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Systematic Literature Review on Indicators Use in Safety Management Practices among Utility Industries

Mohamad xazaquan mansor ali.

1 Centre for Research in Development, Social and Environment (SEEDS), Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia (UKM), Bangi 43650, Malaysia; moc.liamg@4891nauqazax (M.X.M.A.); ym.ude.mku@sabanalza (A.A.); moc.liamg@2891damharihkadhom (M.A.A.)

2 Department of Occupational Safety and Health Malaysia, Ministry of Human Resources, Government Administrative Centre, Putrajaya 62530, Malaysia

Kadir Arifin

Mohd akhir ahmad, muhammad khairil.

3 Faculty of Social and Political Sciences, Universitas Tadulako, Palu 94118, Indonesia; [email protected] (M.K.); moc.liamg@liamedamasnasha (M.A.S.); moc.liamg@7epmalsayli (I.L.)

Muhammad Basir Cyio

4 Faculty of Agriculture, Universitas Tadulako, Palu 94118, Indonesia; moc.oohay@oiycrisab (M.B.C.); moc.liamg@26zdufham (M.M.); [email protected] (M.N.A.)

Muhammad Ahsan Samad

Ilyas lampe, mahfudz mahfudz, muhammad nur ali, associated data.

Not applicable.

Background: Workers in utility industries are exposed to occupational accidents due to inadequate safety management systems. Accordingly, it is necessary to characterize and compare the available literature on indicators used in safety management practices in the utility industries. Methods: The systematic literature review was based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. This study considered 25 related studies from Web of Science and Scopus databases. Results: Further review of these articles resulted in three mains performance indicators; namely, driven leading indicators, observant leading indicators, and lagging indicators consisting of 15 sub-indicators. Conclusions: Future studies should consider researching a more comprehensive range of utility industries, measuring subjective and objective indicators, integrating risk management into safety management practices, and validating the influence of leading indicators on safety outcomes. Further, researchers recommend including accidents, fatalities, lost time injuries, and near misses in safety outcomes.

1. Introduction

The International Labour Organization (ILO) estimates 340 million workplace accidents and 160 million people suffer from work-related illnesses worldwide every year, due to inadequate working conditions, leading to about 6000 workers dying every day [ 1 ]. One of the industries contributing to this statistic is the utility industry, which consists of water, electricity, and gas utilities that provide essential services to commodity providers and other industries, contributing to economic and social growth. Workers in the utility industry are subject to risks associated with their work activities and surroundings. In 2018, 405 fatal cases and 101,393 non-fatal cases of accidents were recorded by the ILO in the utility industry globally [ 1 ]. As a result, occupational accidents cause a burden on the injured individual and society, including monetary costs, such as wages lost and medical expenses, potential lifelong disability, and reduced quality of life [ 2 ]. Even with various programmes implemented by government authorities and organizations at the national level, the number of accidents at work is still high [ 3 ]. Thus, the effort implemented to control unsafe actions and conditions in the workplace is insufficient [ 4 ]. Accidents can be avoided by ensuring the safety level implemented in the organization is maintained and improved from time to time, through measuring indicators that proactively affect safety performance.

Safety performance is conventionally monitored by lagging indicators, such as accident rates, fatal accident rates, and dangerous occurrences, even though failure-focused control measures are less effective in driving continuous improvement efforts [ 5 , 6 , 7 ]. The lagging indicators method measures failures compared to current safety conditions and should not be considered a direct measurement of the level of safety in a working system [ 8 ] because incidents are rare occurrences with a low probability, making the accident frequency statistically unreliable due to variance restrictions [ 9 ]. The rare occurrence of incidents does not mean that the workplace is safer than other places where accidents occur, and it is not a clear performance indicator for hazard or risk management [ 10 , 11 ]. Therefore, lagging indicators that measure weakness rather than safety and ignore the different exposures of risks inherent in work activities should not be considered a direct measure of safety level in a working system [ 8 , 12 , 13 , 14 , 15 ]. Recent research is more focused on proactive action by measuring safety levels through OSH activities that bring safety management systems up to date towards the desired safety goals, enabling organizations to anticipate safety issues and potentially reduce OSH incidents [ 8 , 16 , 17 , 18 , 19 ].

Safety management is frequently considered a sub-system in overall organizational management and is implemented through many forms of safety management practices, the mechanism incorporated into an organization to control hazards at work [ 20 , 21 ]. Safety management consists of procedure, planning, information management, and supervision, which play significant roles in reducing occupational accidents [ 22 ]. On the other hand, the lack of a safety management system can lead to workplace accidents, among the most common causes of industrial disasters, such as the Bhopal gas leak [ 20 , 23 , 24 ]. As a result, it is necessary to detect any deterioration in OSH management systems and quantify the amount of accident risk and how it changes over time [ 5 , 8 , 25 ]. There are two indicators when reviewing safety management procedures: positive indicators that show potential for improvement and negative indicators that serve as early warning signs of management system failures. This proactive indication can help detect and manage safety issues before they turn into an incident or cause harm [ 5 , 8 , 16 , 26 ]. Proactive indicators can also be used as benchmarks for current practice to demonstrate continuous progress over time, monitor safety performance tolerance levels, and take action when these tolerance levels are breached [ 5 , 27 , 28 ]. However, reporting practices for occupational safety and health (OSH) vary by industry and workplace sector, depending on organizational structure, technology, and type of activity [ 16 , 29 ]. Further research is needed to establish more effective OSH performance indicators and assist businesses in implementing them [ 30 ].

Despite the rising relevance of examining proactive indicators, the literature on the utility industry is fragmented. Thus, this research aims to bridge the gap between identifying indicators used in assessing safety performance in the utility industries and their ties to safety outcomes to enhance safety in the utility business. This study aims to conduct a systematic literature review by grasping the concept of safety indicators, measuring techniques, identifying indicators of safety management practices used in utility industries, and the associations between indicators.

The methodology employed in this research was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to formulate the research question, systematic searching strategies, quality appraisal and data abstraction and analysis. The study was conducted from March 2021 till July 2021. This review included three main aspects in the review, namely the utility industry (population), indicators (interest) and safety management practices (context) [ 31 ] and aims to answer the following question: what types of indicators are used in safety management practices among utility industries?

2.1. Systematic Searching Strategies

Three main processes in the systematic searching strategies process are the identification, screening, and eligibility based on PRISMA [ 32 ], as shown in Figure 1 .

This describes the main processes based on PRISMA.

2.1.1. Identification

Identification is a search process using the study’s main keywords, namely safety indicator, safety management practices, and utility industries which relied on keywords developed based on the research question [ 33 ]. To provide more options for selecting databases in the search for more related articles for the review, searching processes used any synonym, associated term, and variation. The identification process relied on past studies, keywords recommended by guidelines and keywords recommended by experts. Scopus and Web of Science databases were used in this research, using enriched existing keywords and developed full search strings, shown in Table 1 . The searching process in these two databases was conducted from March 2021 to May 2021, with the published articles limited from 2000 to May 2021, resulting in 807 articles.

The search strings.

2.1.2. Screening

This study screened all 807 selected articles by selecting the criteria for article selection, which was completed automatically using the database’s sorting function. The authors removed 19 articles that were duplicates from the selected articles. Furthermore, only articles with empirical data published in a journal were included in the review to ensure their quality. Additionally, only items written in English were included in the review to minimize misunderstandings. The inclusion and exclusion criteria shown in Table 2 were used to include 321 articles and exclude 467 articles to achieve the study’s objectives.

The inclusion and exclusion criteria.

2.1.3. Eligibility

Eligibility involved personally reviewing the retrieved articles to guarantee that all the remaining articles after the screening process met the research criteria. This procedure was accomplished by reading the title and abstract and skimming through the papers. The elimination process was based on unclear methodology, non-safety management practice indicators, conducted in non-utilities industries, not related to the safety and health field, and published as a chapter in a book. As a result, 242 articles were removed and 79 were chosen.

2.2. Quality Appraisal

Two specialists were chosen for quality appraisal with a background in safety and health and more than 15 years as an enforcer and auditor of safety management system certification. The remaining articles were sent to the specialists for assessment to ensure that the content was high quality. The remaining articles were categorized into three categories: high, medium, and low, with high and moderate papers being reviewed [ 34 , 35 ]. The articles were categorized when both specialists agreed with the ranking decision. When there was disagreement between the categories addressed, the lowest rank given by either one of the specialists was chosen. This approach yielded 9 high-ranking articles, 16 moderate-ranking articles, and 54 low-ranking articles. As a result, articles with a low ranking were eliminated, leaving only 25 articles suitable for examination.

2.3. Data Abstraction and Analysis

This research study chose the qualitative strategy to synthesize or analyse integrative data [ 36 ]. The researcher read the full text for all 25 articles, focusing on the abstract, findings, and discussion sections. Data abstraction was carried out based on the research questions, meaning any data from the evaluated study that can answer the research question and were then entered into a table. Thematic analysis was then used to identify indicators and sub-indicators within the abstracted data based on noticing patterns and themes, clustering, counting, noting similarities, and relationships [ 37 ].

The first stage in thematic analysis is to produce indicators by looking for patterns in the abstracted data in all the articles reviewed for similarity. Based on a comparison of the conceptual theory of indicators for similarity, the comparable and abstracted data were pooled into three main indicators. The three sets of data were further analysed and synthesized, revealing another 15 sub-indicators. The data were divided into three main indicators: safety management practices acting as a driven leading indicator, safety performance behaviour acting as an observer leading indicator, and safety outcomes acting as a lagging indicator. There were seven sub-indicators in the safety management practices group, four in the safety performance group, and four in the safety results group.

3.1. Temporal and Spatial Distribution

The review consisted of identification, screening, eligibility, and included processes, thus, obtaining 25 selected articles related to the research question. The review’s main indicators were safety management practices, safety performance behaviour, and safety outcomes, and resulted in 15 sub-indicators, as shown in Table 3 . Then, seven sub-indicators under safety management practices that act as driven leading indicators were identified: management commitment, involvement of workers, hazard identification and assessment, hazard prevention and control, training and education, evaluation and improvement, and communication and coordination. Meanwhile, the indicators for safety performance behaviour acting as an observant leading indicator consisted of four sub-indicators: safety motivation, safety knowledge, safety compliance, and safety participation. Lastly, the safety outcomes indicators that served as lagging indicators were identified, consisting of four sub-indicators: occupational accidents, occupational fatal accidents, near misses, and lost time injuries.

The groups and sub-groups.

According to Figure 2 , the maximum number of articles on safety management practice indicators in the utility industry was published in 2019 and 2020, with five articles (20%) each year. The distribution of publications fluctuated during the decade, with only one article published each year from 2006 to 2015 and then increasing in 2016. However, due to the review research being conducted in May 2021, the number of publications released in 2021 appears to be declining. It is expected that more articles will be published throughout the rest of the year. No papers were published from 2000 until 2005, then none in 2008, 2012, 2013, and 2017. The fluctuation trends in the number of published articles showed that researchers focused on proactive actions to anticipate safety issues and potentially reduce OSH incidents.

Number of reviewed papers selected by year published.

Figure 3 shows the number of articles according to their country of origin. Most of the studies were conducted in Australia with three articles (12%), Iran with three articles (12%), and the United Arab Emirates (UAE) with three articles (12%), followed by Canada with two articles (8%), Poland with two articles (8%), and the United States (US) with two articles (8%). Most countries only published one article: Brazil, China, Ghana, Greece, Italy, Malaysia, Netherlands, Norway, Serbia, and the United Kingdom (UK).

Number of reviewed papers selected by country.

The review articles published were focused on general sectors with 10 papers (40%), followed by the gas utility sector with 9 papers (36%), and the electricity utility sector with 6 papers (24%). In their sampling, the articles that researched multiple or various industries, including the utility sectors, were included in this systematic review and were known as the general sector due to their suitability for the utility industry’s safety management practices. From the 25 articles selected, most of the studies were conducted on driven leading indicators with 22 papers (85%), followed by observant leading indicators with 10 papers (38%), and lagging indicators with 8 papers (31%).

Leading indicators can be measured as passive, objective, or subjective. Most of the studies focused on subjective measurement with 20 articles (77%), followed by objective measurement with 6 articles (23%), and passive measurement with 2 articles (8%), from the 25 articles selected. Leading indicators research was distinguished into two phases: the development phase, which included defining, developing, or measuring, and the progressive phase through validation testing of leading on lagging indicators. Based on the selected articles, most of the studies were in the development phase with 18 articles (72%) and the progressive phase with 7 articles (28%).

3.2. Driven Leading Indicators

These studies on safety management practices were a group as the driven leading indicators. They were assessed through seven indicators: management commitment, workers’ involvement, hazard identification and assessment, hazard prevention and control, training and education, evaluation and improvement, and communication and coordination.

Management commitment is an internal safety factor that relates to how senior management appears to prioritize safety issues, communicates well, and acts effectively in an organization that values safety [ 47 ]. Thematic analysis conducted in this research shows that 22 articles (85%) studied management commitment. Indicators for successful implementation of safety management systems depend on top management to develop safety policies; OSH leadership, visible commitment, and safety as core values can shape the safety climate and performance to influence positive and lasting effects on safety.

Workers’ involvement in safety can improve safety performance in an organization, as workers are the best-qualified people to make improvement suggestions because they are the people closest to the job. The thematic analysis found that 15 articles (58%) studied workers’ involvement in safety management practices. Workers’ involvement can be measured through the level of involvement encouragement, empowerment for safety, worker consultation, and removing barriers for workers’ involvement that will lead to their ‘ownership’ towards safety.

The analysis found that only 11 articles (42%) discussed hazard identification and assessment practices in safety management. Hazard identification and assessment are important in identifying and verifying hazards to support the efficient functioning of safety management systems. Through this practice, the prevention of accidents or similar undesirable events from reoccurring can be achieved. This practice is measured through four indicators: identifying existing hazards, workplace inspections, accident investigation, and hazard assessment.

Hazard prevention and control are essential in ensuring adequate hazard controls are implemented and operated effectively. Thematic analysis shows that 14 articles (54%) studied hazard prevention and control. There are four indicators used in assessing hazard prevention and control practices: planning, implementing, managing, and verifying hazard controls. This practice can lead to proactively improving, ensuring implementation, continuous implementation, and verifying control effectiveness.

Training and education were the second-most-studied factor in the review, consisting of 18 articles (69%) out of 25 papers. This practice can be enhanced through management commitment towards safety training that leads workers to gain knowledge, awareness, and ability to recognize hazards, thus, increasing safety levels. Thus, training and education are measured through four indicators: management roles in training, the effectiveness of workers’ training, training on hazard identification and control, and safety awareness.

The safety management systems require an evaluation for the implementation and corrective actions of documented and implemented measures. This practice was studied in 16 articles (62%) from the selected review papers, studying performance evaluation of safety programmes, safety audits, identification of weaknesses, and identification of opportunities. It is important to keep track of performance appraisals and audits, which are essential to detect and describe safety programmes and management conditions. Weakness identification is important to avoid adverse safety incidents following unsuccessful work operations; thus, continuous improvement can be implemented by controlling and reviewing activities, so that performance goals and indicators remain relevant.

Communication and coordination help organizations manage safety issues and progress related issues between organizations with diverse objectives from potential hazards and accidents. This practice is studied in 13 selected articles (50%) and can be measured through four indicators: management communication, safety reporting, supervisory communication, and OSH coordination. Effective safety communication and coordination between managers and workers are important to communicate safety problems or concerns that lead to a positive safety climate. Further, proactive supervisors will emphasize supervisory monitoring practices by being committed to safety, thus, ensuring workers and contractors follow safety rules. These safety management practices and their indicators are detailed in Table 4 .

Safety management practices leading indicators extracted from reviewed articles.

3.3. Observant Leading Indicator

One method that can be used to observe the effectiveness of programmes or activities is by measuring employee safety behaviours. In this systematic literature review, the author identified two main indicators in observant leading indicators: proximal safety antecedents and safety behaviours. Proximal safety antecedents consist of safety knowledge and safety motivation, and safety performance consists of safety compliance and safety participation. Most of the studies focused on safety compliance with 11 articles (42%), followed by safety participation with 8 articles (31%), safety motivation with 5 articles (19%), and safety knowledge with 3 articles (12%).

Safety knowledge is the awareness of proper methods for performing safe behaviours as proximal antecedents of safety performance or mediators of the relationship between personality traits or job and related organizational factors and safety performance [ 45 , 59 , 60 ]. Safety knowledge is measured through a scale of six items, namely workers knowing how to perform the job safely, how to use safety equipment and standard work procedures, how to maintain or improve safety and health in the workplace, how to reduce the risk of accidents and incidents in the workplace, the associated hazards and necessary precautions, and reporting potential hazards noticed in the workplace [ 45 ]. Another proximal antecedent of safety performance was safety motivation, which refers to the enthusiasm to implement safety behaviours and the courage associated with those behaviours [ 45 , 60 ]. Safety motivation is measured through a scale of three items: efforts to maintain or improve personal safety, the importance of maintaining safety at all times, and the importance of reducing the risk of accidents and incidents in the workplace [ 54 ]. In meta-analysis studies, the safety climate was positively related to safety knowledge and safety motivation, both being related to predicting safety performance, which indirectly influences accidents and injuries [ 60 ]. Workers’ health and safety can be improved through investment in knowledge and training that encourage safe behaviour [ 59 , 61 ].

Safety performance has been conceptualized as individual behaviours with a measurable criterion proximally related to psychological factors more than accidents or injuries that can be distinguished into safety compliance and participation [ 60 ]. Safety compliance refers to workers’ behaviour in following safety policies and procedures towards meeting work safety standards, such as complying with personal protective equipment requirements, carrying out tasks safely, obeying safety regulations, and using correct procedures [ 53 ]. On the other hand, safety participation refers to workers’ behaviour in helping create an atmosphere supportive of safety that moves beyond procedures to assist colleagues, engage in voluntary safety activities, promote safety and its principles, take safety initiatives, and improve workplace safety [ 53 ]. Safety practices and leading indicators have positive and strong associations with safety compliance and safety participation [ 45 , 48 , 54 ].

3.4. Lagging Indicators

The authors identified the lagging indicators that represent the safety outcomes based on the review papers: occupational accidents, occupational fatality accidents, near misses, and lost time injuries. Most of the lagging indicators studied were occupational accidents in eight articles (31%), followed by lost time injuries in five articles (19%), occupational fatal accidents in four articles (15%), and near misses in four articles (15%).

Occupational accidents are referred to as accidents that result in injuries needing medical attention [ 60 ]. The reduction in occupational accidents is considered the final goal or outcome of safety efforts in an organization [ 52 ]. Occupational accidents are the outcomes of many factors, including unsafe behaviour, which was a direct trigger factor, with injuries representing low-base-rate and count variables [ 59 ] in most organizational measured injury rates [ 51 ]. Occupational accidents can also be measured by recordable injuries resulting in lost time, recordable injuries requiring medical treatment, and incident rates based on severity and frequency [ 44 , 55 ]. It was found that only five papers discussed or mentioned lost time injuries as a lagging indicator. Fatality was mentioned as the second type of severity related to high-consequence injury and illness resulting in death [ 44 , 51 , 55 ].

Another lagging indicator is measured through lost time injury. There are two ways of reporting lost time: lost time injuries, which refer to the subset of work-related injuries that result in ‘lost time’ due to work absence, and lost time injury frequency rate, which is defined as the number of lost time work-related injuries (fatalities and lost workday cases) per 1,000,000 work hours [ 40 , 55 ]. However, some firms calculated lost time injury frequency rates based on U.S. Occupational Health and Safety Administration Guidance, which uses 200,000 h as the denominator [ 55 ]. Prior research labelled lost time injury as a lagging indicator [ 39 , 40 , 44 , 51 , 55 ].

Near misses are lagging indicators resulting from inadequate safety efforts and are defined as unplanned incidents with short-term results that do not result in an accident or injury [ 52 , 59 ]. However, research shows that workers tend to under-report near misses, causing the relationship between these variables and their predictors to be attenuated [ 59 ]. Near misses can also be considered a leading indicator, measured by the number of near misses investigated [ 44 ].

4. Discussion

4.1. current practices and progress.

The number of published articles regarding indicators used in safety management practices in the utility industries has increased in recent years, from 2000 until 2021. The increasing number of published papers show that there has been a high awareness that safety lagging indicators, such as injury rates, have limited use in preventing future injuries. Thus, proactive measures through predictive measurements can provide early warnings of potential hazards to improve future performance [ 7 , 8 , 65 ]. For this reason, there is a need to proactively measure and identify the adequacy of safety management practices at an early stage to predict any deterioration in safety management system implementation, thus, contributing to positive safety outcomes.

Most papers were published in the United Arab Emirates, Iran, and Australia. The United Arab Emirates and Iran published papers focused on the gas utility industry, the primary players in the oil and gas industries [ 47 , 66 ]. As a leading country in the oil and gas industry, it is essential to ensure supply and productivity are guaranteed in occupational safety and health to avoid disasters or accidents that will disrupt the production process. Thus, it is vital to ensure the effectiveness of a safety and health management system that can eliminate injuries, adverse health impacts, and damage at the operational level, thus, improving the productivity of workers and their physical and mental well-being and workplace satisfaction [ 40 ], thus, showing the importance of proactive indicators in reducing unwanted events in the workplace through the implementation of safety management practices as proactive efforts.

The majority of the selected articles were studied to identify and develop driven leading indicators. These indicators are essential in assessing and improving the functioning of sociotechnical systems as part of an organizational safety management process [ 17 ] that contains safety antecedents as input into safety efforts and measures of any actions to produce the output that can directly or indirectly influence safety performance [ 52 , 60 ]. Leading indicators contain input and activity elements that are critical for safety decisions in the organization to achieve safety objectives [ 18 , 19 , 30 , 52 ]. Thus, safety management practices are considered the antecedent of the safety climate for organizations to improve safety performance. The extensive distribution of studies in the systematic literature review of safety management systems among utility industries indicates that the development phase of leading indicators is very encouraging. This phase involves the identification, development, and measurement of leading indicators. Thus, leading indicators are well defined in ensuring that safety management systems are maintained comprehensively through activities conducted in an organization.

Another finding was that most of the reviewed papers studied subjective indicators in measuring leading indicators. The subjective data are often obtained through surveys or questionnaires with advantages in collecting relative measurements and perceptions, such as quality. The main drawback is that these indicators are difficult and expensive to manage, even when datasets are obtained, monitored, and maintained in the same way as organizations maintain objective performance data [ 18 , 67 ]. Nevertheless, subjective measurement was often used in measuring the level of safety in an organization in the research [ 68 , 69 , 70 , 71 , 72 , 73 ]. Subjective measurement is based on perceptions towards activities implemented in studying a programme’s effectiveness in reaching workers as a target group in organizations. It shows that subjective measurement through a perception measurement scale is the appropriate method for collecting proactive indicators that measure the quality of activity implementation.

Management commitment is an internal factor in an organization, related to self-regulation that significantly influences the safety behaviour of workers and is essential for the success of safety management systems [ 48 , 74 , 75 ]. This study found that safety management practices focused on management commitment practices as the leading indicators for measuring safety levels in organizations, showing that an effective safety management system relies on top management developing company policies and setting resources. It supported stable, consistent, and fair OSH leadership in management commitment, which impacted OSH management system effectiveness to the greatest extent [ 49 , 76 ]. Low accident rates are also associated with administration, showing inspirational motivation by fostering safety goals, promoting safety, and motivating workers to engage in safety behaviours [ 74 , 77 , 78 , 79 , 80 ]. The study found that only five articles discuss transformational leadership. Transformational leaders are the key element to high-safety performance that influences worker’s safety behaviours and safety climate [ 38 , 48 , 53 , 59 , 60 ]. Thus, management leadership plays an essential role in influencing employee safety performance through safety involvement. In turn, improving safety behaviours will reduce accidents, injuries, and absenteeism. Top management has the final say in decision making, as consultation with workers is only supplementary in getting more information towards making the final decision. Authentic OSH leadership always puts safety as a priority and core value in organizations to ensure the safety of workers in the workplace.

Observant leading indicators are another leading indicator related to safety management practices through thematic analysis. These indicators are defined as indicators that provide insights into dynamic systems in the form of questions regarding the activities taking place, the capabilities, skills, and motivations of personnel, routines, and practices, as well as the potential of the organization for safety [ 17 ], in which individual behaviour is an important performance metric to measure and observe the effectiveness of safety activities implemented by organizations [ 52 , 74 , 81 ]. Most review papers found that safety management practices positively predict safety compliance and safety participation, showing observant leading indicators are important indicators in reducing occupational injuries and accidents.

Lagging indicators are the results of activities or events that aim to reduce accidents and injuries through safety efforts within the organization [ 17 , 52 ]. Safety outcomes are measurable and clear to the organization and they include negative performance indicators, such as the number or frequency of accidents at work, the cost of compensation to workers, the number of days not worked due to occupational accidents, and the number of occupational diseases [ 30 , 60 ]. The most studied lagging indicators in the selected papers were occupational accidents, followed by occupational accident fatalities, lost time injuries, and near misses. Accidents result from numerous factors, and individual unsafe behaviour is one of the most direct trigger factors. The severity of an accident is measured by its effect on injuries and property damage. Briefly, an incident analysis will show something about accidents, such as weaknesses in OSH programmes and activities.

The studies found that researchers from the selected papers focus on practical research. It has been shown that seven leading indicators in driven leading indicators were based on a standard, such as ANSI Z10, ISO 45001, and Occupational Safety and Health Administrator guidelines. The safety outcomes proposed by researchers are also in line with the standards and regulations in a particular country, which have also been used by ILO in capturing data regarding occupational safety and health issues, thus, showing that current research is based on practical and industrial-oriented factors.

4.2. Limitations and Challenges

Based on the current thematic analysis results, the number of selected review papers on safety management practices in the utility business is still modest and has only increased in recent years. Most papers are published in the gas utility field rather than other utility industries, such as water utilities, electrical or power utilities, and sanitary services. Additionally, most of the papers were removed in the screening process due to the research’s focus mainly on the construction industry, thus, indicating a gap in the research implemented in these industries that needs to be investigated. Since OSH reporting procedures vary by industry and workplace, additional research is required to identify OSH performance indicators that are more auspicious and can assist firms in implementing them [ 16 , 30 ]. Future research is needed in a broader range of utility industries, which may have more informal OSH standards and procedures by adapting or benchmarking tools across different safety management activities.

Compared to subjective measurements, passive and objective indicators were less studied in measuring safety management practices. Passive indicators designate the likelihood of safety performance being achieved, usually through binary feedback, instead of objective indicators that measure the frequency and subjective indicators that measure the quality of execution that may change over time [ 26 , 82 ]. The main reason objective indicators were less studied could be that the quality of existing systems or activities may not be measurable through objective measurements. Furthermore, objective indicators are likely to be manipulated and distorted to improve the appearance of the organization [ 18 ]. However, future research should measure both objective indicators for key performance indicators of activities implemented and subjective indicators for the quality of the activities. Along with that, indicator selection should be based on specific, measurable, accountable, reasonable, and timely criteria.

Practices for hazard identification and assessment were under-represented in the publications selected for this study. This practice is an initial step in risk management to identify the causes and mechanisms of undesirable events by assessing the likelihood of the event and the severity caused by the event. Therefore, systematic planning in eliminating or reducing safety hazards is essential in safety management to improve the safety climate [ 83 , 84 , 85 ], depending on proactive, ongoing processes and an assessment of hazard elements [ 86 ]. Inadequate hazard identification is one of the key contributing causes of fatal workplace accidents, affecting corporate values, such as ethics and profit. Hazard should be identified and controlled before work is carried out to ensure safety issues are under control but usually take a long time to be eliminated or controlled, thus, increasing the probability of accidents [ 87 , 88 ]. Accordingly, it is crucial to integrate risk management practices into the safety management system to increase the effectiveness of implementing this system in reducing accidents. Integrating risk management practices into safety management will also support the implementation and certification of current safety management systems, such as ISO 45001:2018, that emphasise preventive measures. However, this study has limitations in assessing hazard identification and control findings as it was an understudy in the selected papers. Mainly, risk management was studied in stand-alone research that separated from the safety management system. Future research should incorporate risk management as a crucial indicator to be monitored, essential in preventing occupational accidents and diseases.

Based on the research conducted, occupational accidents resulting in injuries received more interest in the selected papers. They were supported by Tsalis et al. [ 51 ], who found that most organizations provided more information about injury rates. However, attention should be given to all types of accidents, regardless of the degree of damage or loss, such as fatalities, occupational accidents, lost time, and near misses. Accidents that do not result in injury or damage to equipment and materials still need attention as they are signs of future accidents. Further, near miss reporting should be considered a lagging indicator, since luck is often the only difference between a near miss and a fatality [ 89 ]. Future studies should incorporate occupational accidents, fatal occupational accidents, lost time injuries, and near misses as safety outcomes. However, researchers should also focus on positive outcomes, such as productivity, monetary increase, and profit increase due to high safety levels in organizations. Thus, it will encourage management to further implement safety and health in the workplace.

This study found an inadequate correlation between driven leading indicators, observant leading indicators, and lagging indicators. It can be seen through the progress of research, which shows that studies focused on developing indicators that included defining, developing, and measuring the indicators. On the contrary, the analysis focused on progressing the indicators that study the relationship between driven leading indicators and observant leading indicators or when lagging indicators are small in number. In meta-analysis research, proactive measurement through situations and individual difference factors, such as safety antecedents, were negatively related to safety outcomes through proximal antecedents and safety performance [ 60 ]. However, Jiang et al. (2010) found a lack of evidence on safety management practices as predictors and near misses’ relationships due to the probability of underreporting [ 59 ]. Thus, the correlation between leading indicators and safety outcomes is complicated [ 90 ]. Future studies should focus on validating the influence of leading indicators in safety management practices toward safety outcomes. Researchers should try to correlate leading indicators and lagging indicators (safety outcome) to better understand the implementation safety management systems in reducing safety and health issues at the workplace, thus, ensuring productivity is sustained.

Other limitations in this research were due to the focus of the study on leading indicators, mainly in the construction industry compared to the utility industry, thus, making the papers selected for review smaller in number. The study also found that research on leading indicators is limited in quality. Most was published in lower-rank journals with restricted access, making it challenging to review and choose these as selected papers. Most of the documents on leading and lagging indicators were mainly on the concept and theoretical aspects, lacking evidence in empirical analysis.

5. Conclusions

The present study reviewed 25 articles on indicators used in safety management practices in the utility industries, reflecting an understanding of current practices and progress. This study also revealed the potential use and the gaps in knowledge on the use of indicators in safety management practices, plus several subject areas that can be researched further. It was found that the number of studies on proactive measurement in the utility industries has increased in recent years. Most of the studies were conducted in the United Arab Emirates, Iran, and Australia. Furthermore, three main indicators that represented the use of indicators in safety management practices among utility industries were identified based on the systematic review performed. The most researched indicators were driven leading indicators, which were described as indicators that assess and improve the functioning of sociotechnical systems as part of organizational safety management. There was an imbalance in terms of the type of area researched for sectors in the utility industry. Most of the studies focused on gas and electrical utilities compared with water utilities and sanitary services. Furthermore, most of the research focused on management commitment as an essential element in safety management practices, thus, creating an imbalance in practices. The majority of the study focused on identifying, developing, and measuring leading indicators. These findings indicate plenty of opportunities for discovery and new research for OSH practitioners, authorities, and researchers to explore, in terms of the use of indicators to enhance safety management practices in the utility industry.

This systematic review paper confirms several limitations and gaps in the study of indicators used in safety management practices in the utility industries in recent years. Firstly, information on indicators used in safety management practices from other countries and sub-industries among utility industries is still lacking. Future research is needed in a broader range of utility industries, which may have more informal OSH standards and procedures by adapting or benchmarking indicators across different safety management practices. Further, there is still a lack of information on objective data measuring implementation instead of subjective data measuring perception. Thus, in future research, researchers may measure both objective indicators for key performance indicators of activities implemented and subjective indicators for the quality of the activities, which can change from time to time. Inadequate hazard identification and assessment practices in the utility industries were also reported in this study. As a result, researchers should incorporate risk management strategies into safety management systems in future research. Occupational accidents that emphasize injury were the most reported lagging indicators used as safety outcomes in this research. Thus, there is a need to include occupational accidents, fatalities, lost time injuries, and near misses as safety outcomes in future studies. Finally, the development phase of research, which includes identifying, developing, and measuring indicators, was dominant compared to the progressive phase on the indicator used in safety management practices. Next, it is recommended for future studies that researchers explore the relationship between driven leading indicators and observant leading indicators towards lagging indicators. Therefore, further broadening this basic understanding through the integration of diverse research findings may assist the concerned parties in enhancing safety levels, such as OSH practitioners, authorities, and researchers, in developing strategies that align with the needs, abilities, and interests of safety.

Acknowledgments

The authors would like to thank Universiti Kebangsaan Malaysia for providing funding for this study. The authors also want to thank ReadByRose (Rose Norman) for delivering excellent proofreading service for this paper.

Funding Statement

This study has been supported by Universiti Kebangsaan Malaysia through research grant (SK-2020-011 and SK-2021-011).

Author Contributions

Conceptualization (coordinated and reviewed), K.A. and A.A.; Designed, analysed, and drafted the manuscript, M.X.M.A.; Screening and reviewing papers, M.A.A. and M.K.; Evaluating and selecting the quality of review papers, M.B.C. and M.A.S.; review and editing, K.A., M.M. and M.N.A.; visualization, I.L., M.M. and M.N.A.; supervision, K.A. and A.A.; project administration, K.A.; funding acquisition, K.A. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Safety Management Systems (2003)

Chapter: chapter two - literature review.

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5 CHAPTER TWO LITERATURE REVIEW NATIONAL STUDIES Four national studies are addressed in this section. They are Safety Management System: A National Status (3), Safety Management System Update Survey (4), Transporta- tion Infrastructure: States’ Implementation of Transportation Management Systems (5), and a survey conducted as part of NCHRP Project 17-18(05), Integrated Management Process to Reduce Highway Injuries and Fatalities Statewide (6). A Look at the National Status The Safety Management System: A National Status (3) was conducted in cooperation with TRB Committee A3B01, Transportation Safety Management. The purpose of the survey was to gain a national perspective on progress to- ward the development and implementation of each state’s SMS. Fifty-one surveys, including one from the District of Columbia, were returned between June and August 1995. The following conclusions were drawn from the survey: • All states plus the District of Columbia had identified a focal point for the SMS, with 85% found in a DOT or equivalent department. • Most states were using an administrative structure com- posed of a coordinating or executive committee and subcommittees representing a broad-based group of in- dividuals from a variety of agencies and organizations. • More than 80% of the states had developed a mission statement, goals, or major objectives to guide the SMS implementation process. • Sustained commitment to the SMS was seen as struggling in some states, whereas others were using memorandums of agreement or understanding to help sustain support from the various safety partners. • States were using a variety of methods to share informa- tion about the SMS initiative, including computer-based electronic mail, the Internet, workshops, safety program resource books, brochures, and newsletters. • To help deal with the staffing shortage created by the extra work involved in the SMS, 32 states elected to hire consultants. These consultants were asked pri- marily to help with the development of the work plan, resource book, surveys, and workshops. • The primary funding source for the SMS develop- ment was a combination of federal and state money. • Positive outcomes from the SMS process were re- ported by 49 (96%) of the state officials who devel- oped and implemented their systems. • Major barriers to the development and implementa- tion of the SMS were funding, adequate staff, juris- dictional battles, data issues (availability, accuracy, timeliness, jurisdiction, and technical problems be- tween agencies that control data collection and analy- sis), and sustained commitment to the initiative. Appendix A features a summary of the state reports on SMS program elements. A Look at Implementation In 1997, the U.S. General Accounting Office released a Report to Congressional Committees entitled the Transpor- tation Infrastructure: States’ Implementation of Transpor- tation Management Systems (5). The report identified • The status of the states’ development and imple- mentation of the six systems for managing highway pavement, bridges, highway safety, traffic conges- tion, public transportation facilities and equipment, and intermodal transportation facilities and sys- tems; • How the states expect to use the systems; and • The factors that have facilitated or hindered the de- velopment and implementation of the systems. General information about the development and imple- mentation of the systems was collected in the 50 states, the District of Columbia, and Puerto Rico. More detailed in- formation was collected from seven states (Maryland, Michigan, Montana, New York, North Carolina, Oregon, and Texas) selected for case studies because of their ex- periences in developing, implementing, and using the sys- tems. Additional but less comprehensive information was collected from Colorado, Florida, and Missouri. General findings are as follows: • As of September 1996, approximately one-half of the states were moving forward with all six transporta- tion management systems, even though they were no longer mandatory. The remaining states were devel- oping or implementing at least three of the systems. • All states were implementing the pavement manage- ment system, and nearly all states were implementing the bridge, safety, and congestion management systems. • Nationwide, more than half of the states plan to inte- grate the management systems. States recognize that

6 to obtain the optimum use from the systems, they need to be integrated. • Mandating of the systems had several outcomes, in- cluding providing a catalyst to develop and imple- ment the new systems and to obtain high-level sup- port and top-priority status. • Removal of the mandate has had various results. Several states are continuing their efforts because they view the systems as beneficial to the decision- making process, whereas others have lessened sup- port for further developing certain systems. • Some states reported that the failure to issue a clear and timely rule on management systems following the 1991 mandate had caused difficulties in imple- menting the public transportation, congestion, and in- termodal management systems. The following points summarize the General Account- ing Office report conclusions specific to the status of SMS development and implementation: • As of September 1996, 48 states, the District of Co- lumbia, and Puerto Rico were developing SMSs. • South Carolina and Ohio reported that they were not currently implementing their systems. • At least 30 states included all public roads or all state-maintained roads in their systems. Two states were including only National Highway System roads. • The composition of an SMS takes many forms— from an administrative structure composed of a coor- dinating or executive committee and subcommittees representing many agencies to a large database that merges safety information from a number of sources. A Look at Updates In 2000, a second national study, Safety Management Sys- tem Update Survey (4), was undertaken in conjunction with the TRB A3B01 Transportation Safety Management Com- mittee. The purpose of this study was to collect informa- tion to update the status of each state’s highway SMS. Be- cause Section 205 of the National Highway System Designation Act of 1995 made SMSs optional, implemen- tation status was of interest. Survey data were collected in late 2000, with follow-up contacts made in November 2001 to confirm the status of responses. Forty-nine states and the District of Columbia submitted surveys. The study was not published, but the results are worthy of review. The following points summa- rize these results: • Twenty-six states indicated having both an interdisci- plinary committee and an SMS. States indicating that they had only an SMS or an interdisciplinary com- mittee numbered six and eight, respectively. Ten states reported having no SMS or interdisciplinary committee. • SMSs were found to be active at both the state and local levels in 15 states. • Of the 34 states having coordinating committees, 25 were established as a result of the ISTEA mandate, and 30 meet at least three times each year. • Seventy-four percent of the coordinating committees had mission statements, 70% had major goals, and 68% had strategies or objectives. Eighteen states used a subcommittee structure. • Law enforcement, engineers, state highway safety of- fice representatives, health professionals, and state agencies were represented on 75% of the coordinat- ing committees. Community volunteers and construc- tion industry representatives were least likely to par- ticipate on these committees. • Major activities undertaken by the coordinating committees included development of a strategic plan, review of state safety data, formulation of safety leg- islation, and planning of state safety conferences. • Improved communication and coordination between safety agencies and organizations, as well as joint legislative efforts, were the most frequent positive outcomes noted by the respondents. • Resources, jurisdictional issues, coordination, politi- cal factors, time, and leadership barriers have im- peded the effectiveness of the states’ SMS and coor- dinating committees. • Key elements identified as maintaining the momen- tum of a coordinating committee and/or SMS were commitment and buy-in from key agency leadership, regular meetings, development of a strategic action plan, a mission statement, and activities that commit- tees would cite as victories. • Of those states not having an SMS or coordinating committee, 80% reported that the regulation’s change from required to optional was the major reason that these efforts were abandoned. Appendix B features a summary of selected responses from this survey. A Look at Integrated Management A third national study, NCHRP Project 17-18(05), Inte- grated Management Process to Reduce Highway Injuries and Fatalities Statewide, was undertaken by iTRANS in 2001 (6). The study questionnaire collected information in the categories that make up an integrated management sys- tem, including the mission statement, safety management, safety champions, funding, safety initiatives, resource allo- cation decision making, legislation, analysis, and data- bases. With 40 responses, a picture was developed that

7 shows the importance of these elements in the various state management processes. The existence of a safety champion (an individual and not a group) was recognized as “very important.” Follow- ing the implementation of the process, states cited improve- ments observed, which included attaining greater cooperation between agencies; serving as a focal point for safety advo- cates; enhancing communication among enforcement, en- gineering, education, and emergency services; stimulating safety concerns across multiple agencies; and serving as a catalyst for devising new safety initiatives. When asked about the importance of factors that trigger new safety initiatives, states identified federal and state funding and legislation as the main factors. A high-profile event, collision, or crash (e.g., high fatality school bus crash), a program being promoted by a high-profile indi- vidual, and successful implementation of the initiative in other states, were also considered of importance. Quantitative analysis received the highest rating in de- ciding which safety countermeasures to apply. Internal ex- pert opinion was rated more important than the opinion of external experts. Internal safety management processes fell slightly below “important” in the rating. The iTRANS questionnaire asked the additional ques- tion, “Once issues have been identified, could you describe briefly the decision making process as to how funding is allocated to engineering, enforcement, education, or emer- gency medical services with regard to safety initiatives?” Iowa and Louisiana had an SMS component in their re- sponses, whereas Maine, Indiana, Michigan, Nebraska, New York, and Washington mentioned a coalition, partner- ship, team, or collaboration among various groups in their decision-making process. The responses are presented in Appendix C. On average, the benefit of a software package that ac- cepts standardized input for safety analysis was not per- ceived to be much different than documentation of analyti- cal methods for safety analysis, in regard to the question about the benefit of various resources to safety analysis. Overall, the respondents rated the completeness of their da- tabases as “good.” The main components of the Integrated Safety Man- agement System (ISMSystem) developed in conjunction with NCHRP 17-18(05) are leadership, mission and vision, organizational structure, integrated safety management process, resources, and tools and related documentation. Figure 1 depicts the relationship between the different components and conveys the order of development in- volved in building an ISMSystem. The ISMSystem works within and depends on an external environment that in- Exter Mission & Vision Integrated Safety Management Process Leadership Tools Organizational Structure nal Environment Legislation & Funding Resources FIGURE 1 Components of the Integrated Safety Management System (ISMSystem). [Source: iTRANS, NCHRP Report 501: Integrating Management Process to Reduce Highway Injuries and Fatalities Statewide (6).] cludes legislation and funding. Fundamental to the ISMSystem is an interdisciplinary organizational structure, formed through a coalition of highway safety agencies, that allocates different responsibilities to specific groups of people who must work together to maximize safety. Other personnel resources include an operations man- ager (for day-to-day management), task teams that develop strategies and action plans for implementation, and the risk analysis and evaluation group to undertake analyses of highway data to support the decision-making process. The tools necessary to implement the system include the methodologies for identifying crash concerns and evaluating strategies, impact and process performance evaluation meth- ods, optimization approaches, best practice suggestions for maintaining databases, and recommendations for improv- ing interagency coordination and communication (6). NATIONAL REPORTS Several national reports addressing SMSs are available. They include workshop proceedings, good practice re- views, and study tour summaries. This section summarizes several of these key reports. Management Approach to Highway Safety: A Compilation of Good Practices The FHWA developed the initial guidance document in January 1991, with a subsequent revision in April 1991,

8 and a final document completed in December 1991 (7). The purpose was to provide general guidance for develop- ing and implementing a management approach to high- way safety. It outlined eight key elements in the man- agement approach to highway safety to ensure that processes and programs are effectively coordinated and carried out. • Goals—Long- and short-term highway safety goals establish a means for resource allocation. • Accountability—This is an essential management tool for tracking implementation of highway plans and comparing progress with established goals. • Training—Personnel with the knowledge, skills, and abilities to carry out identified responsibilities are es- sential. • Monitoring and evaluation—The design, operation, maintenance, and process reviews determine whether or not the safety processes and improvements are having the desired effects. • Integrated database—An analysis of timely and accu- rate data is necessary to identify safety problems and to select and implement effective accident counter- measures. • Safety analysis—These analyses include accident and operational investigations. • Coordination—Intraagency and interagency coordi- nation will enhance the implementation and man- agement of a comprehensive highway plan. • Technology and information exchange—Proactive research and technology and information exchange provide many opportunities for addressing changes and improving safety. Safety Management System Workshop Proceedings: Managing Mobility Safely From September 17 to 19, 1991, a Safety Management System Workshop was held in Williamsburg, Virginia. The purpose of the workshop was to enable participants to pro- vide guidance for the development and implementation re- quirements of an SMS. The workshop also focused on the experiences of Oregon, Pennsylvania, and Washington in working with the draft Management Approach to Highway Safety in the development of their respective SMSs. The resulting report, Safety Management System Workshop Proceedings: Managing Mobility Safely (8), outlined sev- eral key points resulting from this effort. • The Management Approach to Highway Safety— Good Practices Guide (with minor changes) is a good foundation on which to build an SMS. • Safety management is a workable and useful concept, but it should be implemented not as a new stand- alone system, but as one that integrates safety deci- sions into a state’s overall highway management process. • SMS requirements must be flexible enough to con- form to various organizational structures of the states; they must also be prescriptive and specific enough to ensure safety objectives are achieved. • Coordination must be strongly advocated and prac- ticed within the highway agency and with other agencies and groups having the common goal to im- prove highway safety. Highway agencies need to en- sure this coordination is carried out. Safety Management System: Implementation Workshop Proceedings The FHWA and the National Highway Traffic Safety Ad- ministration hosted a national Safety Management System Workshop on January 20 and 21, 1994. The workshop ad- dressed the issue of what can be done within the limits of the law and the regulations to effectively implement an SMS. Those persons designated as the state’s SMS focal points were invited to attend the workshop. Representa- tives from select metropolitan planning organizations, counties, cities, other federal agencies, highway-user advo- cacy groups, police, emergency medical groups, and motor vehicle administrators also participated. A total of 258 in- dividuals attended the workshop. The goal of the workshop was to have all jurisdictions start in the same direction. Therefore, it addressed what can be done within the limits of the law and the regulations to effectively implement an SMS. There seemed to be a general consensus on the follow- ing items (9): • The SMS was a process for managing highway safety activities, not a plan itself. • The SMS process would not be easy, but it would be worthwhile. • Limited resources are a big problem. • Each SMS would be state-specific, responding to the resources available and the needs in each state. • Proposed guidelines should remain just that and not become mandates. • A uniform system of data records and electronic for- matting was seen as necessary and was proposed. • Data within a state and between states should be han- dled uniformly. • The SMS is a safety effort and not a data collection— only a program. A copy of the draft of Safety Management Systems: Good Practices for Development and Implementation (10) was distributed and reviewed.

9 FHWA Study Tour for Highway Safety Management Practices in Japan, Australia, and New Zealand A U.S. study team examined safety management practices in Japan, Australia, and New Zealand. The visit, conducted from June 10 to June 26, 1994, had as its purpose “ . . . to assess Safety Management Systems (SMS) in the three countries, their programs or components and technolo- gies of SMS activities including people, vehicles, and roads; compile the information; and identify effective strategies for implementation in the United States of America” (2). Japan was investing in information technology to achieve quantum gains in highway safety, whereas Austra- lia and New Zealand used a networking method to include relevant safety stakeholders in the process of decision making to develop and implement highway safety pro- grams, as well as a safety audit process. The report concluded that the major transferable safety management finding of the tour was the management phi- losophy observed in all three countries, namely that of networking and building consensus among stakeholders in the search for solutions to traffic safety problems (2). Safety Management Systems: Good Practices for Development and Implementation This document evolved from a draft document entitled Safety Management Systems: Good Practices for Devel- opment and Implementation (10) produced by the FHWA in November 1993. A subsequent revision was done in Au- gust of 1994, with this expanded document released in May 1996. The purpose of the document was to provide general guidance to managers and safety specialists on the formu- lation of an SMS. The guidance is flexible, recognizing that the development and implementation of an SMS is an evolving process. The document emphasized that because each state is unique, there is no one correct way to develop and imple- ment an SMS. However, the following five major areas should be considered: 1. Coordinating and integrating broad-based high- way safety programs; 2. Developing processes and procedures to ensure that the major safety problems are identified and addressed; 3. Ensuring early consideration of safety in all highway transportation programs and projects; 4. Identifying safety needs of special user groups; and 5. Routinely maintaining and upgrading safety hardware, highway elements, and operational fea- tures. It was further suggested that within each of these five major areas, eight elements should be incorporated, as ap- propriate. 1. Establishment of short- and long-term highway safety goals to address both existing and antici- pated safety problems. 2. Establishment of accountability by identifying and defining the safety responsibilities of units and positions. 3. Recognition of institutional and organizational initiatives through identification of disciplines in- volved in highway safety at the state and local levels; assessment of multiagency responsibilities and accountability; and establishment of coordi- nation, cooperation, and communication mecha- nisms. 4. Collection, maintenance, and dissemination of data necessary for identifying problems and de- termining improvement needs. 5. Analysis of available data, multidisciplinary and operational investigations, and evaluations of ex- isting conditions and current standards to assess highway safety needs, select countermeasures, and set priorities. 6. Evaluation of the effectiveness of activities that relate to highway safety performance, to guide fu- ture decisions. 7. Development and implementation of public in- formation and education activities to educate and inform the public about safety needs, programs, and countermeasures that affect safety on the na- tion’s highways. 8. Identification of skills, resources, and current and future training needs to implement the state’s ac- tivities and programs affecting highway safety; development of a program to carry out necessary training; and development of methods for moni- toring and disseminating new technology and in- corporating effective results (10). Continuous improvement in reducing the number and severity of crashes, as well as the medical and financial consequences is the primary goal of the SMS. The agencies should have an internal quality control system, or a self- assessment process, that ensures continuous improvement and compliance with the goals of the SMS. The self- assessment should not only measure the level of effort, but what is actually being accomplished as a result of that ef- fort (10).

10 • Builds on two basic parts—a collaborative process represented by a standing local agency SMS committee and an eight-element decision-making process. STATE AND LOCAL GUIDES Two publications are discussed in this section: Local Agency Safety Management System (11), developed for lo- cal agencies by the Washington State DOT and Toolbox of Highway Safety Strategies (12), sponsored by the Iowa High- way Safety Management System Coordinating Committee. The eight elements of a local agency SMS are outlined in Table 1. TABLE 1 SUMMARY OF EIGHT ELEMENTS OF SAFETY Local Agency Safety Management System M ANAGEMENT SYSTEMS Element Description Local policy Establishes policy and responsibilities. Data collection Provides information to support decisions and monitors their results. Data analysis Converts field data into usable information to assist decision makers. System output Presents the analyzed and processed data in a format that is usable to decision makers. Project prioritizing and program development Includes final prioritizing of transportation safety needs, selecting cost-effective solutions, and adopting safety policies, standards, procedures, and programs. Program implementation Carries out funded projects resulting in safety enhancements and educational, enforcement, and emergency services programs. Performance monitoring Measures and analyzes results of transportation decisions, countermeasures, and programs for future work program development. Annual safety reporting Annual report of safety system work efforts, expenditures, and system performance. The purpose of this document is to provide Washington’s local agencies with a resource for implementing the Wash- ington State SMS (11). The document is divided into three sections: Overview—Your Safety Management System; The SMS Process: How an SMS Works; and Tools to Get Your SMS Started. The primary goal of the local agency SMS is to prevent and reduce the number and severity of roadway collisions, transportation-related injuries, and property damage (11) (Figure 2). The local agency SMS does the following: • Provides a process for obtaining objective informa- tion that helps agencies identify and prioritize safety needs and choose cost-effective strategies to improve the safety of their transportation systems; • Involves the roadway, human, and vehicle elements; • Identifies methods for addressing safety issues in the engineering, education, enforcement, and emergency service areas; and Toolbox of Highway Safety Strategies The Iowa initiative is not a “how-to” manual for develop- ing an SMS, but a highway safety resource product of the Iowa SMS Coordinating Committee members and friends. Adopting most of the content areas modeled in the AASHTO Strategic Highway Safety Plan, the Toolbox of Highway Safety Strategies was developed as Iowa’s own compilation of problem definitions, data, and potential so- lutions. The purpose of the toolbox is to assist and inspire Iowa’s highway safety professionals, policymakers, and citizens in implementing ways to improve highway safety, thereby reducing death, injury, and economic loss on Iowa’s roadway system (12) (Figure 3). The toolbox contains the following materials: • Toolbox notebook contents—The Iowa SMS Toolbox of Highway Safety Strategies (300+ pages in a 3- hole-punched format); FIGURE 2 Local Agency Safety Management System (11). (Source: Washington State DOT, 1998.)

11 • Law, policy, and enforcement changes; • Education and public awareness to influence driver behavior; • Roadway design changes systemwide or in high- crash-incident locations/segments; • Technology applied to assist drivers or enhance roadways; • Availability and delivery of emergency and medical services; • Data collection and analysis; and • Planning and management. The document is organized into three parts: • Potential strategies for highway safety improvement, organized into chapters on drivers, other users, high- ways, emergency response, and planning and man- agement; • Resources, including primary contributors and key organizations; and • Appendixes providing graphs and trends of Iowa crash data and summary findings of the Iowa SMS Public Opinion Survey. FIGURE 3 Toolbox of Highway Safety Strategies (12). (Source: Iowa Highway Safety Management System, Iowa DOT 2002.) In addition to the printed and CD-ROM versions, the Iowa SMS Toolbox of Highway Safety Strategies and “Highway Safety Strategies for Iowa—Executive Sum- mary of the Iowa SMS Toolbox” are located on the SMS website at www.IowaSMS.org. • Summary booklet—“Highway Safety Strategies for Iowa—Executive Summary of the Iowa SMS Tool- box” (20 pages); • Endorsement—Statement of Iowa’s Commitment to Highway Safety; • CD-ROM—Electronic versions of the Iowa SMS Toolbox of Highway Safety Strategies and “Highway Safety Strategies for Iowa—Executive Summary of the Iowa SMS Toolbox”; and SUMMARY OF THE LITERATURE REVIEW As was discussed, the principles of an SMS process have their foundation in both guides and guidelines focusing on the enhancement and management of highway safety, as well as federal legislation. National studies revealed that the SMS process has brought about many positive out- comes, particularly the enhancement of coordination, co- operation, and communication among key highway safety stakeholders. Successful SMS state initiatives continue to thrive in the absence of a legislative mandate. • SMS “tool” with interchangeable screwdriver heads. The Iowa SMS toolbox reinforces the safety goals, poli- cies, and actions of highway safety agencies and practitio- ners by identifying many alternative actions that could be considered for implementation over the next 10 to 20 years. It also identifies some specific implementation steps that could be completed sooner (12). The document offers a range of potential solutions, including the following:

TRB’s National Cooperative Highway Research Program (NCHRP) Synthesis Report 322: Safety Management Systems (SMS) provides an overview of current transportation agency practices, recent literature findings, and reviews of two model state SMS initiatives. According to the report, benefits derived from the SMS process are increased coordination, cooperation, and communication among state agencies and improvements to data analysis and collection procedures, as well as collaborative strategic plans.

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Please note you do not have access to teaching notes, a systematic review of construction safety research: quantitative and qualitative content analysis approach.

Built Environment Project and Asset Management

ISSN : 2044-124X

Article publication date: 14 October 2021

Issue publication date: 8 February 2022

Construction safety management (CSM) has been intensively researched in the last four decades but hitherto mostly aimed at understanding root causes of accidents, recommending preventive measures and evaluating their implications. However, a systematic effort to present a comprehensive picture of construction safety research is hardly witnessed. Therefore, the study aims to investigate construction safety research contributors, ontologies, themes, evolution, emerging trends and future directions using quantitative and qualitative content analysis.

Design/methodology/approach

A total of 877 journal articles were extracted using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and Scopus literature database and were analyzed using VOSviewer and Nvivo tools to present a comprehensive picture of the CSM body of knowledge.

The study observed rapid growth in construction safety research with contributions from various countries, organizations and researchers. This study identified 3 research levels, 8 project phases, 10 project types, 6 research instruments and 19 research data sources along with their usage in the research domain. Further, the study identified 13 emerging research themes, 4 emerging research trends and an observed paradigm shift from reactive to proactive CSM approach.

Research limitations/implications

The comprehensive study on the emerging themes and findings on proactive CSM has strategic implications to practice to incorporate safety. The identified future directions can assist researchers in bridging the existing gaps and strengthening emerging research trends.

Originality/value

The study presents a comprehensive picture of the CSM body of knowledge using the content analysis approach that was absent in past literature and opened future research avenues.

• Construction safety
• Safety management
• Literature review
• Content analysis

Acknowledgements

Conflicts of interest: The authors declare no conflicts of interest.

Bhagwat, K. and Delhi, V.S.K. (2022), "A systematic review of construction safety research: quantitative and qualitative content analysis approach", Built Environment Project and Asset Management , Vol. 12 No. 2, pp. 243-261. https://doi.org/10.1108/BEPAM-04-2021-0068

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Literatures review: Analysis of Safety Management System Standards

Related Papers

Proceedings of the XXII Edition Summer School “Francesco Turco” Industrial Systems Engineering

Antonio Latora

An appropriate approach to manage Occupational Health and Safety (OHS) is to develop management systems, which can integrate safety into the ordinary and overall management of the company. The Safety Management Systems (SMS) represents now the main instrument adopted in medium to large-sized companies, in order to minimize the occurrence of accidents and occupational diseases. The auditing phase allows the feedback necessary to reinforce, maintain and develop the ability to reduce risks and to ensure efficiency and effectiveness of the SMS. In addition, the correct operation of the SMS requires an information flow across the development, implementation and maintenance stages and the auditing/reviewing stage, in order to manage and control safety performances and to highlight any deviation from the safety improvement program. The aim of the research is to assess the capability of the OHS management system adopted in a medium enterprise operating in the industrial sector of soft drinks bottling. The current SMS complies with OHSAS 18001 standard requirements, but its structure is so singular that external auditors repeatedly challenged its effectiveness. The critical aspect is the assignment of priorities to safety interventions that is currently based on corrective factors applied to the medium risk level of each risk category. A multi-criteria decision process based on Analytic Hierarchy Process (AHP) was proposed to the company by using both the traditional AHP method and a hybrid model based on Value-AHP, which is easier to understand and to apply in the company safety management routine. A three levels hierarchy was identified by considering the priority of interventions as the general objective of the assessment, four criteria for the accounting policies and eight macro-alternatives of risk categories. The result is an integrated management system able to track all risk categories, efficiently addressing the safety improvement program.

Journal of Safety, Health, and Environmental Research

Health and safety management system (HSMS) document reviews show occupational health and safety policies as a primary system element. One way that companies operationalize tasks and communicate expectations to their employees is through their health and safety policies. As a result, policies should be visible and clearly promote desired practices. However, limited research exists on the quantity and scope of health and safety practices within company policies. In response, this study analyzed the publicly available health and safety policies of 26 mining companies to determine the quantity of health and safety practices that mining companies encourage in relation to the plan-do-check-act cycle. A thematic content analysis of the policies identified elements and practices within the text. On average, companies communicated information on about seven elements (range 1 to 14, SD = 3.49) and discussed 15 practices (range 2–34, SD = 9.13). The elements in which companies highlighted the most practices were risk management, emergency management, leadership development, and occupational health. A discussion of the policy trends shows areas that mine sites can improve upon within their plan-do-check-act cycle, in addition to encouraging the use of both leading and lagging indicators when checking and acting to manage health and safety performance.

Journal of Chemical Health and Safety

Charles Geraci

Rakesh Maharaj

In today’s environment, where financial pressures are constraining businesses worldwide, it is vital to challenge the corresponding increase in occupational risk. The focused role of the safety professional in the face of this ubiquitous economic downturn is now more important and challenging than ever. Business Managers will be scathing of business cases for safety programmes where their basis is anecdotal and corresponding investment merely for worker protection may be considered unnecessary. To overcome such perceptions, the safety professional’s ability to demonstrate a tangible relationship between improved safety and business performance is critical. Conventional arguments that present safety as a function of loss control must be challenged. Many researchers have been grappling with this since the mid 1990s according to Veltri et al (2007). Contributing to this body of knowledge, by evaluating the principles of applied systems thinking, this paper contends that the art and science involved in creating a contributory relationship between safety performance and business performance is no longer elusive.

Ikhwan Muhammad

Complex arguments continue to be articulated regarding the theoretical foundation of health and safety management system (HSMS) performance measurement. The culmination of these efforts has begun to enhance a collective understanding. Despite this enhanced theoretical understanding, however, there are still continuing debates and little consensus. The goal of the current research effort was to empirically explore common methods to HSMS performance measurement in mining organizations. The purpose was to determine if value and insight could be added into the ongoing approaches of the best ways to engage in health and safety performance measurement. Nine site-level health and safety management professionals were provided with 133 practices corresponding to 20 HSMS elements, each fitting into the plan, do, check, act phases common to most HSMS. Participants were asked to supply detailed information as to how they (1) assess the performance of each practice in their organization, or (2) would assess each practice if it were an identified strategic imperative. Qualitative content analysis indicated that the approximately 1200 responses provided could be described and categorized into interventions, organizational performance, and worker performance. A discussion of how these categories relate to existing indicator frameworks is provided. The analysis also revealed divergence in two important measurement issues; (1) quantitative vs qualitative measurement and reporting; and (2) the primary use of objective or subjective metrics. In lieu of these findings we ultimately recommend a balanced measurement and reporting approach within the three metric categories and conclude with suggestions for future research. Published by Elsevier Ltd.

Syea Ghazaly

Safety Science

Peter Hasle

Emily Haas , cassandra hoebbel

Research continues to investigate barriers to managing occupational health and safety behaviors among the workforce. Recent literature argues that (1) there is a lack of consistent, multilevel communication and application of health and safety practices, and (2) social scientific methods are absent when determining how to manage injury prevention in the workplace. In response, the current study developed and tested a multilevel intervention case study at two industrial mineral mines to help managers and workers communicate about and reduce respirable silica dust exposures at their mine sites. A dust assessment technology, the Helmet-CAM, was used to identify and encourage communication about potential problem areas and tasks on site that contributed to elevated exposures. The intervention involved pre-and post-assessment field visits, four weeks apart that included multiple forms of data collection from workers and managers. Results revealed that mine management can utilize dust assessment technology as a risk communication tool to prompt and communicate about healthier behaviors with their workforce. Additionally, when workers were debriefed with the Helmet-CAM data through the device software, the dust exposure data can help improve the knowledge and awareness of workers, empowering them to change subtle behaviors that could reduce future elevated exposures to respirable silica dust. This case study demonstrates that incorporating social scientific methods into the application of health and safety management strategies, such as behavioral modification and technology integration, can leverage managers' communication practices with workers, subsequently improving health and safety behaviors.

Journal of Loss Prevention in the Process Industries

The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers' risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers' risk avoidance could impact their near miss incidents on the job-a common precursor to lost-time incidents. Multiple regressions showed that as a miner's level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner's locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.

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Safety Management in Rail Transport: Theoretical Assumptions and Practical Implications

• First Online: 16 March 2022

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• Adam Jabłoński 6  

Part of the book series: Springer Series in Reliability Engineering ((RELIABILITY))

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Purpose : The aim of this chapter is to present the key assumptions for understanding rail transport safety management.

Design/Methodology/Approach : A critical literature review and theoretical and practical reflections aimed at explaining the complexity of technological rail transport management, have been adopted as the methodology for this chapter.

Findings : This chapter presents the interdisciplinary nature of rail transport safety issues.

Research limitations/Implications : The limitations of the analytical and evaluation study stem from the difficulties in identifying those issues which are of the utmost importance in fully explaining the role of safety management against the background of specialist issues and contextual safety determinants of railway systems.

Practical implications : The practical nature of the issues discussed has been demonstrated in the resultant nature of the proposed methods and approaches to attempts to clarify the selected aspects of shaping approaches to rail transport safety.

Originality/Value : The originality of the analytical and research intention is the comprehensive identification of various concepts such as the role of railway market operators, the specificity of the functioning of the railway system, the value chain in rail transport, the safe operation of railway vehicles and the place and role of safety management systems.

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Jabłoński, A. (2022). Safety Management in Rail Transport: Theoretical Assumptions and Practical Implications. In: Digital Safety in Railway Transport—Aspects of Management and Technology. Springer Series in Reliability Engineering. Springer, Cham. https://doi.org/10.1007/978-3-030-96133-6_4

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A Review of Research Topics of Safety Management Systems

Chenggong Guo 1 , Feng Jiang 2 , Tao Chen 3 and Ying Li 3

Published under licence by IOP Publishing Ltd Journal of Physics: Conference Series , Volume 1827 , 6th International Conference on Electronic Technology and Information Science (ICETIS 2021) 8-10 January 2021, Harbin, China Citation Chenggong Guo et al 2021 J. Phys.: Conf. Ser. 1827 012052 DOI 10.1088/1742-6596/1827/1/012052

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1 State Grid Jiangsu Electric Power Co., Ltd., Nanjing, Jiangsu, 210024, China

2 State Grid Xuzhou Power Supply Company, Xuzhou, Jiangsu, 221005, China

3 School of Engineering & Technology, China University of Geosciences-Beijing, Beijing, 100083, China

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Safety management systems(SMSs) is a systematic safety management method, which is widely used and researched all over the world. This article reviews the current literature of safety management systems, summarizes and analyzes eight important research topics at the theoretical level, practical level, and standard level, including analysis of the connotation and extension, effectiveness analysis, integration of a safety management system and other systems, steps and content of construction, evaluation, comparison and selection of standards. Furthermore, based on the above analysis results and the current status of the application of safety management systems in China, two recommendations on important research directions are proposed. The research indicates that in order to improve the application effect of safety management systems in Chinese enterprises, we should concentrate on the basic theoretical research. Three questions need to be answered urgently at this stage: "What is a safety management system (SMS)?", "Why does it fail?" and "How to improve?".

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Efficacy and safety of argatroban in the management of acute ischemic stroke: A systematic literature review and meta-analysis

Affiliations.

• 1 Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA. Electronic address: [email protected].
• 2 Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
• 3 Department of Neurosurgery, Hamad General Hospital, Doha, Qatar; Department of Neurosurgery, Saarland University Hospital, Homburg, Germany.
• 4 College of Medicine/ University of Baghdad, Baghdad, Iraq.
• 5 Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
• 6 Department of Radiology, School of Medicine, University of Virginia, Charlottesville, VA, USA.
• 7 Department of Neurosurgery, Medical College of South Carolina, Charleston, SC, USA.
• 8 Zeenat Qureshi Stroke Institute and University of Missouri, Columbia, MO, USA.
• PMID: 38176219
• DOI: 10.1016/j.clineuro.2023.108097

Background: Acute ischemic stroke (AIS) is a leading cause of death and disability. AIS is caused by an embolus or thrombus that restricts blood flow to the brain tissue. Despite intravenous thrombolysis and endovascular thrombectomy, a substantial number of patients do not achieve effective reperfusion. Argatroban, a direct thrombin inhibitor, can potentially improve neurological outcomes in AIS patients. However, there are conflicting results in the medical literature regarding the efficacy and safety of argatroban in this context.

Objective: This study aims to evaluate the efficacy and safety of argatroban as monotherapy or adjunct therapy for acute ischemic stroke.

Methods: Five major databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were searched for randomized controlled trials (RCTs) that compared the efficacy and safety of using argatroban alone or in combination with recombinant tissue plasminogen activator (r-TPA) in the management protocol of the AIS. We used Review Manager Software (RevMan 5.4.1) for data analysis.

Results: We included 1393 patients from eight RCTs (of them, 726 were treated with argatroban alone or combined with r-TPA, while 667 received the placebo, standard therapy (standard treatments based on current guidelines including antihypertensive, antiplatelet agents, and statins) or endovascular r-TPA). Neither argatroban vs control nor argatroban with r-TPA vs r-TPA showed significant difference regarding the activity in daily living; (SMD= 1.69, 95% CI [-0.23, 3.61]; p = 0.09), (SMD= 0.99, 95% CI [-0.88, 2.86]; p = 0.30), respectively. Also, there was no significant difference in the National Institutes of Health Stroke Scale (NIHSS) score at seven days, the number of patients achieving modified Rankin Scale (mRS) of 0-1 or 0-2 at 90 days (p > 0.05). Argatroban did not significantly increase the risk of adverse events or symptomatic intracranial hemorrhage (ICH), or major systemic bleeding compared to control or r-TPA (p > 0.05) CONCLUSIONS: Argatroban does not demonstrate superior efficacy compared to placebo or standard therapy in terms of ADL, NIHSS and mRS outcomes. Importantly, argatroban does not significantly increase the incidence of adverse events, including symptomatic ICH and systemic bleeding.

Keywords: Acute ischemic stroke; Argatroban; Cerebrovascular accident; Meta-analysis; Novastan.

Copyright © 2024 Elsevier B.V. All rights reserved.

Publication types

• Meta-Analysis
• Systematic Review
• Arginine* / analogs & derivatives
• Brain Ischemia* / drug therapy
• Brain Ischemia* / etiology
• Fibrinolytic Agents / therapeutic use
• Intracranial Hemorrhages / etiology
• Ischemic Stroke* / drug therapy
• Ischemic Stroke* / etiology
• Pipecolic Acids / therapeutic use
• Stroke* / therapy
• Sulfonamides*
• Thrombolytic Therapy / adverse effects
• Tissue Plasminogen Activator
• Treatment Outcome
• Fibrinolytic Agents
• Pipecolic Acids
• Sulfonamides

MINI REVIEW article

This article is part of the research topic.

Improving Services for Neglected Tropical Diseases: Ending the Years of Neglect

Consequences of geographical accessibility to post-exposure treatment for rabies and snakebite in Africa: a mini review Provisionally Accepted

• 1 University of Geneva, Switzerland

The final, formatted version of the article will be published soon.

Rabies and snakebite envenoming are two zoonotic neglected tropical diseases (NTDs) transmitted to humans by animal bites, causing each year around 179,000 deaths and are most prevalent in Asia and Africa. Improving geographical accessibility to treatment is crucial in reducing the time from bite to treatment. This mini review aims to identify and synthesize recent studies on the consequences of distance and travel time on the victims of these diseases in African countries, in order to discuss potential joint approaches for health system strengthening targeting both diseases. A literature review was conducted separately for each disease using Pubmed, Google Scholar, and snowball searching. Eligible studies, published between 2017 and 2022, had to discuss any aspect linked to geographical accessibility to treatments for either disease in Africa.Twenty-two articles (8 on snakebite and 14 on rabies) were eligible for data extraction. No study targeted both diseases. Identified consequences of low accessibility to treatment were classified into 6 categories: 1) Delay to treatment; 2) Outcome; 3) Financial impacts; 4) Underreporting; 5) Compliance to treatment, and 6) Visits to traditional healers.Geographical access to treatment significantly influences the burden of rabies and snakebite in Africa. In line with WHO's call for integrating approaches among NTDs, there are opportunities to model disease hotspots, assess population coverage, and optimize geographic access to care for both diseases, possibly jointly. This could enhance the management of these NTDs and contribute to achieving the global snakebite and rabies roadmaps by 2030.

Keywords: Rabies, Snakebite, Neglected Tropical Desease, Africa, accessibility

Received: 08 Oct 2023; Accepted: 15 May 2024.

Copyright: © 2024 Faust and Ray. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Prof. Nicolas Ray, University of Geneva, Geneva, 1211, Geneva, Switzerland

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• Open access
• Published: 11 May 2024

The role of nurses for patients with Parkinson’s disease at home: a scoping review

• Takako Fujita 1 ,
• Miho Iwaki 1 &
• Yoko Hatono 1  

BMC Nursing volume  23 , Article number:  318 ( 2024 ) Cite this article

129 Accesses

Metrics details

Parkinson’s disease is a neurodegenerative disease, and many patients are cared for at home by nurses. Parkinson’s disease nurse specialists have been certified in several countries. This study aimed to provide an overview of what is known about the role of nurses in the care of patients with Parkinson’s disease at home and to determine the differences between nurses and Parkinson’s disease nurse specialists.

A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. PubMed, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were searched (keywords: Parkinson’s disease AND nurse AND [community OR home]) for studies published in English up to September 2023 describing the nurse’s role in caring for patients with Parkinson’s disease at home. Studies without abstracts were removed, along with protocols, systematic reviews, and studies concerned with other diseases or including data that were difficult to distinguish from those of other diseases. Roles were described and organized by category.

A total of 26 studies were included. The nurses’ roles were categorized as overall assessment and support, treatment management, safety assessment regarding falls, care for non-motor symptoms, palliative care, support for caregivers, education for care home staff, multidisciplinary collaboration, and provision of information on social resources. Medication management and education of care home staff were identified as roles of nurse specialists.

Conclusions

This study revealed the role of nurses caring for patients with Parkinson’s disease at home. Because of the complexity of the patients’ medication regimens, nurse specialists provide assistance, especially with medication management and the provision of education to care staff. This study will facilitate the preparation of nurses to acquire the knowledge and skills necessary to help patients with Parkinson’s disease, even in countries where Parkinson’s disease nurse specialists are not officially certified, and will help patients feel comfortable with the care they receive.

Peer Review reports

Parkinson’s disease (PD) is a neurodegenerative disease affecting 8.5 million patients worldwide as of 2019 [ 1 ]. PD is more common in older people, and the risk increases over time [ 2 , 3 , 4 ]. There are prevalence differences by country even within the same ethnic group [ 4 ].

Patients with PD experience both motor and non-motor symptoms. Oral medication, levodopa–carbidopa intestinal gel (LCIG), apomorphine management, deep brain stimulation (DBS), and non-pharmacologic therapy, such as rehabilitation, can relieve motor symptoms. Oral medication is used as the first-line treatment based on previous evidence [ 5 , 6 ].

Nurses play an important role in supporting patients with PD, and nurses specializing in PD or related diseases (PD nurses) have been certified in several countries. The United Kingdom was the first nation to implement this system, and a competency framework that outlines the competencies for each level of nurse has also been developed [ 7 ]. In the United Kingdom, PD nurse specialists (PDNSs) run clinics in hospitals or the community, and they visit patients’ homes if the patients cannot attend clinics [ 7 ]. However, some countries have not officially approved such certification, even though the number of patients and treatment complexity has been increasing. Therefore, those countries may need to introduce certification in the future.

Many patients are cared for at home by nurses, and the basic treatment is oral medication. As stated previously, some countries have not introduced qualifications for PD nurses. Additionally, nurses in hospitals and clinics only provide care within their departments, and home-visiting nurses only provide care to patients in their own homes or in care homes. Some countries have guidelines for nurses specializing in PD, but these are not focused only on home-based care

This review aimed to provide an overview of what is known about the role of nurses in caring for patients with PD at home, and to determine the differences between nurses and PD nurses caring for these patients.

A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines [ 8 ]. Because the focus of this study was on the role of nurses in caring for patients with PD at home, a scoping review was conducted. We employed the PCC framework to identify the review question [ 9 ], as follows:

P (Population): patients with Parkinson’s disease

C (Concept): the role of nurses

C (Context): the home environment

All types of studies about the role of nurses caring for patients with PD at home were considered. The review protocol was not registered, in accordance with the guidelines.

Search methods

The PubMed, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases were searched with the keywords Parkinson’s disease AND nurse AND (community OR home). All types of studies published up to September 2023 were included, as the qualifications of PD nurses vary among countries and the role of nurses needs to be understood in broad terms.

Inclusion and/or exclusion criteria

All references of interest were imported into EndNote 21 (Clarivate Analytics, Philadelphia, PA, USA). Of the 1,190 references extracted during the search, 900 remained after removing duplicates (Fig.  1 ). Those without abstracts and those written in languages other than English were then removed, along with protocols, systematic reviews, studies concerned with other diseases or including data that were difficult to distinguish from those of other diseases, and studies that did not discuss the role of the nursing profession or home support. Two researchers determined whether studies should be excluded, and another researcher was added to the team to adjudicate for studies that caused a difference in opinion.

Flow diagram of the study

Search outcome

Only English-language literature describing the nurse’s role in caring for patients with PD at home was considered. Roles were described and organized by category.

Quality appraisal

Quality appraisal is optional according to the guidelines for a scoping review; therefore, quality assessment of each study was not performed [ 8 ].

Data abstraction

For each of the selected studies, we listed the author, year of publication, country in which the study was conducted, objective, study design, participants and sample size, type of nurse, and roles of the nurses. The roles of nurses were organized and described based on the thematic content.

All themes relating to the nurses’ roles were extracted from each study by three researchers. The researchers discussed and organized the roles based on similarities. The thematic content of the extracted roles was integrated into the narrative.

The included studies were published between 1999 and 2023 and performed in the United Kingdom ( n  = 12), United States ( n  = 7), Australia ( n  = 2), Sweden ( n  = 1), Germany ( n  = 1), Italy ( n  = 1), China ( n  = 1), and Japan ( n  = 1). PD nurses are referred to as PDNSs in the United Kingdom, Italy, and Germany; as community Parkinson’s nurse specialists (CPNSs) or community-based nurses specializing in PD in the United Kingdom; as registered PD nurses in China; as Parkinson’s nurse experts or movement disorder nurses in Australia; as neuroscience nurses in the United States; and as Duodopa nurse specialists in Sweden. A summary of the selected studies is presented in Table  1 .

In the following section, we describe the identified roles of nurses caring for patients with PD at home.

Comprehensive assessment and care

Comprehensive assessment is required of nurses not only for patients with PD but also for general patient support. Nurses need to plan appropriate care for patients with PD covering communication, personal hygiene, mobility, constipation, swallowing and diet, and psychological problems [ 10 ]. In addition, nurses provide education to the patients, including on therapeutic medications and fall prevention [ 11 ].

PDNSs are responsible for supporting patients by conducting regular in-person assessments, considering possible complications, and identifying changes in motor and non-motor symptoms to prevent worsening of the disease [ 12 , 13 ].

Because worsening idiopathic PD is likely to affect some aspects of a patient’s health and cause serious problems that can lead to hospitalization, such as dysphagia resulting in a chest infection or fractures following falls, an accurate assessment of symptoms by the nurse and an understanding of the concerns of patients with PD and their families and caregivers can help ensure timely responses to emerging problems [ 12 ]. In addition, since patients with PD are knowledgeable about their symptoms and the impact of idiopathic PD, PDNSs can consider patients’ concerns and involve them in decision-making at every stage [ 12 ].

Therapeutic management of motor symptoms

Support for medication adherence.

Medication management is one of the most common forms of support provided by nurses to patients with PD [ 11 ]. The support given by both PD nurses and other nurses includes discussing medication management, providing information and education about PD medications and side effects, and reviewing medication schedules [ 11 , 14 , 15 , 16 , 17 ]. In a study conducted in the United States, nurses performed a detailed medication reconciliation, reviewing multiple medication management methods (e.g., pillboxes, timers) and prescriptions, over-the-counter medications, and supplements, and comparing the actual regimen to that listed at the most recent outpatient visit [ 16 , 18 ]. Patients can also be supported by PD nurses in these respects through telenursing. Neuroscience nurses in the United States provided videophone and telephone guidance, which is helpful in confirming medications, side effects, and schedules [ 14 ]. The nurse–patient relationship was reportedly strengthened by this strong individualized support, and patients appreciated the guidance, especially the visual aspect provided by videophone [ 14 ].

Because oral medications for patients with PD are complex, it is necessary to be aware of a possible decline in medication adherence. A US medication error study involving registered nurses who made home visits to patients with PD reported that the most common medication errors were taking medications that were not known to their care providers, taking medications that patients were instructed to discontinue, taking an incorrect number of doses, and omitting or forgetting to take a dose [ 19 ]. Medication delays can have serious consequences, including impaired physical function and dysphagia, and neuroleptic malignant syndrome can be life-threatening. PDNSs need to be constantly vigilant to ensure that PD medications are not unexpectedly discontinued for any reason [ 12 ]. CPNSs may also consult with pharmacies about medication management and introduce dispensing aids, such as reminders and blister packaging [ 20 ]. One reason for poor medication adherence may be dysphagia. Crushing tablets or opening capsules to make swallowing easier for patients with PD should not be implemented without seeking advice from the dispenser [ 17 ]. Therefore, community nurses should consult with the pharmacist to discuss whether other forms of medications can be used when swallowing difficulties are affecting adherence [ 17 ].

Medication adjustment

Only studies regarding the adjustment of oral medication by PD nurses were extracted. In these studies, medications were adjusted based on knowledge of the association between diet and medications, including the time between meals and medications, and the timing of oral medications was adjusted to reduce drowsiness as a side effect [ 14 , 21 ]. PDNSs may also adjust medications. Studies in the United Kingdom and Italy have shown that PDNSs provide information about medical conditions and the purposes of medications, change medications via formal consultations or by telephone, aim to detect problems early, including side effects, when treatment is changed, and advise on medication adjustments [ 20 , 21 , 22 , 23 ].

A study that conducted semi-structured interviews reported that patients were satisfied with the information provided by PDNSs [ 21 ]. A study in which patients were questioned by community-based nurses specializing in PD, which included patients with and without regular interventions who had their clinical health status and response to treatment monitored (reporting back to their general practitioner or consultant as needed), reported that the intervention group had significantly better scores for overall health [ 24 ]. In a case study, a CPNS in the United Kingdom observed a patient’s hallucinations and discovered that they were a side effect of L-dopa, which led to an adjustment in dosage [ 20 ]. In Italy, a PDNS identified unpleasant hallucinations during telenursing, determined that they were possible side effects of cholinesterase, and provided this information to the physician, which led to modification of the prescription medication [ 23 ]. Similarly, in Australia, a movement disorder nurse conducted advocacy regarding medications, and medication was changed after physician–patient interactions [ 25 ].

LCIG care was reported in one study conducted in Sweden that implemented care at home using telehealth. In that study, Duodopa nurses provided training in the use of the equipment before and during the introduction of telemedicine, support through home visits, and instruction to patients using a video communication system; patients, neurologists, and nurses were all satisfied [ 26 ].

Apomorphine management

One study in the United Kingdom reported on apomorphine management. A community nursing team was responsible for the daily management of apomorphine, supported by guidance from PDNSs. The role of community nurses in apomorphine management was to supervise and support patients, caregivers, and family members, including by selecting appropriate sites for the infusion, setting up the pump, and siting and removing the needle. Apomorphine users, nurses, and caregivers should follow best practices to minimize severe reactions to apomorphine infusion, and better documentation of the rotation of the infusion site and nodule severity assures a high standard of care [ 27 ].

Postoperative management of DBS

In a US intervention study, home health nurses supported the postoperative management of patients who had undergone DBS. Postoperatively, trained nurses visited the patients at home to measure vital signs, implement an app-based program, and administer medications and clinical rating scales. The study reported no significant differences in motor symptoms, PD symptom severity, or quality of life compared with outpatients [ 28 ].

Safety assessment related to falls

As patients with PD are at increased risk of falling because of motor and non-motor symptoms, treatment, and other factors, they need to be assessed in terms of safety. Therefore, it is important to identify motor fluctuations [ 12 ]. Specifically, nurses use the Unified Parkinson’s Disease Rating scale (I and II) and fall assessments, paying particular attention to tremors; falls; frozen gait; dysphagia; independence level in dressing, toileting, and walking; and environmental safety assessments at home, such as in the bathroom and kitchen, including assessments of clutter and uneven floors [ 16 , 18 ]. In addition, nurses check orthostatic vital signs given the prevalence of orthostatic hypotension [ 16 ]. Because conditions change over time, PDNSs have a role in providing strategies for adapting to changes and advice for maintaining safety, such as by avoiding falls [ 12 ]. The appropriateness of mobility aids such as canes and walkers should also be assessed, and it is essential to educate family members about these aids [ 15 ].

In a study from the United Kingdom, it was reported that there were no significant differences in motor symptoms or quality of life between patients treated by community-based nurses specializing in PD and those treated by general physicians, and the nurse group had significantly better overall health scores [ 24 ]. An Italian telenursing service operated by PDNSs reported 13 telephone contacts during a 3-month intervention period and, at enrollment, 99 falls in the previous 3 months; this decreased to 3 falls in the 3 months after the intervention [ 23 ].

Support for non-motor symptoms

Support for sleep disorders.

Sleep disorders are also associated with quality of life and the risk of falls in patients with PD. One study from the United Kingdom found that after PDNSs received education on helping patients with PD and sleep disorders, patients reported a reduction in anxiety over sleep problems, feeling able to manage their sleep, having a sense of control over their sleep, and experiencing improved sleep efficiency (time to fall asleep) and quality of life [ 29 ]. This education included recognition of sleep problems in patients with PD, health education on sleep and insomnia, sleep assessment, sleep hygiene practices, use of stimulus control and sleep restriction procedures, implementation of relaxation methods, and cognitive approaches to manage insomnia symptoms [ 29 ].

Support for Dysphagia

Dysphagia is also associated with the previously mentioned oral medications. One role of community nurses for patients with PD in the United Kingdom is to be aware of the risks of dysphagia, to actively ask patients if they have experienced swallowing difficulties, and to consult with pharmacists about the shape and other aspects of the medication, given that difficulty swallowing can affect medication adherence [ 17 ]. In Italy, a case study reported that after 13 telenursing sessions over 3 months, in which a PDNS provided symptom assessment and individualized advice by telephone, the initial moderate dysphagia completely disappeared at the follow-up interview 3 months later [ 23 ].

Support for excretory problems

Urinary problems and constipation need to be incorporated into the nursing plan because of their impact on patient distress [ 10 , 15 ]. For urinary problems, a comprehensive assessment should be conducted before an appropriate treatment plan is implemented, including a continence assessment conducted with a trained professional and supporting families with tailored bladder training, such as a regular toileting routine, pelvic floor muscle training, and the supply of products for incontinence [ 30 ]. Regular clinical monitoring, medication management, and good communication with patients can help empower them to make decisions and choices related to their care [ 30 ]. It was reported that urinary problems were common in patients with Hoehn and Yahr stage V, and urinary and indwelling bladder catheters were commonly required [ 31 ].

Support for mental health

Mental health support and counseling are provided by nurses and PD nurses [ 11 , 22 ], and were among the most frequently performed nursing activities for patients with PD in a study of nurse care managers in the United States [ 11 ].

In terms of specific individualized support, in the United Kingdom, CPNSs found that patients continued to fall, lost weight because of anorexia, and felt increasingly depressed; the nurses discussed the best way forward with multidisciplinary staff and family members [ 20 ]. In Australia, a movement disorder nurse provided emotional support to her patient, with a reduction in illness uncertainty achieved through the sharing of information about future expectations [ 25 ]. In a case report about a telenursing service provided by a PDNS in Italy, 13 telephone support calls in 3 months led to a reduction in depression and anxiety [ 23 ].

Palliative care

Palliative care is designed to provide specialized disease management and physical, psychological, spiritual, and social support, to reduce suffering and improve quality of life for patients and their caregivers [ 32 ]. PDNSs play a role in symptom reduction and pain relief for both patients and caregivers, for example, by addressing dysuria, constipation, and sedation in patients and providing counseling, education, and advice for both patients and caregivers, including by facilitating referrals and collaborations with other agencies [ 22 ].

In China, a study of factors promoting and inhibiting palliative care provision by registered PD nurses was conducted, and the facilitatory factors included the desire for palliative care knowledge among healthcare professionals, the presence of social support, nurses acting as a bridge between the patient and physician, convenient community services, and the availability of hospital–community–family based services [ 32 ]. Factors inhibiting palliative care included misconceptions about this form of care among healthcare professionals, patients, and caregivers (e.g., believing that palliative care does not include surgical or conservative treatments and is similar to hospice care); lack of time for communication between patients and healthcare professionals; lack of specialized palliative care nurses; lack of palliative care referral criteria; lack of information on palliative care resources; and lack of maintenance of continuity of care [ 32 ].

Support for caregivers

Counseling and education about PD are provided to both patients and caregivers by PD nurses and other nurses, both in the home and over the phone, when patients are living at home [ 18 , 24 , 31 ]. In a US study, a program of home visits by several professionals, including nurses, to assess the psychosocial needs of patients and caregivers, along with follow-up by telephone to address any remaining needs, indicated that 98.1% of caregivers were satisfied with the program [ 18 ]. Another study reported that nurses mediated between physicians and patients or their families, such as by providing information to caregivers when the patient’s medication was changed [ 25 ]. When palliative care is provided, as noted above, PDNSs are responsible for providing counseling, education, and advice to both the patients and caregivers, as well as for facilitating referrals and coordination with other agencies [ 22 ].

Education for care home staff

Patients with PD may need to be admitted to a care home if they have difficulty living at home. Staff providing care to patients with PD find hallucinations, falls, and physical difficulties difficult to manage [ 33 ]. In the United Kingdom, 62% of PDNSs reported training care home staff, providing training to staff when a patient who had been in the care of a CPNS was admitted to a care home and providing training in the area of responsibility in collaboration with the Education and Training Officer of Parkinson’s UK [ 20 , 33 ]. Specifically, they provided materials and information related to the care of patients with PD, regular reviews of patients by PD nurses or general practitioners, and regular training for new employees [ 33 ]. An Australian study introducing an educational program (including video presentations, a 1-hour lecture, and a refresher program after 4–6 weeks) for staff in residential aged care facilities, developed primarily by Parkinson’s nurse experts and focusing specifically on therapeutic medication knowledge and management, reported that program implementation increased levels of knowledge [ 34 ].

Multidisciplinary approach

According to the included studies, PD nurses and nurses collaborated with neurologists, pharmacists, movement disorder specialists, social workers, psychologists, physiotherapists, occupational therapists, speech therapists, and other therapists specializing in neurology, as well as with nutritionists, care staff and, in the United Kingdom, other staff involved in caring for Parkinson’s patients, with contact maintained with hospital staff during admission and discharge [ 12 , 15 , 16 , 18 , 24 , 33 , 35 ]. Collaboration involved joint home visits, the exchange of information through conferences, and referrals to other professionals such as psychologists and therapists [ 12 , 20 , 33 ].

Nurses need to work as a care team to address both aspects of the clinical environment and the care provided in the home for patients with PD [ 13 ]. When working within a multidisciplinary team, nurses need to assess the patient’s abilities and plan appropriate care, including in relation to both written and verbal communication; personal hygiene; mobility (with consideration of problems related to moving in bed, transferring, and initiating and maintaining mobility); toileting, with special attention paid to the possibility of constipation; swallowing and eating; and psychological issues [ 10 ]. Nurses play a liaison role, working with the primary care team for ongoing assessment and treatment as needed [ 24 , 32 ]. The role also includes training nursing home staff and various other clinical and general staff, as well as educating the community [ 20 , 22 ].

The effects of multidisciplinary collaboration on patients have also been reported. A study conducted in Germany reported clear improvements in emotional well-being, stigma, communication, and physical discomfort through collaboration among PDNSs, community neurologists, and movement disorder specialists [ 35 ]. A study of palliative care in China stated that the registered PD nurse should serve as a coordinator between the physician and the patient, as the absence of this collaboration results in poor palliative care [ 32 ].

Provision of information on social resources

Nurses have a role in providing patients with PD, and their families and caregivers, with local and national resources and information, such as recommendations for respite and day hospitalization care, assessment of eligibility for social benefits, and special assistance at home [ 12 , 15 , 22 , 24 ]. For example, in an Australian study, movement disorder nurses provided extensive practical support through a variety of strategies, incorporating home modifications and housekeeping support to assist patients with daily living [ 25 ]. In a study of palliative care in China, a lack of information on social resources led to a lack of service utilization [ 32 ]. Finally, a case study conducted in the United Kingdom reported that a patient who had repeated falls, worsening depression, and difficulty living alone was referred to a nursing home [ 20 ].

This study was conducted to provide an overview of what is known about the role of nurses in caring for patients with PD at home, and to determine the differences between nurses and PDNSs caring for these patients. Nine main roles were identified: overall assessment and support, treatment management, safety assessment regarding falls, care for non-motor symptoms, palliative care, support for caregivers, education for care home staff, multidisciplinary collaboration, and provision of information on social resources. Most of the roles were similar to those associated with nursing care at home for patients in general [ 36 ] and were performed by both nurses and PD nurses. The results suggest that the main role of PD nurses at home is to manage medication and educate care staff. While these are also important roles for PD nurses in clinics, PD nurses in the home environment can provide superior support because they understand patients’ daily lives. The results of this study will help nurses prepare by providing them with the knowledge and skills needed to help patients with PD, leading to more reliable care for patients, especially in countries lacking a PD nurse system.

Because the basic treatment for PD is oral medication, medication management by nurses, subsuming medication adherence and dosage adjustment considering side effects and timing, is considered to be particularly important in supporting home care. Most patients with PD, particularly those with early stage disease, engage in medication non-adherence behaviors, often intentionally [ 21 , 37 ]. One common reason for hospitalization among patients with PD is falls or fractures caused by motor symptoms; in fact, this accounts for 65% of all falls [ 38 ]. For preventing hospitalization, nurses should be aware that patients are likely to show non-adherence behaviors, and they should aim to prevent missed or incorrectly taken medications by using medication boxes, building a relationship in which the patient feels free to ask for help regarding medication problems, and possibly providing guidance to family members and other support persons. The role of medication dosage adjustment was extracted only from the studies about PD nurses included in this review. It would be particularly meaningful for PD nurses to be involved in this aspect of care because they might spend more time with patients than other professionals; they can assess side effects and the need to add, subtract, or change medication doses at particular times, as well as explain the situation to the physician. In addition to oral medication, nurses are responsible for the daily management of apomorphine in homebound patients and are supported by guidance from PD nurses [ 27 ]. Novel non-oral medications may emerge in the future as alternatives to apomorphine, LCIG, and non-pharmacological treatments such as DBS. PD nurses may be required to advise nurses and to make suggestions to the patient’s physician regarding changes in administration methods and treatments, including implementing other non-pharmacologic therapies.

When patients with PD have difficulty living at home, they may be considered for admission to a care home, especially if they have advanced PD or comorbidities that significantly increase the possibility of admission, such as hip fracture or dementia [ 39 , 40 ]. Care needs for admitted patients with PD may not be met if staff knowledge of PD-related problems is insufficient [ 41 ]. In addition to the complexity of oral medications for PD, patients take medicines for the treatment of comorbidities as needed, which may make it difficult for care home staff without sufficient knowledge to assist patients in taking their medications. Therefore, education of care staff by PD nurses is necessary to ensure the safety of patients with PD.

Other roles of nurses related to motor and non-motor symptoms in patients with PD at home are generally applicable to patients with other diseases as well. Specific details of the nurse’s role regarding constipation, which is one of the non-motor symptoms of PD, were not extracted from the studies included in this review. However, the frequency of constipation varied among the studies, from 7 to 70%, and constipation is considered a common symptom in patients with PD because of the effects of the both the disease itself and oral medications [ 42 ]. In the management of constipation, dietary intervention with probiotics and prebiotics and the use of lubiprostone and macrogol have been suggested to be potentially effective, whereas the evidence for the efficacy of abdominal massage is considered insufficient [ 43 , 44 ]. A nurse intervention program for constipation in patients with PD has been created in China [ 45 ], and its results suggests that support for defecation is one of the forms of care that nurses should provide. Sleep medications are sometimes used to treat sleep problems, which are classified as non-motor symptoms. However, in patients with PD, only the dopamine agonist rotigotine has been shown to be effective; evidence for the efficacy of other drugs is insufficient [ 44 ]. Among older patients with PD, 18.6% were prescribed hypnotics, with benzodiazepines being reported to increase the risk of injury significantly, and melatonin receptor agonists reportedly significantly increasing the risk of femoral fractures [ 46 ]. Therefore, it is important to understand the treatments for non-motor symptoms and to provide nursing care while considering their side effects. This can be expected to improve the quality of life of patients with PD.

In addition to nursing care to address the symptoms of patients with PD at home, we found that nurses need to play roles in multidisciplinary collaborations and provide information on social resources. There are differences among countries and regions in terms of the granting of qualifications and the tasks performed in accordance therewith. This study found that there are PD nurses in the United Kingdom, Italy, Germany, Sweden, Australia, the United States, and China, and a competency framework for nurses working in PD management has been created in the United Kingdom [ 7 ]. In the Netherlands, which was not covered by this study, professional qualifications have been granted, and guidelines have been created [ 47 ]. Nurse-led community care is also provided in Singapore, particularly for patients with severe motor impairments and those without a caregiver; patients are visited by a PD nurse and, if necessary, referred to relevant community services [ 48 ]. In these countries, PD nurses take the lead in supporting patients, which is essential for patients to live at home. By contrast, in Japan, for example, nurses at hospitals and clinics only provide care within their departments, and home-visiting nurses only provide care to patients at home or in care homes. As such, some countries are not able to provide nursing care across all inpatient, outpatient, and home care settings. Instead, Japan has a national qualification for public health nurses, who are mainly affiliated with government agencies, playing a liaison role by providing information on available social services and communicating with various agencies. However, they do not provide patient support under the orders of a physician and cannot provide medical assistance. The introduction of PD nurses in countries such as Japan will require that they be given PD-specific roles in accordance with the national system. Clarifying the roles of each type of care provider in every country may increase the likelihood that patients with PD can continue to live at home.

This review has some limitations. First, we only included articles written in English; references written in other languages or included in databases from other countries were not extracted. On the basis of the distribution of the included studies by country, selection bias is plausible given that the countries with multiple references were all English-speaking countries. Second, no studies in this review described in detail the differences between the roles of PD nurses and other nurses in countries where PD nurses are qualified, and the relative impact on patients of interventions implemented by the different types of nurses was not evaluated. Interventions implemented by PD nurses may lead to greater improvements in patients’ symptom control and quality of life compared with those implemented by nurses. Therefore, further research focusing on the differences in nursing roles and outcomes is needed.

This study clarified the nine main roles of nurses caring for patients with PD at home, including overall assessment and support, treatment management, safety assessment regarding falls, care for non-motor symptoms, palliative care, support for caregivers, education for care home staff, multidisciplinary collaboration, and provision of information on social resources. Because PD medications are complex, medication management and education for care staff are particularly important roles for PD nurses. This study will help prepare nurses by providing them the knowledge and skills necessary to assist patients with PD, even in countries that do not have a PD nurse system, thereby leading to care that will improve patients’ sense of security.

Data availability

Not applicable.

Abbreviations

• Parkinson’s disease

levodopa–carbidopa intestinal gel

deep brain stimulation

Parkinson’s disease nurse specialist

community Parkinson’s nurse specialists

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Acknowledgements

We thank Michael Irvine, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

This work was supported by JSPS KAKENHI (grant numbers JP23H03231 and JP23K27921). The funding body did not participate in the design of the study; the collection, analysis, or interpretation of the data; or the writing of the manuscript.

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Takako Fujita, Miho Iwaki & Yoko Hatono

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TF, MI, and YH made substantial contributions to the study conception and design, the selection of and extraction of content from studies, and the drafting and revising of the manuscript; they also provided final approval of the manuscript.

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Fujita, T., Iwaki, M. & Hatono, Y. The role of nurses for patients with Parkinson’s disease at home: a scoping review. BMC Nurs 23 , 318 (2024). https://doi.org/10.1186/s12912-024-01931-y

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Received : 28 February 2024

Accepted : 10 April 2024

Published : 11 May 2024

DOI : https://doi.org/10.1186/s12912-024-01931-y

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