Occupational Health Nursing in Turkey

Health Care System

The Ministry of Health administers the health care system in Turkey (Tatar et al., 2011). Privatization has been growing rapidly in all sectors but, specifically, private health care systems have become particularly common in recent decades. Most private health care centers have total or partial agreements with the General Health Insurance Institute to provide some or all curative health care services. Private insurance companies, mostly working internationally, provide some employees with private insurance but employees are still required to pay a national insurance premium.

Usually, if workers choose private insurance, they are responsible for paying the premiums. Private hospitals and clinics usually have agreements with private insurance companies. The situation all depends on the socioeconomic status of individuals, but many residents and foreigners prefer to have private insurance coverage.

The initial law, which defines health care system policies and practices, was enacted in 1930, and revised in 1936. The 1936 legislation included regulations on labor (Akdur, 2003; Bilir & Yildiz, 2013). No further relevant changes were made to the law until the Constitution of 1961 was enacted; “the law on socialization of the health service no: 224” was passed in 1963 revolutionizing the health care system in Turkey. The aim of this law was to establish a horizontal organizational structure of health care systems, to allow individuals to participate in health care decision-making, and ensure health services to all regardless of socioeconomic conditions. The law was first implemented in some pilot areas but, unfortunately, never extended to all of Turkey due to a change of government, ideological differences, and international and local liberal political pressures (Akdur, 2003). In particular, the influence of neoliberal systems on health legislation increased after 1980. Many amendments followed but radical changes in health legislation, The Transformation of Health Program, were enacted in 2003 (Savas, 2012). Currently, almost 19 million individuals in Turkey are insured, but many Turkish citizens with low incomes are not able to pay insurance premiums (Tatar et al., 2011).

Health Status of Turkish Citizens

Many factors affect the health status of Turkish citizens. Smoking is one of the primary behavioral risk factors in Turkey. It is estimated that 25% of the adult population are daily smokers. Physical inactivity is another behavioral risk factor estimated at 54% (Ministry of Health, 2011). According to WHO (2013), obesity, hypertension (32.8% in total), overweight (61.9% in total), and hypercholesterolemia (38.3%) are the primary metabolic risk factors in Turkey. Cardiovascular diseases are the cause of 50% of all deaths in Turkey, followed by cancers at 18%.

However, as in some European countries, communicable diseases, especially HIV/AIDS, continue to increase. Unfortunately, no current statistical data for these diseases exist in Turkey. Moreover, almost 85% of children were fully immunized in the west of Turkey and almost 65% of children who live in the east (Hacettepe University Institute of Population Studies, 2009). According to WHO, poliomyelitis was eradicated in Turkey in 2002. However, new cases have been emerging during recent months due to the influx of Syrian refugees (Turkish Society of Public Health Specialist, 2013).

Occupational Health and Safety System

As in many other countries, it is the responsibility of the Ministry of Labor and Security to oversee occupational health services (OHS) in Turkey. The first labor law was passed in 1930 (Bilir & Yildiz, 2013) and revised in 1936 and again in 1971 (Esin, Emiroglu, Aksayan, & Beser, 2008). The Ministry of Labor and Security reviewed a new labor law in 1993 but it was never enacted. The major problem in Turkey is that it is not sufficient to establish reasonable legislation; it is equally important to ensure implementation of the law and inspection of workplaces. However, due to international pressure on the Turkish government, revision of the law was commenced in 2004 and finalized in 2012 (Fisek, 2013). At the moment, OHS are organized according to the 2012 Occupational Health and Safety Law (no: 6331), and related regulations but some regulations remain incomplete. According to the labor law, two types of units are responsible for occupational health and security services in Turkey. Workplace health and safety units (WHSUs) are located in workplaces and managed by employers; the other type, Joint Health and Safety Units (JHSUs), are independent from employers and found in specific areas (Development of Legislation and Publishing General Directorate, Legislation Information System, 2012b). All companies with more than 50 workers are legally required to establish a WHSU. However, it is estimated that 99% of Turkish companies employ less than 50 workers. According to some research, 98% of occupational accidents occurred in workplaces without health units. For this reason, the JHSUs were established to provide OHS to all workers.

These health care units primarily control the physical environment (e.g., radiation, noise, and lighting) by visiting workplaces on request and providing advice and training services (Ministry of Labor and Social Security, 2008). Employer responsibilities include identifying occupational hazards and providing programs and services to prevent occupational diseases and accidents, responding to emergency situations, and providing first aid services and general occupational health and safety services either via a WHSU within the workplace or by agreement with a JHSU. The legislation requires companies to employ occupational health teams consisting of physicians, occupational safety experts, and other occupational health staff proportional to company size and hazard category (Development of Legislation and Publishing General Directorate. Legislation Information System, 2012a). However, many unregistered workers and unprofitable companies are not able to afford health services. Therefore, unregistered workers are often employed by companies with unsafe working conditions and exposed to workplace hazards.

Occupational Health and Safety Hazards

In the 21st century, new health problems and psychosocial risks have emerged in workplaces around the world. These health problems vary by the social and financial development of each country. In the past, the focus of occupational health and safety was preventing physical health problems, but today mental health problems are given increasing consideration. However, it continues to be unhealthy and unsafe working conditions that are the fundamental causes of occupational accidents and diseases. At the global level, according to the International Labor Organization (ILO), each day an average of 6,300 workers die from work-related injuries or diseases. Hazardous substances kill about half a million workers annually (ILO, 2014). In the European Union (EU), 8.6% (20 million) of workers experience work-related health problems (e.g., musculoskeletal injuries; stress, depression, and anxiety); 27% of workers are exposed to occupational hazards that can adversely affect mental well-being (Eurostat, 2009).

In Europe, the three main work sectors are service, industry, and agriculture. The service sector employs the largest number of European workers with almost 70%, the industry sector employs more than 25% of workers, and agriculture about 5% (Eurostat, 2010). However, work situations in Turkey are quite different from other European countries. In Turkey, the majority of workers are employed in agriculture, forestry, and fishing; manufacturing; construction; and health and education. Employment in the agriculture sector has decreased since 1970. According to Turkstat (2013), 25 million workers (26% female) were employed in Turkey with approximately 24% in agriculture, 19.1% in industry, and 49.8% in the service sector. Each sector has its own occupational risk factors and resulting work-related injuries and diseases. In Turkey, between 2007 and 2010, 63,000 workers reported occupational injuries, and 533 reported occupational diseases. Unfortunately, many occupational diseases and injuries are not reported. The construction sector, coal and lignite mines, and the textile industry are the most dangerous workplaces with many reported occupational injuries and diseases (Ministry of Labor and Social Security, 2011).

The health service sector also has many occupational hazards to which the nursing shortage is thought to contribute. Compared with EU countries with 140 nurses per 100,000 population, Turkey has the lowest number of nurses in the WHO region (Ministry of Health, 2011). The shortage of nurses has a negative effect on the quality of health care, and also results in health problems for nurses themselves due to higher workloads, more overtime, and poor working conditions. Research on work-related stress among health care professionals, particularly nurses in Turkey, has shown that depersonalization and burnout levels are related to workload, overtime, shift work, nurse shortage, salary dissatisfaction, and perception of social status within communities (Akbolat & Isik, 2008; Gunusen & Ustun, 2008; N. Kaya, Ayık, & Uygur, 2010; Pınar & Kavlu, 2009). Nurses have physical health problems related to workplace hazards, particularly low back pain. According to Alcelik, Deniz, Yesildal, Mayda, and Serifi (2005), low back pain was reported by 52.9 % of the nurses in their study. However, other studies have reported the rate of back pain in Turkish female sewing machine operators to be much higher than nurses (62.5%; Öztürk & Esin, 2011). Gastrointestinal, musculoskeletal, and cardiovascular health problems are also common within the nursing profession (Altinel, Kose, & Altinel, 2007; Yıldız & Esin, 2009).

Occupational Health Nursing

The nursing profession emerged in Turkey with the demands for caregivers during the War of Tripoli in 1911 and the Balkan War in 1912. At the time of the Ottoman Empire, women from affluent families were enrolled voluntarily in a 6-month nursing course in Istanbul. Safiye Huseyin Elbi was the first volunteer nurse to treat wounded soldiers on the battlefield and in hospitals (Alpar & Bahcecik, 2009; Ozaydın, 2002). Nurses worked for a long time without any legislative definition. The first law to regulate nursing was enacted in 1954 and revised in 2007 with some intermittent regulation between these major enactments. Nursing now includes specialized fields including occupational health nursing.

The history of occupational health nursing in Turkey is long but unfortunately without written documentation. The current number of occupational health nurses in Turkey is not clear but is estimated to be more than 4,000. The Turkish Occupational Health Nursing Association (TOHNA) was founded in 2003 and has since monitored changes in the field. TOHNA has been a member of the Federation of Occupational Health Nurses within the European Union (FOHNEU) since 2010 with observer status (FOHNEU, 2010).

The first university nursing school in Turkey was established in 1955 at Ege University in Izmir with the influence, and mostly suppression, of international organizations. Later, in 1960, vocational health schools were established. Master’s degree programs in nursing began in 1968 and doctoral programs in nursing were initiated in 1972 at Hacettepe University in Ankara (Aksayan, 2003; Esin et al., 2008). Briefly, general nursing education has changed many times in Turkey. High school diploma, bachelor’s degree, and associate degree nursing program all existed until 1997. Since 1997, all nursing education programs are offered by universities.

The length of basic nursing education programs is now 4 years following high school, and at some universities a 1-year English course is required. Presently, 118 nursing schools and departments affiliated with universities, some private, offer nursing degrees in Turkey (Student Selection and Placement Exam System, 2013).

Educational Perspective

Basic education requirements are the same in all nursing schools and nurses have no legal restrictions on where they practice in Turkey. However, nurses with advanced degrees are preferred and paid more in the health sector. On the whole, occupational health nurses have the same basic education as registered nurses although some have earned master’s or doctoral degrees in public health nursing and taken specialized courses in occupational health, safety, and environmental health. It was found that 1 to 6 hours of theoretical classroom content and 4 to 9 hours of clinical training including workplace observation were required during the occupational health nursing semester of public health nursing programs (Esin et al., 2008).

According to a 2004 FOHNEU survey conducted in 13 European countries prior to Turkey joining the FOHNEU, 6 countries had occupational health nursing content in undergraduate nursing education. In all, 10 countries had specialized occupational health nursing education programs at the postgraduate level, and 4 countries had an occupational health program as part of public/community health nursing coursework (Staun, 2012). According to the combined FOHNEU survey of 18 European countries including Turkey, 12 countries have established occupational health nursing specialization programs, originating in the United Kingdom in 1934 and followed by Finland in 1948. Occupational health content is included in public/community health nursing postgraduate courses of at least 1-year duration, whether specialization or master programs, in Cyprus, Portugal, Greece, and Turkey. Experience is a prerequisite for applying to a specialization program in Denmark, Germany, Switzerland, and Finland. In all countries, including Turkey, all registered nurses are eligible for specialization with the exception of Finland, where only public health nurses may specialize in occupational health nursing. The content of the specialized programs varies from country to country but common content includes “health promotion and health education, prevention policies at the workplace, environmental surveillance and health protection and emergency care in the workplace” (FOHNEU, 2012).

Despite the advances in nursing education, since 2011, programs have suffered. Despite the objections of professional nursing organizations, many private and public health vocational schools have reopened due to nurse vacancies and potential financial profits (Turkish Nurses Association [TNA], 2013). The students who enroll in these schools are, on average, 14 to 15 years of age and the duration of the program is 4 years. Programs include theoretical content and clinical training in hospitals. The aim of these programs is to close the gap between the number of nurse graduates and hospital vacancies. However, nursing and other non-governmental agencies have objected to this solution referencing the quality of the education provided and the risks to patients. These students are experiencing an intensive curriculum at an early psychological and physical developmental stage, which may adversely affect both young nurses and their patients.

Practical Perspective

Occupational health nursing education is advanced compared with many countries, but complicated legislative challenges persist. Previously, a registered nurse with a doctoral degree or recently graduated from high school could be employed as an occupational health nurse. Over time, many changes in regulations about occupational health services and nursing practice (June 2012) have formally added the occupational health nurse to the occupational health team along with occupational physicians and occupational safety specialists. The 2012 legislation was the first time that occupational health nursing was defined as an occupation by law. However, the duties and roles of occupational health nurses had not been identified, so their work can vary from elementary to advanced and professional (Development of Legislation and Publishing General Directorate, Legislation Information System, 2012b).

In 2012, further regulation defined occupational health nurses as assistants to physicians under the subheading of other personnel including emergency medical technicians and environmental health technicians; the roles and duties of occupational health nurses were not described in the legislation as comprehensively as current occupational health nursing practice. Nevertheless, new regulations emerged in late July 2013 giving all nurses the right to distinguish their practice based on different levels of education and qualifications and differentiating nursing practice from other health staff with different curricula and training (Development of Legislation and Publishing General Directorate, Legislation Information System, 2012a). Although the term occupational health nurse is not identified in this regulation, occupational health nurses remain active participants in the Turkish health care system and are aware of their internationally accepted roles and duties, including health promotion, research, advisory, consultation, risk assessment, case management, surveillance, health education, and leadership and management. According to one project, 87% of occupational health nurses provided treatments and procedures, 10% surveillance, 6% case management, and 0.6% health education, guidance, and counseling (Kaya, Esin, Erdogan, & Ardic, 2012). In another study, researchers found that almost 70% of occupational health nursing interventions involved treatments and procedures, 23.2% surveillance, 7% health education, guidance, and counseling, and approximately 3% case management. More than 70% of nursing diagnoses collected through the Omaha system were about musculoskeletal problems at the workplace (Isci & Esin, 2009).

In spite of improvements in the United States and Europe regarding legal acceptance and clear definitions of occupational health nursing, Turkey still has not embraced the benefits of employing nurses at the workplace although research studies have documented these benefits (Aktas & Esin, 2012; Koseoglu & Esin, 2012; Tekbudak, Avci, Esin, & Aktas, 2011).

According to the findings of the FOHNEU survey in 2012, occupational health nursing interventions have changed compared with 2004 survey results. Occupational health nursing duties were reported as “health education and promotion, disease and injury prevention, health surveillance and assessment, first aid services and administrative duties” (FOHNEU, 2012).

Nonetheless, employers are not obliged to hire occupational health nurses for a WHSU or JHSU if a full-time physician is employed (Development of Legislation and Publishing General Directorate, Legislation Information System, 2013). It is clear that occupational health nurses should be defined as independent entities with job duties and responsibilities clearly stated and consistent with international standards because occupational health nurses have the education and experience to provide a variety of programs and services that are not now listed in Turkish regulations.

Conclusion

It is accepted that health and safety at the workplace play an essential role in the quality of life of Turkish workers. It is therefore in the interest of all to provide occupational health services to the workforce as a basic human right. The occupational health nurse is a valuable contributor to the occupational health team preventing work-related diseases and injuries and protecting and promoting health. Health and safety at the workplace increase worker productivity and company competitiveness.