MEDI CAL REPORTS RECOMMENDI NG W ORK
RESTRI CTI ONS AT A TEACHI NG HOSPI TAL I N BRAZI L
1Giov an a Pim en t el Gu r gu eir a2 Neusa Mar ia Cost a Alex andr e3
Gurgueira GP, Alexandre NMC. Medical report s recom m ending w ork rest rict ions at a t eaching hospit al in Brazil. Rev Lat ino- am Enfer m agem 2006 j ulho- agost o; 14( 4) : 510- 6.
Th i s n o n - ex p er i m en t al an d cr o ss- sect i o n al d escr i p t i v e st u d y ai m ed t o ev al u at e m ed i cal r ep o r t s recom m ending work rest rict ions for workers at a t eaching hospit al in Brazil. A form was used for dat a collect ion, char act er izing t he m edical r epor t s and w or k r est r ict ions, w it h it s cont ent pr ev iously v alidat ed. A t ot al of 176 m edical r epor t s w as analy zed, cont aining 337 w or k r est r ict ions, r ecom m ended fr om Januar y 2001 t o Januar y 2004. The r esult s dem onst r at ed a high r at e of w or k r est r ict ions in t he st udy hospit al. The m ost r est r ict ions fr equent w er e er gonom ic ( 78. 6% ) , and t he m ost oft en pr escr ibed w er e: no w eight lift ing or car r y ing and no r epet it iv e m ov em en t s. Th er e w as an av er age of t w o r est r ict ion s per m edical r epor t , 7 9 . 5 % of w h ich w er e definit ive and t he m ean r est r ict ion per iod w as 13 m ont hs.
DESCRI PTORS: hospit al unit s; hum an engineer ing; occupat ional healt h; nur sing
LAUDOS MÉDI COS RECOMENDANDO RESTRI CCI ONES
DE TRABAJO EN UN HOSPI TAL UNI VERSI TARI O EN BRASI L
Est e est udio descr ipt iv o, no ex per im ent al y de cor t e t r ansv er sal t uv o por obj et iv o ev aluar los laudos m édicos cont eniendo r est r icciones de t r abaj o, pr escr it as a t r abaj ador es de un hospit al univ er sit ar io en Br asil. Par a la colect a de dat os, fue ut ilizada una ficha par a car act er ización de los laudos m édicos y r est r icciones de t rabaj o, previam ent e validada cuant o al cont enido. Fueron levant ados 176 laudos m édicos con rest ricciones de t rabaj o, prescrit as en el período de enero del 2001 a enero del 2004, t ot alizando 337 rest ricciones. Los result ados dem ost r ar on que er a elev ada la ocur r encia de r est r icciones de t r abaj o dent r o de la inst it ución est udiada. Las m ás fr ecuent es fuer on er gonóm icas ( 78.6% ) , sendo que las m ás pr escr it as fuer on: no lev ant ar ni t r anspor t ar p eso y n o ej ecu t ar m ov im ien t os r ep et it iv os. Hu b e u n p r om ed io d e d os r est r iccion es p or lau d o m éd ico, el 79.5% er a definit iv o y el per íodo pr om edio de v igencia fue 13 m eses.
DESCRI PTORES: unidades hospit alar ias; ingenier ía hum an; salud ocupacional; enfer m er ía
LAUDOS MÉDI COS RECOMENDANDO RESTRI ÇÕES DE
TRABALHO EM UM HOSPI TAL UNI VERSI TÁRI O NO BRASI L
Tr at a- se d e u m est u d o d escr it iv o, n ão ex p er im en t al, d e cor t e t r an sv er sal, q u e t ev e p or ob j et iv o avaliar os laudos m édicos cont endo rest rições de t rabalho prescrit as a t rabalhadores de um hospit al universit ário n o Br asil. Par a a colet a d e d ad os, f oi u t ilizad a u m a f ich a p ar a car act er ização d os lau d os m éd icos e d as r est r ições d e t r ab alh o, p r ev iam en t e v alid ad a q u an t o ao con t eú d o. For am lev an t ad os 1 7 6 lau d os m éd icos cont endo r est r ições de t r abalho pr escr it as no per íodo de j aneir o de 2001 a j aneir o de 2004, t ot alizando 337 r est r ições. Os r esu lt ados dem on st r ar am qu e er a elev ada a ocor r ên cia de r est r ições de t r abalh o den t r o da in st it u ição est u dada. As m ais fr eqü en t es for am er gon ôm icas ( 7 8 , 6 % ) , sen do qu e as m ais pr escr it as for am : não levant ar nem t ransport ar peso e não execut ar m ovim ent os repet it ivos. Houve um a m édia de duas rest rições por laudo m édico, 79,5% er am definit ivas e o per íodo m édio de vigência foi de 13 m eses.
DESCRI TORES: u n idades h ospit alar es; en gen h ar ia h u m an a; saú de ocu pacion al; en fer m agem
1
Art icle ext ract ed from t he m ast er's t hesis; 2 Nurse, Mast er in Nursing, e- m ail: gpg@t erra.com .br; 3 Nurse, Mast er and Doct or in Nursing, Associat e Professor; e- m ail: neusalex@fcm .unicam p.br. School of Medical Science, St at e Universit y of Cam pinas
I NTRODUCTI ON
H
osp i t al s ar e en t er p r i ses associ at ed w i t h healt h car e ser v ices, aim ing at car e, t r eat m ent and cure of t hose affect ed by disease. However, t hey alsopose a ser ies of h ealt h r isk s t o t h ose w h o w or k in t hem . Most hospit als have a st ruct ure wit h a high level
o f c o m p l e x i t y a n d d i v e r s i t y o f s e r v i c e s a n d , consequent ly, varied occupat ional risks( 1). Researchers
an d or gan izat ion s h av e iden t if ied a v ast n u m ber of biological, chem ical, physical, ergonom ic and accident
r isks in t he hospit al w or k env ir onm ent( 2- 5).
Th e acci d en t l aw i n Br azi l , co n cer n i n g i t s so ci a l p r i n ci p l e , h a s t h e o b j e ct i v e o f p r e v e n t i n g ,
at t enuat ing and indem nifying dam age or loss, t hrough t he rendering of benefit s and services. I n accordance
wit h t his act , when an accident or occupat ional disease h a s b e e n i d e n t i f i e d , t h e St a t e i s r e sp o n si b l e f o r
r epair in g t h e dam age su f f er ed b y t h e w or k er. At a l at er st ag e, i t i s t h e r esp o n si b i l i t y o f t h e Med i cal
I n v est i g at i o n Un i t o f t h e Nat i o n al So ci al Secu r i t y I nst it ut e ( I NSS) t o v er ify or elim inat e t he cause and
ef f ect con n ect ion of disease an d w or k on beh alf of
t h e i n s u r e d w o r k e r. La t e r, h o w e v e r, i t i s t h e r esp o n si b i l i t y o f t h e Med i cal I n v est i g at i o n Un i t t o
su b m i t t h e i n su r ed w o r k er t o f u n ct i o n a l ca p a ci t y evaluat ion, wit h t he obj ect ive of grant ing benefit s ( sick
leav e, acciden t leav e an d disabilit y r et ir em en t ) an d t o r efer t h e w or k er t o occu pat ion al r eh abilit at ion( 6 ).
I n accor d an ce w it h Reg u lat or y Nor m n . 7 ( NR- 7 ) , appr oved by Edict n. 3.214/ 78 of t he Labor Minist r y,
w h en t h e occu r r en ce or w or sen in g of occu p at ion al
diseases is det ect ed, or alt erat ions in any t ype of organ or biological sy st em ar e found, ev en in t he absence
of sym pt om at ology, t he responsible physician has t he follow in g obligat ion s: r equ est t h e com pan y t o issu e
t he Accident at Work Report ( CAT) ; recom m end, when necessar y, r em oval of t he w or ker fr om r isk exposur e
or from work; direct t he worker t o Social Securit y for d e t e r m i n a t i o n o f t h e c a u s a l n e x u s , i n c a p a c i t y
evaluat ion and definit ion of social securit y conduct in r elat ion t o w or k ; and or ient t he em ploy er r egar ding
t he necessit y t o adopt cont r ol m easur es in t he w or k
en v i r o n m en t . I t sh o u l d b e n o t ed t h a t a n i n su r ed w or k er w ho has been affect ed by an occupat ional or
w or k- r elat ed d isease is assu r ed of t h e sam e social secu r i t y an d l ab o r r i g h t s g u ar an t eed t o a w o r k er
inj ur ed in an accident at w or k( 7). The Medical Repor t is t he writ t en and det ailed descript ion of every specific
f a ct o f a p e r m a n e n t n a t u r e r e l a t e d t o a m e d i ca l inv est igat ion, r equest ed by a com pet ent aut hor it y t o
an official inv est igat or or, in t heir absence, t o unofficial
inv est igat or s, but w ho hav e a m or al com m it m ent t o see t hat j ust ice is done. They are used t o com m unicat e
t he decision of ex per t s( 8).
Th er e is r eason f or con cer n in t h e h ospit al
f ield r eg ar d in g t h e lim it at ion s im p osed on w or k er s who operat e in t his sect or. Such work rest rict ions are
r equest ed w it h t he obj ect iv e of r em ov ing t he w or k er f r o m e x p o su r e t o o ccu p a t i o n a l r i sk s, d u e t o t h e
im possibilit y of per f or m in g t h e specif ic f u n ct ion s of a n a c t i v i t y o r o c c u p a t i o n , i n c o n s e q u e n c e o f
m o r p h o l o g i ca l , p sy ch o l o g i ca l a n d / o r p h y si o l o g i ca l
a l t e r a t i o n s c a u s e d b y d i s e a s e o r w o r k - r e l a t e d acci d en t . Th ese r est r i ct i on s m ay b e t em p or ar y or
per m anent . I n gener al, t his m ay lead t o a ser ies of organizat ional and psychosocial sit uat ions in t he work
environm ent , m ainly if t here is a significant decrease in hum an resources. Despit e it s im port ance, lit t le has
been published in Brazil on t he subj ect . Moreover, as a result of an inform al survey by t he Hum an Resources
Depar t m en t of a t each in g h ospit al w h er e t h e st u dy was carried out , it was found t hat t he great m aj orit y
of r est r i ct i on s i m p osed on i t s w or k er s ar e d u e t o
m u scu l o sk el et al sy m p t o m s an d er g o n o m i c i ssu es. Wit hin t his cont ext , t he evaluat ion of m edical report s
cont aining w or k r est r ict ions in a hospit al is j ust ified b y t h e cu r r en t u sef u ln ess an d con t r ib u t ion t o t h e
co m p r e h e n si o n o f t h e h e a l t h - d i se a se p r o ce ss o f h osp it al h ealt h car e w or k er s, in t h e sen se t h at it
facilit at es prevent ion and rehabilit at ion program s and personnel rot at ion. The obj ect ive of t he present st udy
was t o analy ze t he epidem iological aspect s ( num ber,
t y pe, occu r r en ce, du r at ion ) of m edical r epor t s w it h r e st r i ct i o n s p r e scr i b e d t o w o r k e r s o f a t e a ch i n g
hospit al, in a t hr ee- y ear per iod.
METHODS
Ty pe of st udy
Th is is a n on - ex per im en t al an d t r an sv er sal
d e scr i p t i v e st u d y, w i t h r e t r o sp e ct i v e i n f o r m a t i o n
obt ained by m eans of ident ificat ion of m edical report s wit h work rest rict ions, across a period of t hree years.
St u dy Scen ar io
The inst it ut ion st udied in t his invest igat ion was
a t eaching hospit al, locat ed in t he cit y of Cam pinas,
field of research because it is a general, governm ent al
and reference hospit al t o ot her inst it ut ions, wit hin and
out side t he st at e of São Paulo.
Pop u lat ion
All m edical r epor t s ( n= 176) cont aining w or k
r est r ict ion s p r escr ib ed in a t h r ee- y ear p er iod w er e
included, t ot aling 337 r est r ict ions.
I nst r um ent for dat a collect ion
A for m w as dev eloped for char act er izing t he
m edical report s and work rest rict ions, wit h t heoret ical
support of ot her invest igat ions( 9). A prelim inary st udy
o f t h e ch a r a ct er i st i cs o f r est r i ct i o n s co n t a i n ed i n
m edical r epor t s an d occu pat ion al h ealt h st at em en t s
at t he Hum an Resources Depart m ent of t he inst it ut ion
w as done pr ior t o t he pr epar at ion of t he for m . The
f o r m c o n t a i n e d q u e s t i o n s a b o u t g e n e r a l a n d
o c c u p a t i o n a l d a t a ( n a m e o f e m p l o y e e a n d
p r of ession al cat eg or y ) as w ell as con sid er at ion s of
t h e r est r i ct i o n s ( n u m b er o f p r ev i o u s r est r i ct i o n s,
r est r ict ion per iod, du r at ion an d t y pe of r est r ict ion ) .
Fo r t h e co n t en t v al i d i t y ev al u at i o n , t h e f o r m w as
subm it t ed t o six ex per ienced specialist s in t he field,
all st aff m em bers of t he St at e Universit y of Cam pinas
( U N I CA M P) . Th e i n s t r u m e n t w a s s u b s e q u e n t l y
adapt ed and cor r ect ed t o obt ain it s final v er sion.
Dat a collect ion
All m edical r epor t s for ident ificat ion of w or k
r est r ict ions pr escr ibed fr om Januar y 2001 t o Januar y
2 0 0 4 w e r e i n cl u d e d i n t h e st u d y. Th e d a t a w a s
collect ed f r om t h e pr of ession al r ecor ds f iled at t h e
Hu m an Resou r ces Dep ar t m en t of t h e Hosp it al an d
inser t ed in a dat abase using Micr osoft Access 2002.
Dat a an aly sis
D a t a w e r e a n a l y ze d w i t h t h e h e l p o f t h e
St at ist ics Sect or at t he School of Medical Science. The
collect ed dat a were organized and insert ed in Microsoft
Ex cel 2002. For t he st at ist ical analy sis, t he pr ogr am
“ The SAS Sy st em for Window s”, ver sion 6.12 ( 1996)
was ut ilized. A descript ive st at ist ical analysis was done
t o ev alu at e cer t ain ep id em iolog ical asp ect s ( t y p e,
incidence, dur at ion) of t he m edical r epor t s and w or k
r est r ict ion s.
Et hical aspect s
The Pr oj ect w as pr ev iously appr ov ed by t he
Resear ch Et h ics Com m it t ee of t h e Hosp it al, u n d er
pr ocess num ber 9 9 / 2 0 0 3 .
RESULTS
A t o t a l o f 1 7 6 m e d i c a l r e p o r t s a n d
o ccu p a t i o n a l h e a l t h st a t e m e n t s, p r e scr i b i n g 3 3 7
r est r ict ions in a t hr ee- y ear per iod, w er e ident ified.
Ta b l e 1 sh o w s t h e d i f f e r e n t o ccu p a t i o n a l
cat egor ies, com par in g t h em t o t h e t ot al n u m ber of
em ploy ees in t he st udied inst it ut ion.
Table 1 - Dist ribut ion of workers wit h m edical report s
p r e s c r i b i n g w o r k r e s t r i c t i o n s a c c o r d i n g t o t h e i r
occu pat ion al cat egor y. Cam pin as, 2 0 0 4
* Cat egory delet ed by t he Federal Nursing Council ( COFEN) in 1986 y r o g e t a c l a n o i t a p u c c O s r e k r o w f o l a t o T n o i t u t i t s n i e h t n i n i s r e k r o w f o l a t o T n o i t u t i t s n i e h t
n n %
s l a i r e t a m f o r o t u b i r t s i
D 1 1 100.0
r o t i n o m n o it a e r c e
R 1 1 100.0
n a i c i n h c e t c i n a h c e
M 4 3 75.0
t n a t s i s s a y r d n u a l l a t i p s o
H 24 14 58.3
t n a t s i s s a n o it i r t u
N 2 1 50.0
n a i c i n h c e t y s p o r c e
N 2 1 50.0
k o o
C 8 3 37.5
n o s r e p g n i v r e
S 42 13 31.0
r e c if f o t i n u n o it a z il a t i p s o
H 19 5 26.3
n a i c i r t c e l
E 4 1 25.0
t n a t s i s s a n e h c t i
K 25 6 24.0
t n a t s i s s a y r o t a r o b a
L 27 6 22.2
t n a t s i s s a e s r u
N 229 45 19.7
r e v i r
D 17 3 17.6
n a m r i a p e r l a r e n e
G 6 1 16.7
* e d i a s ' e s r u
N 33 4 12.1
t s i n o it p e c e
R 51 6 11.8
t s i c a m r a h
P 9 1 11.1
t n a t s i s s a e v it a r t s i n i m d
A 127 14 11.0
t n a t s i s s A g n i n a e l
C 71 7 9.9
t n a t s i s s A t s i c a m r a h
P 12 1 8.3
r o t a r e p o r e t u p m o c o r c i
M 27 2 7.4
r o t a r e p o t n e m p i u q e l a t i p s o
H 14 1 7.1
n a i c i n h c e t y g o l o i d a
R 29 2 6.9
t s y l a n a m e t s y
S 15 1 6.7
t n a t s i s s a l a c i n h c e t l a t i p s o
H 15 1 6.7
y t i r u c e
S 17 1 5.9
n a i c i n h c e t y r o t a r o b a
L 38 2 5.3
t n a t s i s s a s ' r e k r o w l a i c o
S 20 1 5.0
t s i g o l o i
B 63 3 4.8
n a i c i n h c e t e v it a r t s i n i m d
A 140 6 4.3
n a i c i n h c e t g n i s r u
N 401 11 2.7
e s r u
N 310 8 2.6
l a t o
Am ong t he occupat ional cat egories for whom
work rest rict ions were prescribed, t he sam ple showed
t h a t t h e m o s t a f f e c t e d w e r e t h e c a t e g o r i e s o f
dist ribut or of m at erials and recreat ion m onit or ( 100%
in bot h inst ances) . I t should be point ed out t hat t his
result was obt ained due t o t he fact t hat each of t hese
cat egories has only one worker for t he ent ire hospit al.
The follow ing cat egor ies w er e also highly affect ed by
work rest rict ions: m echanic t echnician ( 75% ) , hospit al
laundr y assist ant ( 58. 3% ) , nut r it ion assist ant ( 50% )
an d n ecr opsy t ech n ician ( 5 0 % ) . Table 2 sh ow s t h e
frequency of work rest rict ions am ong t he nursing st aff.
Table 2 - Fr equency of r epor t s w it h w or k r est r ict ions
a m o n g t h e n u r si n g st a f f i n a t h r e e - y e a r p e r i o d .
Cam pin as, 2 0 0 4
y r o g e t a C e h t n i l a t o T n o i t u t i t s n i ) n ( h t i w l a t o T s n o i t c i r t s e r ) n ( e h t n i % y r o g e t a c e h t n i % n o i t u t i t s n i e s r u
N 310 8 2.6 0.4
g n i s r u N n a i c i n h c e
t 401 11 2.7 0.5
e s r u N t n a t s i s s
a 229 45 19.7 2.1
e d i a s ' e s r u
N 33 4 12.1 0.2
l a t o
T 973 68 7.0 3.2
n o i t c i r t s e
R Frequency(n=337) Percentage(%)
l a c i g o l o i
B Avoidperforminghygienetasksforthepaitents,transportcontaminatedclothingtothe f o g n i n a e l c t n e r r u c n o c , s r e p a i d e g n a h c , h t a e d r e t f a y d o b e h t e r a p e r p , s e it il i c a f n o it a z il i r e t s s t n e it a p t r o p s n a r t , s e g a d n a b y l p p a , t i n u t n e it a p
8 4.5
s t n e it a p e s a e s i d s u o i g a t n o c s u o it c e f n i h t i w k r o w t o n o
D 1 0.6
l a c i s y h
P Mandatoryuseofearprotectorswhenexposedtonoise 3 1.8 t c u d o r p d e c i e t a l u p i n a m t o n o
D 1 0.6
s e r u t a r e p m e t h g i h o t fl e s r u o y e s o p x e t o n o
D 1 0.6
l a c i m e h
C Donotperformacitviitesthatrequiretheuseoflatexgloves 7 4.0 s t c u d o r p l a c i m e h c e t a l u p i n a m t o n o
D 5 2.8
d e t a l u p i n a m e r a s t c u d o r p l a c i m e h c e r e h w s e c a l p n i n i a m e r t o n o
D 1 0.6
c i m o n o g r
E Donotilftortransportweights 106 59.7
s t n e m e v o m e v it it e p e r m r o f r e p t o n o
D 39 22.2
s r e b m e m r e p p u f o h t g n e r t s e s u t o n o
D 34 19.3
n o it i s o p g n i d n a t s a e r i u q e r t a h t s e it i v it c a m r o f r e p t o n o
D 28 15.9
h t g n e r t s l a c i s y h p y o l p m e t o n o
D 26 14.8
n m u l o c l a n i p s e h t h t i w s t n e m e v o m n o it a t o r d n a n o i x e lf , n o i s n e t x e t p u r b a e k a m t o n o
D 15 8.5
n o it i s o p g n it t i s a e r i u q e r t a h t s e it i v it c a m r o f r e p t o n o
D 10 5.7
s t n e m e v o m g n i k l a w t n a t s n o c n i e g a g n e t o n o
D 8 4.5
/l a i c o s o h c y s P l a n o it a z i n a g r o s e it i v it c a n o it o m e v it it e p e r e t u n i m -0 5 h c a e t a s e t u n i m 0 1 f o k a e r b k r o
W 35 19.9
s e c a l p h g i h n i , s e n i h c a m g n it a t o r n o g n i k r o w s a h c u s s e it i v it c a s u o r e g n a d m r o f r e p t o n o D s e l c i h e v e v it o m o t u a g n i v i r d d n
a 4 2.4
s e c a l p y s u b y r e v n i k r o w t o n o
D 2 1.2
s t n e it a p ll i y l s u o i r e s g n i h c a o r p p a e r i u q e r t a h t s n o it a c o l n i k r o w t o n o
D 2 1.2
d a o l k r o w y li a d f o n o it p m u s e r l a u d a r g h t i w s r u o h g n i k r o w d e c u d e
R 1 0.6
Th e n u r s i n g s t a f f ( n u r s e s , t e c h n i c i a n s ,
assist ant s and aides) account ed for 7% of t he workers
wit h rest rict ions in t he cat egory and 3.2% in t he whole
i n st i t u t i o n . Of t h e n u r si n g w o r k e r s w h o r e ce i v e d
r e s t r i c t i o n r e p o r t s , t h e m o s t a f f e c t e d w e r e t h e
a ssi st a n t s ( 6 6 . 2 % ) , f o l l o w e d b y t h e t e ch n i ci a n s
( 16.2% ) , nur ses ( 11.8% ) and aides ( 5.9% ) .
Ap p r o x i m a t e l y 1 4 % o f t h e s u b j e c t s h a d
p r ev i o u s r ep o r t s w i t h w o r k r est r i ct i o n s ( SD = 0 . 6 ,
values bet ween zero and four) . I t was found t hat t he
m ean r est r ict ion per iod of t h e m edical r epor t s an d
o c c u p a t i o n a l h e a l t h s t a t e m e n t s w a s 1 3 m o n t h s
( SD= 8.8, v ar y ing bet w een 20 day s and 38 m ont hs) .
When t he rest rict ion t im e was cat egorized as definit ive
or t em porary, it was observed t hat t he great m aj orit y
w as d ef i n i t i v e ( 7 9 . 5 % ) . Reg ar d i n g t h e n u m b er o f
rest rict ions by m edical report and occupat ional healt h
st at em ent , t here was a variat ion from one t o six, wit h
an av er age of t w o r est r ict ions per r epor t ( SD= 1) .
I n or d er t o f acilit at e d at a an aly sis, it w as
decided t o classify work rest rict ions int o t he following
g r ou p s: b i ol og i cal , p h y si cal , ch em i cal , er g on om i c,
psy ch osocial an d or gan izat ion al( 9 ). Table 3 specif ies
t he t y pes of w or k r est r ict ions in t hese subgr oups.
Table 3 - Classificat ion of t he t ypes of work rest rict ions prescribed t o healt h care workers in a t eaching hospit al.
Cam pin as, 2 0 0 4
Am o n g r est r i ct i o n s, i t w as f o u n d t h at t h e
m o st f r eq u en t w er e er g o n o m i c ( 7 8 . 6 % ) , a n d t h e
m o s t p r e s c r i b e d w e r e : d o n o t l i f t o r t r a n s p o r t
w e i g h t s ( 5 9 . 7 % ) ; d o n o t p e r f o r m r e p e t i t i v e
m ov em en t s ( 2 2 . 2 % ) . I t w as ob ser v ed t h at 7 9 . 5 %
of t h e 1 7 6 m edical r epor t s an d occu pat ion al h ealt h
st at em en t s con t ain ed on e or m or e er gon om ic w or k
DI SCUSSI ON
I n a t hr ee- y ear per iod, 176 m edical r epor t s
a n d o c c u p a t i o n a l h e a l t h s t a t e m e n t s w i t h w o r k
r est r ict ions w er e ident ified, t ot aling 337 r est r ict ions.
Am o n g t h e o c c u p a t i o n a l c a t e g o r i e s t h a t
received work rest rict ion recom m endat ions in t he last
t h r ee y ear s, t h e m ost af f ect ed w er e d ist r ib u t or of
m at er ials and r ecr eat ion m onit or. When w e obser v e
t he occurrence of m edical report s wit h work rest rict ions
in t he nur sing occupat ional cat egor ies, w e find t hat
t he assist ant s were t he m ost affect ed. This inform at ion
m ay be ex plained w hen t he specific t ask s per for m ed
by n u r se assist an t s ar e an aly zed, t h at is, act iv it ies
t hat r equir ed a gr eat deal of phy sical ex er t ion.
I n r elat ion t o t he num ber of r est r ict ions per
m edical report and occupat ional healt h st at em ent , t he
a v e r a g e n u m b e r w a s t w o w o r k r e s t r i c t i o n s .
Ap p r o x i m a t el y 1 4 % o f t h e su b j ect s h a d p r ev i o u s
m edical r epor t s w it h w or k r est r ict ions. I t is believ ed
t hat t his m ay be explained by t he fact t hat rest rict ions
ar e n o t p r o p er l y f o r m u l at ed , t h at i s, t h ey d o n o t
m in im ize or r em ov e t h e r isk s t o w h ich w or k er s ar e
e x p o s e d . I t m a y a l s o h a p p e n t h a t t h e w o r k
environm ent is not being m odified in accordance wit h
t he subj ect s’ ( in) capacit ies, leading t o furt her exposure
t o occupat ional risks aft er t he rest rict ion period is no
longer in for ce.
On e of t h e pr oblem s obser v ed in t h e w or k
r est r ict ions pr ocess at t he inst it ut ion w as t he ser ial
p r e scr i p t i o n o f t e m p o r a r y r e st r i ct i o n s i n se v e r a l
r ep o r t s, u n t i l f i n al l y t h e d ef i n i t i v e r est r i ct i o n w as
r ecom m en d ed . Th is f act sh ow s t h e act u al n eed t o
d ev el o p an d i m p l em en t ear l y m easu r es f o r i n j u r y
pr ev en t ion , u sin g a m u lt idisciplin ar y t eam , t o av oid
t his v icious cy cle in w hich t he w or k er ends up being
d e f i n i t i v e l y r e m o v e d f r o m h i s l a b o r a c t i v i t i e s .
Pr ev en t iv e an d h ealt h car e st r at eg ies in t h e acu t e
phase should be im plem ent ed, as w ell as t he inj ured
w or k er ’s r et ur n t o w or k planning.
Th e m e a n w o r k r e st r i ct i o n p e r i o d i n t h e
st u d i e d sa m p l e w a s 1 3 m o n t h s w h i l e , w h e n t h e
r e st r i ct i o n t i m e w a s ca t e g o r i ze d a s d e f i n i t i v e o r
t em p o r ar y i t w as o b ser v ed t h at t h e m aj o r i t y w as
def in it iv e ( 7 9 . 5 % ) . Few st u dies h av e ev alu at ed t h e
efficacy of w or k r est r ict ion s t o lim it t h e du r at ion of
in capacit y or t h e f r equ en cy of n ew episodes. Som e
aut hors indicat e t hat t em porary work rest rict ions m ay
offer prot ect ion against t he exacerbat ion of sym pt om s
during convalescence( 10). The safe r et ur n t o w or k, as
s o o n a s p o s s i b l e , r e q u i r e s t h e i d e n t i f i c a t i o n o f
problem s and favorable negot iat ing condit ions for t he
healt h car e t eam and t he inv olv ed com pany sect or s,
t o ensure an adequat e st at e of affairs for t he inj ured
w o r k e r( 1 1 ). Re s e a r c h s u g g e s t s t h a t o n e o f t h e
possibilit ies of achieving early ret urn t o work for
non-specific low - back pain pat ient s is t he pr escr ipt ion of
t e m p o r a r y w o r k r e s t r i c t i o n s( 1 2 ). S t u d i e s o n
ad m in ist r at iv e an d occu p at ion al h ealt h p olicies ar e
n e e d e d , s i n c e t h e m e r e p r e s c r i p t i o n o f w o r k
r est r ict ion s w ill n ot solv e t h e pr oblem of lon g- t er m
ex p osu r e of w or k er s t o occu p at ion al r isk s. A j oin t
i n st i t u t i o n a l w o r k - r e st r i ct i o n f o l l o w - u p p r o g r a m ,
cont inued educat ion and t raining, as well as m odified
w or k posit ion should be im plem ent ed.
A p r o l o n g e d w o r k r e st r i ct i o n p e r i o d m a y
r ef lect an in f or m al ef f or t on t h e par t of t h e h ealt h
car e st aff t o m odify t he physical w or k effor t in
high-dem an d occu pat ion s. Su ch st r at egy, h ow ev er, does
n ot seem t o b e t h e b est op t ion f or t h e w or k er. I n
cont rast wit h a replanning of form al work, rest rict ions
b r i n g w i t h t h e m t h e b u r d e n o f p e r i o d i c m e d i ca l
r eev al u at i o n , t h e st i g m a at t ach ed t o t h e af f ect ed
su bj ect s, t h e pr obable iden t if icat ion of t h e w or k er s
as in cap ab le an d t h e r u p t u r e of t h e w or k p r ocess.
Aft er invest igat ing er gonom ic w or k r est r ict ions, som e
a u t h o r s su g g e st e d t h a t a f a v o r a b l e a p p r o a ch t o
secondary prevent ion could involve w ork m odificat ion
t o r edu ce ph y sical dem an d for all su bj ect s ex posed
t o h eav y loads, or at least for t hose r em ov ed fr om
work due t o low back pain( 10).
Aft er classifying work rest rict ions int o groups
( b i o l o g i c a l , p h y s i c a l , c h e m i c a l , e r g o n o m i c ,
psy ch osocial an d or gan izat ion al) , it w as f ou n d t h at
t he m ost frequent one was ergonom ic ( 78.6% ) . Wit hin
t his group, t he m ost prescribed were: do not lift and
t r a n s p o r t w e i g h t s ( 5 9 . 7 % ) a n d d o n o t p e r f o r m
r epet it iv e m ov em en t s ( 2 2 . 2 % ) .
An invest igat ion point ed t o t hree m ain causes
f or t em p or ar y w or k d isab ilit y af t er id en t if y in g t h e
grant ing of 6,906 benefit s of t he com m on sick- leav e
t y pe in a m edical inv est igat ion, car r ied out in 1998:
e x t e r n a l c a u s e s , m u s c u l o s k e l e t a l d i s o r d e r s a n d
m en t al d i seases. Th ese co n d i t i o n s ar e p o t en t i al l y
r elat ed t o t he w or sening of qualit y of life and w or k .
Th e lar ge pr opor t ion al in ciden ce of m u scu losk elet al
disorders – especially t enosynovit is and low back pain,
r epet it ion of m ov em en t s at w or k – possibly r ef lect
t he fact t hat t hey are under- recorded as work- relat ed
diseases( 1 3 ).
I n a st udy carried out wit h 105 assist ant s and
t ech n ician s of a p u b lic h osp it al, w h er e on e of t h e
o b j e c t i v e s w a s t o e v a l u a t e t h e p r e s e n c e o f
m u scu losk elet al sy m pt om s in t h ese w or k er s, it w as
f o u n d t h a t 9 3 % h a d co m p l a i n ed o f so m e k i n d o f
m usculosk elet al sy m pt om in t he last 12 m ont hs and
62% in a sev en- day per iod. The highest pr ev alence
of t hese sy m pt om s, accor ding t o t he anat om ic ar ea,
w as: lum bar r egion ( 59% ) , shoulder s ( 40% ) , k nees
( 33.3% ) and cervical region ( 28.6% ) . I t was also found
t hat 29.5% of t hose w ho answ ered m issed w ork and
47.6% saw a doct or due t o t he sam e sym pt om s( 14). A
r esear ch w it h n u r sin g st af f w or k er s of a t each in g
hospit al w ho had suffer ed som e k ind of w or k- r elat ed
accident w it h spinal colum n inj ury dem onst rat ed t hat
m ost accident s occurred in t heir own work unit ( 50% ) ,
during t he act ivit y of m oving and t ransport ing pat ient s
and equipm ent and also as a consequence of slippery
floor s( 2 ).
The process by which t he occupat ional healt h
t eam pr escr ibes w or k r est r ict ions has not been w ell
d escr ib ed in t h e lit er at u r e as y et . Fu r t h er st u d ies
should be car r ied out t o gat her t he infor m at ion used
t o pr escr ibe a w or k r est r ict ion and t he int ent ion t hat
m ot iv at ed t he pr escr ipt ion. The inv est igat ion should
e x a m i n e : t h e t r a j e c t o r y o f w o r k r e s t r i c t i o n
p r e s c r i p t i o n s , w h e t h e r s u c h r e s t r i c t i o n s r e d u c e
e x p o s u r e t o k n o w n o r s u s p e c t e d r i s k f a c t o r s
associat ed w it h pr olonged r ecover y; t he ext ension t o
which t he prescribed rest rict ions are im plem ent ed and
m aint ained at t he workplace; whet her t he rest rict ions
int r oduce differ ent r isk fact or s t hat m ight br ing on a
n e w i n ca p a ci t y o r p r o l o n g e d r e co v e r y. Ev i d e n ce
indicat es t hat , once w or k r est r ict ions ar e pr escr ibed,
t h e y a r e m a i n t a i n e d b e y o n d t h e r e q u i r e d
con v alescen ce per iod( 1 0 ).
I t has been wit nessed in Brazilian realit y t hat
t h er e ar e a l ar g e n u m b er o f co m p an i es t h at o n l y
b eg i n l o o k i n g f o r p r o g r a m s f o r m a n a g em en t a n d
pr event ion of w or k- r elat ed m usculoskelet al disor der s
( W MSD s) a f t e r f a ci n g a n a c t u a l o u t b r e a k o f a n
ep id em ic d isease. I n t h ese con d it ion s, in t er v en t ion
d if f icu lt ies ar e g r eat ly in cr eased , as w ell as f ailu r e
pr obabilit y( 11). Br azilian com panies ar e not pr epar ed
t o deal w it h in div idu als in capacit at ed f or w or k an d
t he m ain int erest ed part ies, which are t he com panies,
t h e u n ion s, in su r an ce com p an ies an d t h e Nat ion al
So ci al Secu r i t y I n st i t u t e ( I NSS) , d o n o t h av e t h e
necessary st ruct ure t o m eet t he requirem ent s of t hese
w or k er s, such as j ob r eplacem ent , r et ur n t o w or k or
inform at ion about benefit s and legal right s. The realit y
is t hat t here is a growing num ber of civil responsibilit y
claim s in v olv in g com p an ies, as w ell as r eg r essiv e
law suit s t hat Social Secur it y m ay file against t hem .
One of t he ways t o solve or at least abat e t he problem
w ou ld b e t o cr eat e m ech an ism s t h at w ou ld en ab le
t he effect ive requalificat ion of t he worker wit h sequels,
by m ean s of f ast an d agile dev ices f or f iscalizat ion
a n d co n t r o l , i n a d d i t i o n t o o r i e n t i n g t h e d i r e ct l y
involved agent s about t he pot ent ial problem s t hat t hey
m ay face if t hey r elegat e such w or k er s t o a second
place( 15). The healt h care t eam should prescribe work
r e st r i ct i o n s w h e n i t b e co m e s a p p a r e n t t h a t t h e
m odificat ion of act iv it ies w ill facilit at e t h e r et u r n t o
work or lim it exposure t o physical dem ands t hat m ay
ex acer b at e sy m p t om s or h in d er f u ll r ecov er y. Th e
per cept ion of t h is t eam r egar din g ph y sical effor t of
t he workers can be im proved t hrough discussions wit h
t h e w o r k e r s , v i s i t s t o t h e w o r k p l a c e s , a n d
m ult idisciplinar y w or k w it h w or k er healt h sect or s( 10).
Th e r e s t r i c t i o n s d e s e r v e m o r e s p e c i f i c
inv est igat ion of im plicat ions, bot h for t he inst it ut ions
( ad m i n i st r at i v e, econ om i c an d soci al ) an d f or t h e
w or k er s ( psy ch osocial an d econ om ic) .
CONCLUSI ONS
I n t he present st udy, 176 m edical report s wit h
a t ot al of 337 work rest rict ions in a t hree- year period
w e r e a n a l y z e d . Th e m o s t a f f e c t e d o c c u p a t i o n a l
cat egor ies w er e: dist r ibu t or of m at er ials, r ecr eat ion
m o n i t o r, m e c h a n i c t e c h n i c i a n , h o s p i t a l l a u n d r y
assist ant , nut rit ion assist ant and necropsy t echnician.
As regards t he nursing t eam , t he assist ant s were t he
m ost af f ect ed. Th e m ean w or k- r est r ict ion per iod in
t he m edical r epor t s w as 13 m ont hs, w hile w hen t he
r est r ict ion p er iod w as cat eg or ized as d ef in it iv e or
t em por ar y it w as obser v ed t h at t h e gr eat m aj or it y
w as definit iv e.
The result s dem onst rat ed a high incidence of
w o r k r e st r i ct i o n s i n t h e st u d i e d i n st i t u t i o n , w i t h
p r ev alen ce of er g on om ic r est r ict ion s. Th e p r ocess
u sed b y t h e occu p at ion al h ealt h t eam t o p r escr ib e
REFERENCES
1. Mulat inho LM. Análise do sist em a de gest ão de segurança e saúde no am bient e de t rabalho em um a inst it uição hospit alar. [ d i sser t ação ] . Reci f e ( PE) : Esco l a d e En f er m ag em / UFPB; 2 0 0 1 .
2 . Al e x a n d r e NMC, Be n a t t i MCC. Aci d e n t e s d e t r a b a l h o a f e t a n d o a co l u n a v e r t e b r a l : u m e st u d o r e a l i za d o co m t r abalhador es de enfer m agem de um hospit al univ er sit ár io. Rev Lat in o- am En fer m agem 1 9 9 8 abr il; 6 ( 2 ) : 6 5 - 7 2 . 3 . Gold m an RH, Jar r ar d MR, Kim R, Loom is S, At k in s EH. Priorit izing back inj ury risk in hospit al em ployees: applicat ion and com parison of different inj ury rat es. J Occup Environ Med 2 0 0 0 Ju n e; 4 2 ( 6 ) : 6 4 5 - 5 2 .
4 . Nish id e V, Ben at t i MCC, Alex an d r e NMC. Ocor r ên cia d e acident e de t r abalho em um a unidade de t er apia int ensiv a. Rev Lat in o- am En f er m agem 2 0 0 4 abr il; 1 2 ( 2 ) : 2 0 4 - 1 1 . 5 . Ro c h a FLR, M a r z i a l e M H P, Ro b a z z i M LCC. Pe r i g o s p o t e n c i a i s a q u e e s t ã o e x p o s t o s o s t r a b a l h a d o r e s d e e n f e r m a g e m n a m a n i p u l a ç ã o d e q u i m i o t e r á p i c o s an t in eoplásicos: con h ecê- los par a pr ev en i- los. Rev Lat in o-am Enfer m agem 2 0 0 4 j unho; 1 2 ( 7 ) : 5 1 1 - 7 .
6 . An dr ade E. Cr it ér ios par a av aliação m édico- per icial das d o e n ç a s o c u p a c i o n a i s . A r q B r a s Me d 1 9 9 2 n o v e m b r o -d ezem b r o; 6 6 ( 6 ) : 4 7 9 - 8 1 .
7. Miranda CR. I nt rodução à saúde do t rabalhador. São Paulo ( SP) : At h en eu ; 1 9 9 8 .
8 . Cr oce D, Cr oce Jr D. Med icin a Leg al. São Pau lo ( SP) : Sar aiv a; 1 9 9 5 .
9 . Be n a t t i MCC. Ac i d e n t e d o t r a b a l h o e m u m h o s p i t a l univ er sit ár io: um est udo sobr e a ocor r ência e os fat or es de r isco ent r e t r abalhador es de enfer m agem . [ t ese] . São Paulo ( SP) : Escola de En f er m agem / USP; 1 9 9 7 .
1 0 . H i e b e r t R, Sk o v r o n ML, N o r d i n M, Cr a n e M. W o r k r est r ict ions and out com e of nonspecific low back pain. Spine 2 0 0 3 Ap r i l ; 2 8 ( 7 ) : 7 2 2 - 8 .
11. Assunção AA, Alm eida I M. I n: Mendes R. Pat ologias do t rabalho. 2. ed., São Paulo ( SP) : At heneu; 2003. p. 1502- 39. 1 2 . Loisel P, Du ran d P, Aben h aim L, Gosselin L, Sim ar d R, Turcot t e J, et al. Managem ent of occupat ional back pain: t he Sh er b r ook e m od el: r esu lt s of a p ilot an d f easib ilit y st u d y. Occu p En v ir on Med 1 9 9 4 Sep t em b er ; 5 1 ( 9 ) : 5 9 7 - 6 0 2 . 13. Boff BM, Leit ea DF, Azam buj a MI R. Morbidade subj acent e à concessão de benefício por incapacidade t em porária para o t r abalh o. Rev Saú de Pú blica 2 0 0 2 Ju n h o; 3 6 ( 3 ) : 3 3 7 - 4 2 . 1 4 . Gu r g u e i r a GP, A l e x a n d r e N M C, Co r r ê a - Fi l h o H R. Pr e v a l ê n c i a d e s i n t o m a s m ú s c u l o - e s q u e l é t i c o s e m t r abalh ador as de en fer m agem . Rev Lat in o- am En fer m agem 2 0 0 3 ou t u b r o; 1 1 ( 5 ) : 6 0 8 - 1 3 .
15. Per eir a CE. Um est udo sobr e a r ealidade dos por t ador es de DORT/ LER nas em pr esas. [ disser t ação] . São Paulo ( SP) : Facu ld ad e d e Ad m in ist r ação/ PUC- SP; 1 9 9 9 .
