of those recommendations on his ability to earn his living.

Recommendations to crew members:

Before you consult with a Medical Doctor, discuss the various possible diagnoses and their consequences with your union representative and family members. Do not hesitate to inform your MD of the safety critical position rules and discuss options with him before he writes a prescription.   However, a diagnosis is for your care and protection. It is important that you take it into account and act accordingly for your own health, safety and the safety of others.


 [t1]Hyperlien section medical rule

 [t2]Hyperlien : section 5.2.