Good morning everyone. Welcome to our session on the landscape research on workplace impairment related injury and fatality. My name is Jenny Burke. I'm going to get us started this morning. My colleague Claire Strohr is here. We're from the National Safety Council and we'll be presenting on some of our work that we're doing today. Go ahead and get going here. Our agenda is as follows. We're going to cover impairment in workplaces. So really how is that defined? What are we talking about when we say impairment? Some of our core research questions that we've been using so we can really better understand impairment and its impact on safety. I'll tell you a little bit about the council in a second, but that's really important to us. And then we're going to go over a brief methodology summary of some of the research that we're doing, provide some of our initial findings in one of our more recent research projects, and then kind of go through some next steps with you. But then also we'd love to hear from you and some of your experiences in this space as well. So how many of you guys have heard of the National Safety Council? Yay. All right. That is fantastic to hear. I'm so glad. Well, for those of you who don't know, our mission at the National Safety Council is to eliminate preventable deaths from the workplace to any place. And that's through leadership, through research, through education, and through advocacy. And so we do a combination of all of these things to really help workplaces be safe, help roadways be safe, and then help people bring that knowledge that they're learning home to them and have safer homes and communities as a result. And so all of our work really focuses on that safety piece. We've been around for over 100 years, since about 1913 to be exact, so I guess 110 now. There's a little bit of math I can do, not a ton, but just a little. And so that's really the core of everything we do is really focuses on that safety piece. But what we started to notice is that although we were making some really great strides in keeping people safe at work, we've done a lot in a lot of trainings, a lot of research on hard hats, steel-toed shoes, PPE, things that keep workers safe on the outside of their bodies. But then we really kind of stopped making a dent in that safety space and really started to look more internal to say, what's going on inside the body that might also be impacting safety? How do we understand what's happening there? And then with COVID, that made it become even more important and more people started getting interested in talking about it because all of a sudden, we're talking about mental health, we're talking a little bit more about substance use, we're talking about things that are impacting our workers that are talking about our ability to make good decisions about keeping each other safe, and how that impacts workplaces, roadways, and homes. And so really for the National Safety Council, we really define impairment as a person's like temporary inability to do their work safely. And we call it temporary because it may not be all the time. It might just be a temporary point in time that would keep you from using your typical ability to do a job. And there's a lot of different factors that might actually be causing that. And so we really want to understand what are those things that can keep you from being safe? So when we talk about, I might trip and fall on the carpet, but did I trip and fall on the carpet because there was a hazard on the carpet, or because I wasn't thinking about it because I was distracted about something else? You know, am I worried about one of my kids? Did I take a bunch of cold medicine this morning, and therefore I'm a little bit hazy? You know, like, so there's some different things that we're not necessarily looking at. And so that's kind of where we've really focused. Around our definition of impairment, we define it one way, but there really is a lack of a consistent definition across the board. So as we really dug into this issue, we've really learned that there's no industry standard agreement on what the word, the actual word impairment means, or how it should be used when we're talking about safety. We know from looking at our friends next door in Canada, that they actually have a workplace impairment standard. They have a definition and a definition that they use to really kind of navigate their path in their workplace culture. That doesn't necessarily fit within the United States because we're just starting to get there. But, so we don't have a standard, a workplace impairment standard. We do have a lot of different types of things that are getting at that standard. So we have related terms like total worker health, fitness for duty, ready to work, performance, cognitive and physical effects, productivity, all of these different words that we're kind of getting at that. We're scratching at the surface of what impairment means, but not necessarily getting all the way there. We also know that impairment tends to be frequently associated with substance use. So when we're talking about are you impaired, a lot of us will say, oh, is that driving? Are you doing some impaired driving? Are you driving drunk? Are you driving high? Still a lot of people aren't getting that one either, but that's kind of where our brains go, right? So was somebody drinking in the workplace and then therefore couldn't do their job. But it's really a lot bigger than that when we start to look at how things impact safety. And that's one of the things that we've really been digging into. And so what are these physical and cognitive changes that can really lead to impairment? This is not news, I'm sure for most of you, but this is something that we really work with workplaces on to help them understand that all of these different things are changes in the human body based on types of impairment. So anything from your breathing, your heart rate, tremors, how you're making decisions, what your response time is in making those decisions. Is your brain foggy, like I was mentioning earlier? Is your balance off? I'm really hoping I have good balance right now because I'm really nervous I'm going to step off the stage. So I'm going to hide a little bit behind the computer. But all of these different changes and all these different physical and cognitive changes can really lead to impairment, but they can lead to then workplace injuries, incidents, and fatalities. And so how can we best understand what's happening and then how do we keep people safe as a result of that? Because we know that we can see impairment on the top. If somebody is drinking and using a substance or somebody's really out of it, you know you can see that, right? But you may not be able to see all of it. You may not be able to see all of those underlying factors. Sometimes there's more than just one. Sometimes it's more than just one. Sometimes it's a combination of a lot of different things. And so it's really important that we address all the root causes because that's really the only way we're going to get at preventing impairment in the workplace and really preserving that physical safety that is really our goal at the end of the day. So when we're looking at impairment, we have acute impairment, so happening at the time, and then we have chronic impairment. Acute impairment is really that person's ability to do their job safely in the moment in real time. Okay, so you're looking at right now, are you ready? Can I manage to stay on this, whatever we call it, safely and not fall off? Okay, let's hope that we can do that. But with chronic impairment, if we have recurring instances of acute impairment, then it becomes chronic. The chronic P's can actually be associated with chronic conditions. So things like diabetes, things like sleep disorders. We know most people don't have undiagnosed sleep disorders. And so you're not managing that. So that becomes a chronic impairment condition. Unmanaged mental health disorders. So if somebody needs treatment for mental health but is not getting it. Unmanaged substance use disorders. All of those things can really contribute to having unsafe working conditions or exposures in the workplace to unsafe working conditions that can really impact safety. And so we really have to look at the in the moment situation, but then also reoccurring issues. And so it's not just one thing. This makes it a little bit more confusing because there's different types, acute and chronic impairment, that can require different solutions. And so when we look at what might be the causes here. So we know that there are about basically like three different categories of causes. We have chemical causes. So again, those substance use issues. So opioids, cannabis, alcohol, all of those different things. And then obviously there are many more. But all of those different chemical factors. So the more traditional way that we might be looking at impairment. And then we have physical factors. So physical factors tend to be things like fatigue or extreme heat or cold. Things that affect you physically but really help really keep you from being able to concentrate. And then psychosocial factors. This is where that mental distress piece comes in. So someone who's experiencing mental distress might be more fatigued, might resort to substance use. So all these things are related to each other, but can also just be kind of in one category as well. But they're really all related. And so when we think about how that impacts the workplace, we think about chemical exposures in the workplace. So not necessarily something that you're ingesting on your own, but something that you might be exposed to in a workplace. With physical factors. So physical factors in the workplace could be extreme temperatures. They could be exposure to an extreme temperature. They could be scheduling. So depending on if you're working long shifts or you don't have enough shift return time. So you could be spending too much time on one task. All of these different issues that may relate to fatigue. That's affecting your physical factors for impairment. And then we have psychosocial. So in addition to all these things that might be happening to your body that way, we're also dealing with things like psychological safety, with harassment in the workplace, with violence in the workplace. And unfortunately, that's something that's becoming more and more prevalent and something that we're having to deal with. So we're talking about chemical issues, physical issues, psychosocial issues that are all happening in the workplace per se. And not even necessarily something that are workers doing, but something that's absolutely impacting their ability to do their job. And then we have the workers themselves. And so then when we talk about workers themselves, the chemical issue becomes back to what I was saying earlier, the legal drug use, illegal drug use, alcohol use, substance misuse, all of those more traditional things. But then we talk about workers and their undiagnosed sleep disorder, right? So they might be struggling with fatigue. They might have some blood sugar issues related to their diabetes. They might have blood pressure issues. They may not be getting any sleep. Maybe they have an infant at home and the baby's up all night. Or worse, maybe they have a teenager that's keeping them up all night because the teenager's getting into trouble. You never know. All these things could really impact what they have going on. And then in addition to that, so they might be tired and exhausted because they've got a family member who's not sleeping. And guess what? That starts to impact your mental health, right? And there's a lot of different things that can impact your mental health. You might just be more anxious. You might be more stressed out. You're fatigued. You might be worried about a family member who's struggling with something. Maybe somebody is sick. And a lot of examples of this have become way more commonly talked about and commonly identified by workers during COVID, right? And I think we're all kind of probably a little tired of hearing about it, except that the really great part of this is we're finally having this conversation. We're finally talking about the way mental health can impact your safety in the workplace. And so it becomes really, really important to have these conversations because we know that it's impacting safety. And so one of the things that we were kind of curious to ask you, and yes, there is audience involvement this morning, so sorry. We're going to put you guys to work a little bit. But we were just wondering if anyone had an example of how they might want to explain to the group about how they're considering impairment in their own practices. So do any of you guys have any way that you're specifically defining impairment? You've heard how the National Safety Council is doing it, but does anyone want to share how you might be addressing it? Anyone? Yes, sir. I'm from the Children's Hospital. We've been working to kind of rewrite our disability policies and kind of incorporate this more holistic kind of view of it. So, you know, and not just, you know, there is that technical mindset of like, you know, you're impaired, we can make sure you're not. We do drug testing, we do alcohol testing, but we're not necessarily in the past really been addressing all those other psychosocial issues. So we're trying to incorporate in sort of our DAP resources and our other kind of mental health resources to kind of more holistically define what it is that we're looking at and develop an assessment sheet to kind of document what those different issues might be outside of this, you know, substance. Great. So I'm just going to kind of rephrase because I want to make sure we get that a little bit in the recording. But so you're from a children's hospital. You're looking at reviewing your fitness for duty policies. It sounds like you might have a group of people, is that right, that are actually reviewing this and creating some sort of assessment that really gets at some of these issues that are larger than your traditional fitness for duty. So the recognition that this is happening, but not necessarily a full-fledged tool that you're using as of this point, correct? Okay. And I think a lot of people are getting there. Sir, do you want to? Jenny, you've got one thing missing from your model. Okay. That's psychological. And for example, in our institution, in our clinic, one of the main emerging issues is post-COVID syndrome. And I couldn't see that that's covered by chemical, physical, or psychological. It's partly covered by psychological, but not all post-COVID syndrome is psychological. Right. So I just wanted to point that out. That's a really good point. Thank you. And just to also capture that in the recording, the jump from Mayo, you said, Mayo Clinic has pointed out that we may want to consider adding biological so that we can include COVID symptoms as well. I can make a note on that. So I'll point out too that this definition that we have in our approach is definitely something that's evolving and there's a lot of different frameworks and opinions about how to categorize things. So we definitely acknowledge that and there's a lot of blurry lines and fluidity with how we talk about this issue in general. I think when we're talking about certain things like medical conditions, we've looped those into the physical category. So I think that's where we've been terming them, but I think there's a lot of different ways in which we could classify it. So I think that's a great call out though to recognize that those are all things that can impact performance and fitness for duty. Yes, ma'am. In a previous copy I worked for, oil and gas used it as a lagging indicator in an investigation using a human factor to try and prevent COVID. In the first instance, they would then go back and say, were they even dead? And then they would look through a lot of the categories that were out there and sort of top-set what they used. But to be honest, as a lag, they weren't particularly good at doing it on the front end and say, let's prevent COVID. And then you're also asking, when you're looking at a lagging indicator, do you remember if this was a situation at the time? Right, right. And those are not things that our brain is trained to look at. So unless that's something that we're talking about consistently is to recall what that looked like for you, your brain may not be learning to point it out. And for example, we're kind of pointing out there's no handrail for the stairs. So safety issue, right? Because I'm trained to do that because this is where I work and we're trained to identify safety hazards. We are not trained at this point to identify the safety hazards that may exist with an impairment. And so the better we get at that, the better we'll be at finding those lagging indicators. But when you're asking somebody to go back and think about a situation or a factor to an incident that they never would have thought might have been a cause, they're not going to identify it. So we'll talk a little bit more about that later. But I think that's a really good point to bring up. Thank you. And so one of the things that we really want to understand is what do we know about the risk? Okay? So we're all trying to manage the risk within a workplace, the risk on a roadway to keep people safe. And so we really want to get at that. How do we identify the risk and then how do we manage that? We know that impairment impacts safety. We know it impacts people's wellbeing. And then we know that it costs employers a lot of money. We have a lot of different ways to show this. We have a lot of different ways to really explain to people that there are safety impacts. So things like substance use disorders, mental health distress, sleep problems. We know that all these things increase your risk for safety incidences. We know that, right? We know that it impacts wellbeing. We have research that says 70% of people with a substance use disorder are in the workforce. They're going to work every day. Okay? So what can we do to help those folks? How can we help them stay safe? We know that 20% of Americans are living with a mental illness. That's not the number of ones with self-identified issues with anxiety, with a more acute form or mental distress. That's people who have an identified mental illness. And then we have about 43% of employees who are sleep deprived. There may be a fatigue issue, an undiagnosed sleep disorder, but there may also be the infinite home or the spouse who's snoring all night and the other person can't sleep. I have no idea who that could be, but it might be me. And then all of that can cost employers money. So you're thinking about what are employers actually spending on this? And when you actually add up the numbers, it gets pretty crazy. Untreated sleep disorders can cost about $3,500 a year per employee to an employer. Untreated substance use disorders, $8,800 a year per employee. Experiencing mental distress, not teaching your staff some resiliency techniques, not addressing the fact that people might be struggling in the workplace, not connecting them to resources, can cost almost $15,000. But for every dollar that an employer invests in supporting mental health, you'll see about a $4 return on that investment when you really dig into supporting the mental health of your employees. So there's definitely an ROI here. We'll talk through some of those resources. We can help you identify that at the end of this presentation today. But just to kind of lay that out for you, these are big impacts on employers, and so it's really important that we share that. We did a survey at the National Safety Council on what are employers and employees thinking about impairment. And so I wanted to share a couple of those results with you. We know that a little over half of the respondents in our survey stated that they know that impairment is decreasing the safety of their workforce, but they're not necessarily quite sure how to manage that. You know, I mean, just like the gentleman from the children's hospital, it's hard to kind of, you know you need to change some things, but you're not quite sure exactly how you need to change things or what's going to work. We know that over almost half of employers are saying, you know what, we know this is causing some more near misses. We know that there are things going on. 39% say impairment is causing more injuries. They know things are happening, but because this is so amorphous, they don't know how to deal with it. They don't know how to manage it. They don't know how to prevent it. So how can we really get at that? There's a lot of different factors that you have to dig into, and so that's where it gets really confusing. It's not just one thing that you can address. So we lost, unfortunately, last year about 107,000 people to overdoses. Overdoses in the workplace have risen over 500% since 2011. So in the last dozen years, unfortunately, we've seen that number increase over 500%. Almost 10% of workplace fatalities are drug overdoses. That includes opioid overdoses and alcohol overdoses happening at work. Yet, we have just made Naloxone over the counter, and it is not required to be in anyone's first aid kits at this time. Something to think about. It's such an easy fix for a problem that is creating a lot of, unfortunately, safety incidences. We know that workforce drug test positivity has climbed to its highest level in two decades. So the chemical issue is not going away. It's getting progressively worse, worse and worse all the time. We know that about a third of employees say that they've actually observed people using cannabis in the workplace. I'd like to share that that survey is from two years ago. So as we think about how much more prevalent cannabis has become in the last couple of years or continues to become on a daily basis, think about what that number probably looks like now. It's probably significantly greater. NHTSA released a report in December that pointed out that among trauma centers, among car crashes that ended up in trauma centers, the most prominently identified substance in the body was cannabis, not alcohol, for the first time. So we have this little piece of data, but it's starting to show up to be significantly more prevalent. Now, the most prevalent combination was alcohol and cannabis combined. When we think about that, that doesn't come out of your system when you get to work, right? If you're driving on the road with impaired by those two things, you're very likely at home impaired that way, or you're very likely in the workplace impaired that way. So just some food for thought there about how this data is starting to be collected and why it's important that we're looking at it. When we think about physical factors, we know that about 13% of workplace injuries can be attributed to sleep problems. This also shows up on the roadway. When we look at fatal crash investigations, we know that fatigue is a factor in about 20% of those. Okay, so fatigue is absolutely a factor in workplace safety. It's a factor in roadway safety, and yet something that we don't actually account for. We barely look at it as a lagging indicator, but we know that it shows up in these places where we're actually looking for it. We know that almost every single employee at one time or another has a risk factor for fatigue, almost every employee. So why aren't we doing some prevention around it? So see just one other place where this is kind of an issue. In addition to the fatigue, which is one of the more common ones, extreme temperatures also negatively impact safety outcomes. So we're thinking about extreme heat or extreme cold. So there's a lot of different things that are happening, but back to that sleep piece, and this is probably no surprise to any of you all, but even just losing two hours of sleep, when we think about that 97% of employees who have at least one risk factor, even if you just lost two hours of sleep. So last night I traveled all day yesterday to get here. It was hard for me to fall asleep last night. I probably lost two hours of sleep. So I'm basically up here like I've had three beers. That's what the equivalent is. So that's the presentation you're getting this morning. I'm joking. But just to illustrate though, I mean, that is actually a real statistic. If you lose two hours of sleep, you're performing similarly often to someone who's had three beers. So it's a rule of thumb, like should you be driving? And so I like to illustrate this, you know, when people are on the road, take your stops every two hours, take a rest, walk around, get some, you know, reinvigorate yourself so that you can manage your fatigue. And there are ways to do that, but this is something that can impact safety. I may also blame it on me falling off the ledge if I fell off. So in addition to those physical factors and those chemical factors, there are psychosocial factors as well. And so this is something that we've started talking about, as I said, way more post COVID than, or at least in the world we're living in now. More than one in 10 American workers has had at least one episode of serious psychological distress in the last 12 months. One in 10. And I would argue that that number is pretty low. We know that moderate and severe mental distress have been found to increase risk for workplace safety incidences. We know that people who are struggling with moderate and severe mental distress probably also have issues with fatigue. They probably also have issues with substance use disorders, because this is what we're dealing with on a daily basis. All of us have to deal with stress. It's a part of life. But at some point, that stress is going to impact your safety. So think about this and, you know, have you gotten an argument with someone and then gotten behind the wheel to drive somewhere? How focused were you on the road? Did you get an argument? And sorry, I keep throwing out these teenager responses because it's the world I live in, but, you know, are you arguing with them while you're driving? How focused are you on the road? Did you drive late at night when it's dark outside and you worked all day? All of these different things, your life stressors, whether those are personal, whether those are work, that unresolved conflict that you're having in a workplace can absolutely impact how safe you are in the workplace and on the road. So understanding how big of a problem this is though is a really big issue. So we just talked about that with the woman from the oil and gas industry about, you know, okay, we're asking people to report this in an incident report after the incident, right? So post-incident, we're coming back to this, you know, maybe a day later, maybe even a few hours later, maybe a week later. We don't know. We have some of that data that we just shared. So all those different things that I just shared that give us those on the impact that those factors have on safety, but we don't have a complete picture of what that looks like. So one of the things that we did in the roadway is we actually looked at crash reports. So, and I was giving you all that different data on what's happening on the roadway. We know some of that data because we're actually collecting it in some places. The National Safety Council released a report a few years ago called Undercounted is Underinvested, where we literally looked through all 50 states crash reports. And we said, are you looking at all of these different factors related to impairment on our roadway? Risky road behavior is still one of the top three causes of roadway crashes and fatalities. But we found, and this is the example I like to give, and I grew up in Colorado, so I can pick on it a little bit. When Colorado legalized cannabis, recreational and medically, at the beginning of that time in 2017, their crash reports did not require an investigation to look at whether someone was impaired by alcohol or cannabis. They did not have to test for either one. It was optional on the crash report. How can you make good decisions about roadway safety if you do not understand what's happening on your roadway? So roadway is thankfully a little bit ahead of where we are in workplaces. Colorado now has required documentation in their crash reports, thank goodness, as well as several other states. When we released that report, several states did change their crash reports. And we're looking at doing an updated version of that because it really kind of gets people to see, oh my gosh, I didn't know all this stuff was happening. I didn't realize I wasn't capturing it. But this is exactly what's happening in workplaces. So all of these things are happening in your workplace. You're seeing safety incidences increase, but we're not looking at why. We're not really digging into the why. So we know that you might count that slip, trip or a fall, but not whether the person was impaired. So just like the woman had pointed out, we're not going back or we're asking you to remember something that happened a while ago. Your brain is not trained to think about those things at that time. And so we know that the data is difficult to gather. You can't necessarily measure specifically, okay, yes, I know I got two hours of sleep less than my normal average. Unless you've got a really good Apple Watch and I don't even think mine does that, you don't know what your average sleep is necessarily or in a way that you would calculate it, right? Nor are our brains trained to think about that. So it's difficult to measure impairment. If you're not feeling well, maybe you have a really bad cold and you took some cold medicine. You don't know what that impact necessarily is, nor are you asked to report that. So we have to start thinking about this in a different way. And we need to do some research on what does this look like in real life? And so we've really kind of tried to dig into this. You know, we've talked about fatigue this morning a little bit, and we do have some data around fatigue, but we need to really look at doing some research in a more rigorous way to understand, can we isolate fatigue as an issue to really understand how much of an impact fatigue only in and of itself has? But what we've also heard me tell you this morning is that a lot of these factors combine together to produce impairment in the workplace. And so how do we really get around that? It's super complicated. There are not per se limits for anything around impairment other than alcohol. And the blood alcohol content is the closest thing we have, but it's not perfect. It's a proxy measure for impairment, and it only measures that one thing. You know, there's been so many arguments on the per se limit for cannabis. At least we all kind of understand now that there can't be that because it doesn't actually show impairment. It just shows a level in your body. And so there's national databases that exist, which are usually kind of a gold standard for measuring things, but we don't understand how to do it with impairment. And so we don't understand how much anxiety, how much depression do you have to have before you're impaired by it? I would argue that a fleeting argument with your spouse or your teenager or parent is just as impairing as, you know, something else. Like if you're behind the wheel and you're arguing with somebody in the seat next to you, or even if you just had an argument and got in the car, you are not focusing on the road. Same thing at work. If you just got in an argument with somebody or you just were made to feel really bad at work for some reason, and then you're asked to go do a safety sensitive task, are you going to be able to do that safely? I would argue no. So we have to think about how do we address this in the workplace. We're going to talk about a little bit, some of our research, and I'm going to hand this off to Claire here in a minute, but there's a lot of gaps because we don't have methods that exist to determine impairment. So just like the gentleman was mentioning earlier, you know, you're getting a group together to look at fitness for duty. You're getting a group of people together to talk about this. It's great to get started, but we don't necessarily have those gaps yet. So how can we start figuring out how to do that? And Claire's going to talk to you a little bit on that, about how the National Safety Council has really kind of dug in and started to look at addressing these gaps and do a little bit more research into how we handle this better. So I'm going to handle this off to Claire. Thank you. All right. Hi there, everybody. Apologize. You're probably not going to be able to see me too well. I'm a little shorter than Jenny. And like she's alluded to, there's a treacherous cliff right here. So I'm not going to step out too far so you can see my face, but I would be happy to meet you all after so you can get to know me a little bit better, even though I'm going to be hiding a little bit behind the screen right now. But like Jenny mentioned, my name is Claire. I'm a senior program manager at the National Safety Council on our impairment team, and I've got a public health background. And I came to NSC because we've been doing a lot of groundwork in, of course, substance use disorders and dealing with the opioid epidemic. And as she shared, we've really changed our approach into looking at all these different issues that can impact performance and safety, not just related to substance use, but also to these other factors, those chemical, physical, and psychosocial factors as well. So like we've been talking about, there's a lot of different gaps here. We have an understanding, we know that all these different issues can impact safety, but we're just scratching the surface. We don't have a true picture of what this data looks like. So I'm going to share with you a little bit about a project that we've been working on at NSC to better understand this issue, also to help us identify opportunities to improve data collection efforts in the United States. So this is really our first step in a long process we're going to be taking to really dig more deeply into this issue at large. And I do want to clarify that these are preliminary results I'm going to share with you. We're still in the middle of this work. There's a lot of different factors that we've talked about this morning, so it's taking a long time to dig into all the different research that's available. But we've gotten a really exciting start to hopefully be able to share with you some interesting findings that we've had so far. So we've been working on this project since July, and here are some of the core research questions that we've developed to help better understand this issue. So firstly, how is workplace impairment conceptualized and operationalized? So generally, how are people talking about this issue? Are we using the word impairment? Should we be using a different word perhaps? It's a very confusing term. Under each category of impairment, so that physical performance and psychosocial issues, and then also chemical. So underneath those categories, what are the risk factors that have actually been studied? What's been most frequently researched, and where are some gaps? What are the impacts of impairment on workplace safety and work activity performance? So what are the actual safety outcomes that have been researched? Currently, how is workplace injury and fatality and its relation to impairment documented? So how are we sharing this information, both within the research realm and also within workplace reporting structures? And how should impairment be included in workplace documentation and investigation? Like I said, we're looking for opportunities to improve the current state of this issue. So what can we actually be doing to make better change here? So to actually do this work, we've done both a scoping review, and we've also conducted interviews with key informants and subject matter experts. So in the scoping review, we identified over 1,500 articles, and we narrowed it down to about 421 articles. It's been really fun, guys. We've been spending a lot of time with all my screens open with all the articles looking at all of this information, and it's been a little bit of a doozy, as you can imagine. So, and we've been looking at research up to from 1992. And then we've really been focusing within the articles on the definition, measurement, and then obviously the impact on safety and those outcomes and safety outcomes. Within the interviews, we really wanted to conduct interviews as well as doing a scoping review because we wanted to add color to these results. There's a lot of context and nuance to this conversation, so we've been reaching out to different groups to better understand their perspective on this. And of course, that's why we've been asking you guys a few questions as well to understand how you're perceiving this issue and where we could be doing a little bit better to tackle it ourselves at NSC. So we've talked with surveillance and regulatory institutions, unions, for example, workers' compensation organizations, insurance providers, employers as well, really a whole gamut of different experts in this space that touch on this subject matter area. We've also done a review of public databases just to understand what's being formally tracked and available to the public. So some good examples of some of those databases we've looked at are CFOI and SOI through the Bureau of Labor Statistics and also data sets like the National Survey on Drug Use and Health, which I'm sure you're all familiar with. Okay, so what did we actually find? When we're looking at the definition of impairment, like we've alluded to, there's no widely agreed definition, especially when we're looking at the research. It's very cloudy and it's very contextual. So when we've seen the word impairment in the articles we've been looking at, a lot of times it's more used as a decrement of some kind of outcome, not necessarily the cognitive and physical changes that might be happening to an employee or a subject because of their mental state or their other factors going on. So it's not really something that's used consistently within the research. And we're also having to untangle the risk factors, like we've been talking about potential substance use disorders or sleep problems or any other thing that could impact impairment and those risk factors from studies that have been actually just looking at cognitive performance, for example, very broadly. And then also looking at the safety outcomes, which are a really small component of the studies we've actually found. And from the interviews, we've had a lot of conversation with subject matter experts about how this word impairment might not be the best word or best categorical way to talk about this. So I'd be curious if you guys have other suggestions for us because we haven't quite found another way to approach it yet. Especially because it can put a lot of onus or blame on the employees for having these kind of symptoms that they might be bringing into the workplace, which also, as a reminder, could be because of workplace factors, not just personal factors. So the word we have found, especially from our interviews, to be a little bit stigmatizing. So we're trying to figure out a better way to talk about this issue without really putting all the blame on the employee. And like we've also talked about, it really refers to substance use. That's something that where this term has kind of been founded. But we're making a lot more headway into talking about the other more holistic nature. We've used that word a little bit and approaching this more holistically. So I think we're making some good progress here in how we're talking about this issue. And then there is a discrepancy between field use and clinical use. So really, when we've been talking to some of the clinicians, such as yourselves, it's more about an impact of an injury or fatality, not necessarily the general concept of a performance change that an employee might be experiencing. So really trying to unpack those differences and clearly articulate those so we can come to a consensus around how we should be talking about this issue, both within the research and within the field. So when we are looking at how to actually detect for impairment, most of the articles looked at anything that was a significant deviance, either from an individual's baseline or for the control groups. That's how it was typically defined and measured. But we saw mostly self-report information. So using different scales, for example, to actually understand if somebody might be experiencing a diagnosable sleep disorder or be experiencing sleepiness. We saw a lot of the Carolinas does sleepiness scale or the Epworth sleepiness scale. And a lot of the articles, like I'll talk about, fatigue was the most commonly studied factor. So that's why we talked about that a lot today because that's where the research is coming from. We did also see some objective measurements, drug testing. I'm sure you're not surprised to see that there was plenty of studies that incorporated that. But as we all know, drug testing does not equate to impairment. More about the presence of drugs. So again, trying to unpack that and figure out if these proxy measures can help us to better understand actual impairment. There was a lot of bio and physiological tests as well. For those of you who are familiar with things like impairment detection technologies, things like psychomotor vigilance testing were commonly deployed, or things like fatigue wearables, for example, as well, were used in the studies. We also saw a lot of simulation and observation studies. So using driving simulators or looking at different performance areas under observation. And in general, from the interviews, it was an overall acknowledgement. This is a very tricky area. It's very hard to understand and measure impairment. So most of the emphasis that was placed on using a human-based approach. So really training supervisors and employees to understand the signs and symptoms of impairment so that they can intervene and talk with employees to get them help. Understanding because there's not really a way for them to measure this and control for this through other mechanisms at the moment. We have to do a better job of really encouraging employees to come forward and providing a positive culture for them to feel comfortable coming forward to share when they might not be able to perform and they don't feel their best that day. So that's something that we've talked a lot about, going in that direction, because there's a lot of gaps right now with what we can actually do to control for this outside of taking that human-based approach. So generally what has been studied and what have the research articles been, what have they been showing us? So most of the studies that we've seen have been focusing on those physical factors, especially fatigue, especially in the context of healthcare, as I'm sure you're not surprised. A lot of the studies have focused on things like shift work and shift sleep disorders as well. We have seen some information on heat and extreme heat, but not really much on extreme cold, for example, but a lot more on extreme temperatures related to heat and certain medical conditions, especially as they relate to the workplace like musculoskeletal disorders and their impact on employee performance. When we're talking about chemical factors, we've seen, of course, a lot on alcohol, not surprising since that's been studied for the longest, I think out of all of the different substances that we think about when we're thinking about impairment, but also chemical exposures and other toxins that might be impacting, especially the cognitive performance of workers on the job. And cannabis as well, because it's a hot topic and it's new, and there's a lot more research that we've seen as of late about the impacts of cannabis and performance. And as it relates to psychosocial factors, we've seen the least amount of the data relating to this, but we have seen some of the research on anxiety, stress, and trauma, especially as it relates to first responders. So generally, when we're talking about the impact of all these different issues, there's inconsistent results. A lot of these studies have been in a lab and in controlled environments. They couldn't necessarily be replicated as something that we can try to do within actual workplace settings to understand what's going on on the ground. There's a negative impact on cognitive and task performance, which is not surprising. Like we've shared all the information from earlier in the presentation. We know this is happening. So we have seen some studies that focus on cognitive and performance outcomes, especially as it relates to fatigue, chemical exposure, extreme heat, and substance use in general. So unfortunately, the least amount of data we've seen as it relates to safety outcomes. So looking at things like near misses, injuries, fatalities, and driving errors or crashes, I'd say is less than a quarter of the actual articles that we found look at those outcomes. A lot of it is based on self-reported information and it's based on lagging indicators. We're going back rectoactively and retrospectively to get this information. We have also seen a little bit, too, on burnout, which is something that's obviously interrelated to all these things and fatigue. Some other topics that we've seen in the research that we weren't necessarily looking for primarily but we saw a lot about was patient safety as an outcome. Also concepts like presenteeism and absenteeism, which we don't really consider impairment per se, but it definitely relates to these concepts. We saw a lot about that as an outcome. And then obviously worker health and well-being is a very related concept to this. We did see some research on that. So when we're talking about how impairment in general is documented, a lot of the public databases that we looked at, of course, primarily focused on direct cause, which is not surprising because we haven't actually been digging into and investigating these issues more deeply. Because there's not really information to share outside of very surface-level data on the direct cause of the injury. So that slip, trip, and fall, not necessarily any underlying causes that might be associated with that because we're not able to do a lot of those incident investigations in the first place. So the depth of root cause investigations really depends on the investigators. That's something we talked a lot about in our interviews, is that people might be using the five whys, but they might stop after the second question if there's a cause that seems like, okay, we figured out what the cause is. We're not going to keep on asking those questions to dig in more deeply. So if you have that as a common practice within workplaces, we're not going to get to the details that we might need to know, especially when we don't know to investigate impairment. This is definitely related to safety. People aren't thinking about it in that way. Other sources that carry some information that we're interested in and we've seen a little bit in our research, things like forensic reports, death certifications, drug testing, field interviews, also emergency room data. The list goes on. Other avenues that we can look at to dig in more deeply, but the research is sparse. And of course, the data is collected at different levels that aren't really talking to each other. So we did talk with some employers that have access to some information, but if they have, for example, occupational health staff, they have access to different information than maybe the safety team has access to, and they're not really communicating with each other about what those larger trends look like so they can work together to dig in deeply to that information and identify ways to prevent or address some of these issues that might be more common than they realize. And the reason for that is, of course, privacy and confidentiality are top of mind. So when we're looking for solutions, we'll obviously have to keep that into consideration to figure out a way to keep employees protected in these conversations so that we can make sure that our solutions are benefiting them instead of harming them. So what does this all mean? When it comes to the end of the day, we don't have a lot of data. And that's because we aren't really doing the investigations to understand when impairment might be involved in different incidents, injuries, and fatalities in the workplace. And that's because we're not really reporting this information in the first place because we don't understand it might be an issue to investigate further. And that's also because we're not able to detect impairment. There's no measure that we can use for all these different factors to understand when somebody objectively might be impaired. And that also comes down to a lack of awareness in general about impairment being an issue that is a prime concern for safety. So just some opportunities that we're thinking about moving forward. We are going to be doing a lot of work next year to really drill into these more, but just from a high level for now. We want to try and figure out a better way to use consistent language for organizational buy-in and also for research that we know we're using the same word. We're talking about impairment. We're talking about the actual cognitive and physical effects. Are we talking about the risk factors that relate to the impairment? It's very messy, very fast. So if there's a better way that we can be talking about this issue together, both in the research and in the field, I think that will get us light years ahead of where we are right now. We also need to figure out ways to integrate impairment into safety management systems. There's systems already in place. What can we be doing to actually integrate this into the systems that exist and the conversations that are already happening? We don't have to recreate the wheel. Like we've talked about, there's opportunity for more thorough incident investigations. Just asking more questions and understanding that this might be a factor. So just starting somewhere simple. That also relates to conducting more routine fitness for duty assessments. So are there opportunities to work with your employer organizations to better understand when employees are able to work and look for opportunities for them to maybe have other accommodations or get them assistance that they need to, to make sure that they're safe on the job? And then really leaning into the positive support and organizational culture for employees that they can seek help and come forward if they might be experiencing any kind of symptoms related to impairment. So we've been digging a lot more into total worker health at NSC. We see a lot of value in that approach. So how can we work with employers to really embrace that framework so that we have more employees feeling comfortable to come forward and have those conversations with their employers so that they can seek help and then also come to work safe and fit for duty? And embracing that human-based approach as well, training supervisors to understand the signs and symptoms of impairment so they can approach employees and get them help before hopefully anything else would happen after that that would lead to an injury or fatality. So overall, as you've heard us say, it's really important just to dig deeper. We have scratched the surface. There's a lot of opportunity for us to be doing more, to ask more questions, and to understand and do more research here. So that's really our main message right now is just to unpack some of those layers and dig deeper so we can understand when impairment is actually causing more injuries and fatalities, despite the fact that this is a really big issue. This is a really big ask. We know this is not an easy thing to do, but we can make baby steps into better understanding all these different topics and how they relate to safety so we can better work with employers to create better solutions and preventative mechanisms to save lives. So what now? Our full research report is going to be available in the fall. So we're going to be sharing that at our annual conference that we host every year. And so we are really hoping to use this foundational data to have an understanding and conversation to move forward to look for those opportunities. So we're going to be hosting expert advisory panels and focus groups to look at what those recommendations might be, and we're going to break those down by policy recommendations, so doing some advocacy work perhaps, looking at research opportunities, both clinical studies, for example, but also organizational and workplace-related studies. We didn't see a lot of workplace-oriented studies in what we found. And then looking for recommendations for employers themselves as well. So just to give you an overview, we talked a lot about what we're doing to better understand the issue, but this is a framework that we've recently created just to share with employers on how they can address impairment in general. So there's a lot of things on here, and we're limited on time, so I'm not going to go through all these steps. But there's a lot of things that you can do within workplaces and you're working with employers to actually address this issue, and it extends from preventative opportunities also to early intervention, incident response, reoccurrence prevention, and then ongoing health, wellness, and safety. So this is a really big topic area that we're working on at NSC, not just the data collection piece, right? So just wanted to share some of the resources that we have that get at some of those other elements. Most of them are free, so I encourage you to go to our website at nsc.org backslash impairment to check some of these out, especially as they relate to more specific topic areas, depending on what you're interested in or dealing with. So some of our resources that we have on chemical factors I'd like to highlight are Opioids at Work Employer Toolkit. This toolkit is free, and you can go and actually reference it for anything, you know, it's geared towards opioids, but it's really anything you can use related to dealing with substance use in the workplace at large. So there's policy templates in there, there's basic resources for safety professionals, a lot of employee education material, so if any of that would be helpful to you when you're working with employers, I encourage you to check that out. We also have resources on psychosocial factors. We do have some cost calculators as well. Jenny shared some data earlier on the financial impact of all these different topics, and we have these calculators that you can go in and plug in different information based on where your organization is located, how many employees you have, and what kind of industry you're in, and it'll shoot out the cost so you can use that to share with people to get their attention and kind of hook them in to share that this is really a big issue. So we have calculators for mental health and for substance use and also for fatigue, and those are all free. And we do also have a fatigue at work employer toolkit, so similar to the opioids at work employer toolkit, there's a lot of great resources for fatigue, again, policy templates, educational materials, really how to create a robust fatigue risk management system. And then as it relates to all these different factors, of course, we've talked about the interrelationship between these different factors. We do have resources that get to that in the more general term of impairment and the holistic nature of this issue. We do have an impairment recognition and response training for supervisors that we've just newly created, and we do also have some information on impairment detection technology. So I briefly talked about psychomotor vigilance testing. That's one example of impairment detection technology, and so we did some research on that trying to understand what is out there and how they work and how they're being evaluated. So we do have a report on that, and that's something that we're going to continue to dig into as well at NSC. Okay. So I know that was a lot of information. There's a lot of different topics that we talk about and underneath the umbrella term of impairment. So we have some time for discussion because we'd love to learn from you, especially because we're in the middle of this research at the moment. We'd love to pick your brain to see what you're dealing with and what are some barriers you might be running into and if you have any ideas for us to use in our research moving forward. So for the first question, we'd love to understand what data do you have access to or even our tracking related to any of these topic areas? I know it's really hard to get, but I'm curious if anybody's looking at these metrics within their own workplaces. I had a feeling we might not have many volunteers for this question, but I had to ask. Go for it. Okay. So like an impairment detection technology. Great. That's awesome. What was the last thing you said? Okay. Great. So just to repeat what he said, using forms of impairment detection technology and also drug testing just to get at some of the objective measures that we have the ability to track. Great. So in-vehicle technologies that sound like they have a video component. Right. Awesome. Go for it. Okay. Right. I do think that's a really great way to approach it though with having employees come forward to volunteer. At least when we've been talking about impairment detection technologies, we've heard a lot of employers that use it as a coaching opportunity because it's really hard to get buy-in to do this kind of surveillance for obvious reasons. So if you can even get some of the employees to come forward to do that, you can usually get more buy-in after that once there's a group that have kind of piloted it in a sense. So I think that's pretty great that you're doing that. I'm going to pass this on to the next questioner, next speaker I should say, so that it gets recorded for the association. Appreciate that. I did want to point out that what you're talking about here has some similarities to vital statistics with respect to recording the cause of death. We had a lot of discussion over the past two or three years on people and how many died from the coronavirus. In China particularly, a lot of those deaths were not classified as being due to COVID. They were due to heart disease or lung disease or something like that. So impairment is very similar. There are multiple causes that can be associated with impairment. I think it would be wise, if you haven't done so already, to look at the vital statistics literature with respect to classification or nosology, because I know there has been some fairly good research done as to how best to classify causes of death, even though most physicians who are actually the ones that put the words on the paper aren't very good at it. That's really helpful. I haven't heard anybody share that feedback with us, so we'll definitely look into that. I appreciate that. And I can move us to the next question. I know we've got a few more minutes. You might have more to share on this question. Do you have any barriers when you're talking about identifying or addressing potential employee impairment? For example, when you're doing fitness for duty examinations or working with employers about how to actually address all these different factors, where are you running into barriers? Where can we work at NSC to help try and break some of those down? Or you all have it figured out? We're good? Okay. Oh, we've got someone back there. Oh, we've got the mic coming to you. In a work setting, the employee's not going to want to tell me that he was taking antihistamines or had an argument with his wife, and that made him fall, because that leads to apportionment and the blame goes back to him, not to the workplace. Right. So there's a... Or he's not going to tell me that he was smoking pot and drinking beer the night before the accident. So there's a barrier there to identify the real cause of, why did you slip and fall on the staircase at work at 8.30 in the morning when you just started your shift? Right. Yeah, 100%. I think that comes back down to that positive culture framework, and then also providing avenues for employees to share information. It's really hard to acknowledge when something might be going on at home, that's not something easy for us to share, even if we feel comfortable in a work setting sharing those kind of things, if it's a psychosocial-related factor. So how can we create systems that really embrace employees coming forward and do not penalize them for coming forward? Most importantly, outside of the data tracking, just to get them help, right? Thanks, Jenny. Anybody else have any barriers they want to share? Generally, not knowing in the workplace... Okay. So in the workplace, or when we do fitness for duty evaluations, not knowing on the other side at the employer's location if they have any policies in place where they screen for impairment, what training supervisors have to detect impairment, how is it reported, all that kind of a secret world, if they even have anything in writing, is a barrier in assessing fitness for duty in many cases. Yeah, that makes a lot of sense, and I'd say that mirrors another gentleman who's sitting in this room that I see, who we interviewed about this, and he shared the same piece of information. So there's almost two worlds on what the employer has access to and what occupational health professionals have access to, and we have to do a better job of communicating and bringing that together where it's possible, so we can better look at those trends, right? And to piggyback off of what she said, even if the employer is able to get some type of lab study, we don't get those results in real time, so we're kind of stabbing around in the dark, and then there's a delay in getting the lab results so that we can give our final comment on what caused the issue or not. Right. So you're not able to do a thorough assessment without all the facts. Yeah. I think the most useful thing for me is a robust model, like you're presenting, and I think that most of us are approaching this problem in different ways. So what immediately came to mind for me was the ICF, we've been looking at that in the context of the WHO International Classification of Functioning, and I just thought about that only in chronic impairment, which we think of in the context of accidents and that kind of whole person impairment, but not in the field of acute impairment, and how could models like that also be? And then once you've got the model, it can help you to develop an approach, and probably one aspect I want to call out is workplace factors, like shift work, the structure. The fundamental problem with shift work is the fact that we work at night, and getting that understanding and that a person will always be impaired if they do shift work, because they are circadian beings, and so therefore there's no such thing as a good shift system. So if you look at the way it's managed in aero, in pilots, and how it's managed in road, totally different. Very different. I think we've established how it could be done, but people who are not flying planes won't manage a truck driver the way they manage a pilot when they should, if they truly want to get the results. So I think those kind of structural factors, and it's not just them, it's unions, employees, and employers around cost and optimal shifts, as one example, but I think that's probably the number one cause of impairment, work-related impairment in industry as an issue. Yeah, and that's a good call-out that we are going to need. Obviously this is very early on, but we, as we create frameworks, need to have very specialized frameworks for different industries, and for different causes, because all of this really cannot be a one-size-fits-all approach, so I think that's a good call-out. And something I didn't emphasize earlier that we've been talking a lot about is that this is all on a spectrum. This is not a black and white issue. You're not just impaired, or you're not impaired. So we need to figure out ways to acknowledge that, and figure out where that threshold really is, where we truly think this impacts safety, because otherwise we're really infringing upon employees and their confidential information that we really don't need to be investigating. So I think that's just another component of this conversation, so thanks for mentioning that too. So one thing I've noticed, which actually was a removal of barrier two years ago, but I feel now it's become a barrier, is implementing new technologies, or using telehealth, or virtual platform in identifying and addressing potential employee impairments. I would like to see more research in showing the validation of different virtual platforms. Are they really, is the sensitivity and specificity the same? Because the COVID pandemic has really propelled, I would say, me, I don't know about my colleagues, but using and identifying different virtual platforms, mobile apps, telephone, video conferencing, using extenders, self-examinations when appropriate. And I do see that there is going to probably be some permanent use of these technologies. And then to piggyback that, there's an increasing use of artificial intelligence in preparing and developing some of these information collecting mechanisms in addressing employee impairment. And what is the accuracy of it, allogrithic tools that could be done. So that's just another potential research as well. Yeah, that's very interesting. I haven't seen a lot of research into telehealth platforms and how those can be used in this conversation, so I think that's a really good opportunity. And I know we're a little bit over time, so we do have a survey. I know there's other evaluation that you're probably completing for the conference. But if you have any feedback on some of the questions we shared, we didn't even get to all of them, because this is obviously something that's hard to fit into just one hour. If you have any feedback on this topic that you'd like to share with us, I'd love if you could participate in the survey. We also have a way to evaluate the presentation as well. But if you'd like to add anything to this conversation, or if you're interested in digging a little bit more deeply with us, I'd love to hear from you, because this is going to be an evolving project that lasts us for a few years, if not forever. I don't think we're ever going to fully figure this out. It's going to take a long time. So if you're interested in this and have feedback for us, I'd love to connect with you. But thank you guys so much for being here and being part of the conversation.

workplace impairment-related injuries

workplace fatalities

temporary inability to work safely

substance use

psychosocial factors

data collection

supervisor training

positive culture

help-seeking

National Safety Council