From the clinics of South Africa, where there are "No Gun" signs on the walls; to the rural island hospital in Micronesia, where there is no running water; to the urban hospitals of Los Angeles serving non-English speaking clients from around the globe; to the nurse-run clinics in the harsh Alaska frontier, nurses are focused on doing their best to give quality nursing care. This focus on providing quality care is commendable. However, nurses must also focus on taking care of themselves so they are able both to continue providing quality care for their patients and to maintain the profession's ability to recruit and retain new nurses. In nursing textbooks from the late 1980s and early 1990s, risks to health care workers were listed only as sub headings in sections such as infectious agents and musculoskeletal injuries, or in general chapters on "women's work." It is a remarkable sign of progress that there is now a discrete focus on the health and safety of health care workers.
This article provides a general introduction to the topic of nurse safety. First the major areas of health and safety concerns and the Hierarchy of Controls framework for risk reduction will be outlined. Next, findings from American Nurses Association (ANA) surveys which helped to crystallize the issue of safety and challenged the profession to focus on nurse safety will be presented. Following this, the linkages between patient safety and nurse safety will be discussed. Finally national reports, environmental initiatives, and policy successes and opportunities related to nurse safety will be noted.
Key words: hierarchy of controls, injury prevention, nurse safety, nursing health, occupational health, patient safety, work practices
Nursing personnel have one of the highest job-related injury rates of any occupation. When Dr. Linda Rosenstock, previous director of the National Institute of Occupational Safety and Health (NIOSH), the research arm for occupational health in the United States and one of the divisions within the Centers for Disease Prevention and Control (CDC), testified at hearings and Congressional briefings about the injury trends in all workers, she placed special emphasis on health care workers. She noted the injury rate for health care workers was greater than for the two historically high-risk occupations of construction work and agriculture. Her testimony is available on the CDC website (Rosenstock, 2000).
The large number of registered nurses (RNs) in the United States makes threats to nurse safety an important public health concern. Nursing is the largest of the health professions. In 2000, there were about 2.7 million registered nurses in the United States (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000) with approximately 2.3 million registered nurses being employed in 2002 (U.S. Department of Labor, Bureau of Labor Statistics, 2004a) reflecting an increase of RNs working in nursing since 1996 (Spratley et al.). There are also approximately 700,000 licensed vocational/practical nurses (U.S. Department of Labor, Bureau of Labor Statistics, 2004a) and an estimated 2 million assistive personnel (nursing aides, orderlies, attendants, and home health aides (U.S. Department of Labor, Bureau of Labor Statistics, 2004b) who work with RNs in hospitals and nursing homes.
Major Areas of Health and Safety Concerns
In 1997, Dr. Bonnie Rogers, an expert occupational health nurse, delineated five categories of safety risk hazards. These areas include: biological/infectious risks, chemical risks, environmental/mechanical risks, physical risks, and psychosocial risks. Each of these risks will be described below.
| ...five categories of safety risk hazards...include: biological/infectious risks, chemical risks, environmental/mechanical risks, physical risks, and psychosocial risks. |
Infectious or biological risks are among the oldest of hazards that nurses have experienced. Respiratory illnesses and other communicable diseases, such as Severe Acute Respiratory Syndrome (SARS) and tuberculosis (TB), are examples of infectious illnesses. Bloodborne infections, such as Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus (HIV) are also part of the health care landscape. Biological/infectious risks from needlesticks are addressed in this OJIN topic by Susan Wilburn, ANA Occupational Health Specialist.
The second major category is that of chemical risks. Serious chemical exposures in the health care work environment can result from sterilizing agents and chemotherapeutic agents. Disinfectants and cold sterilants, used to disinfect instruments, can provoke reactive airway symptoms and skin problems. Ethylene oxide, used to sterilize heat-sensitive items such as plastic equipment, has produced cancer in animals. Antineoplasticine agents represent a significant hazard for those who handle these substances. The article in this OJIN topic by Polovich addresses safe handling of these dangerous but life-saving medications.
Another common chemical hazard in health care is the risk from latex. Latex items protect from one source of injury, namely bloodborne infections, but present risks to workers and patients who are demonstrating an increase in the development of latex allergies. The use of latex products skyrocketed when gloves were required as an essential barrier to risks from blood and body fluids. Latex reactions can range from contact dermatitis, to systemic reactions, to anaphylaxis. Latex allergies occur in patients as well as in nursing staff. The CDC/NIOSH (n.d.) website has federal guidelines to reduce allergic reactions to latex. This site links to other information sources regarding latex allergies including, among others, the ANA Health and Safety site.
The third category of risks addresses environmental/mechanical risks. Patient handling poses physical risks to nurses and assistive health personnel. In this OJIN topic, both deCastro, and Nelson and Baptiste provide in-depth discussions related to safe patient handling and movement.
The fourth category of risks that of physical risks, refers to physical agents that cause tissue trauma, such as heat and cold, vibration, and noise. In health care, radiation exposure is the most likely physical hazard. In addition, lasers may create skin or eye injury due to the light emission.
The last risk category is that of psychosocial risks. Violent behaviors towards health care workers by hospitalized medical, surgical, and psychiatric patients, as well as nursing home patients are well known to those who work in those areas. Yet, the problem is considered to be under-reported. Emergency department health care workers and those in psychiatric settings seem to be most at risk. In this OJIN topic, McPhaul and Lipscomb outline the risks and recommended interventions to promote safer health settings.
Hierarchy of Controls
| The Hierarchy of Controls...assists in systematically identifying hazards and prioritizing intervention strategies. |
Occupational health practitioners recognize that throughout the world people must perform work that may produce a risk. In addition, whether it is the painter who does not use a respirator each time he or she is spraying paint, or the bridge worker who does not attach the safety clasp on the lifelines with every use of a ladder, human nature can and does make risky work even riskier. Castillo, Pizatella, and Stout (2000) have developed a framework to evaluate risks and identify the most appropriate intervention strategy in risk-provoking situations. This framework is known as the "Hierarchy of Controls." The Hierarchy of Controls approach helps to redirect activity to the level of intervention most likely to reduce the risk. We are now recognizing that strategies to promote a change in workers’ behaviors that were once thought of as most effective are the least successful in bringing about change. The hierarchy assists in systematically identifying hazards and prioritizing intervention strategies (de Castro, 2004). The most effective to least effective control measures include elimination controls/substitution controls, engineering controls, administrative controls, work practice controls, and personal protective equipment controls.
In the Hierarchy of Controls framework, the most successful approach to decreasing risk is to eliminate or substitute for the hazard. The first line of defense, known as substitution, is considered the most effective activity in the hierarchy (most effective in reducing harm to the worker). Consider, for example, the need to decrease the risk of infection from a bloodborne pathogen. In the case of risk from a contaminated needle, eliminating the needle altogether to administer a drug is a form of substitution. Examples of substitution would be administration of medications orally, transdermally, with inhalers, or with an internal pump.
The next rung in the hierarchy, the second most effective control, is that of engineering control. If the risk of injury cannot be removed entirely, an engineering control introduces some form of protective safeguard through the use of technology (Castillo et al., 2000). In health care, needles still need to be used for some critical purposes, for example, intravenous (IV) administration or phlebotomy relies on the introduction of needles. Examples of engineering controls are innovations that modify the device so that it is no longer sharp after use. Ideally, that modification should occur as soon, and as "passively," as possible in that it doesn’t require the worker to activate the safety feature. One such innovation is a needle that is blunted, shielded, or retracted after use.
Administrative controls, the third line of defense, rely on policy and management controls designed to limit exposure to the hazard and to protect the workers. Castillo et al. (2000) defines an administrative control as an active control since worker involvement is essential to its effectiveness. Examples include allocation of resources to initiatives that enhance health care worker safety, such as a needlestick prevention committee, an exposure control plan, removal of all unsafe devices, and consistent training on the use of safe devices. Although some safety control programs describe training as a distinct step, this article integrates training into the administrative controls level since there must be administrative support to design and support that training.
Work practice controls can be classified as a subset of administrative controls. These controls include policies intended to require compliance with prevention strategies, and require managerial commitment to a consistent pursuit of safety. Examples of work practice controls include policies mandating that gloves must be used whenever working with blood and body fluids, or bans on recapping of used syringes, with consequences for not implementing the policy. Workers report a greater sense of workplace safety when policies and a supporting culture are present. Gershon et al. (2000) found that health care workers were more likely to comply with bloodborne injury reduction protocols when there was senior management support for programs that support safer practices, few barriers to safe work behaviors, and clean units and work sites
The last rung in the hierarchy is the use of personal protective equipment (PPE). If the hazard cannot be reduced by substitution or engineering, then workers are given another level of protection through the use of PPE. PPE effectiveness depends on good design and worker vigilance. An example in health care is the use of goggles and face shields. Devices must fit well, be available, and most importantly, not impede safe patient care; otherwise workers will not use the devices.
In health care, there are numerous examples of workers who have practice patterns that may create risks for injuries, such as needlestick injuries. A work practice control, such as procedures related to never recapping syringes, may have been practical and logical, but it did not change most workers’ behaviors; and it did not remove the root cause of needlestick injury, the needle! Early health worker studies confirmed that recapping needles remained a frequent practice in spite of instructions to the contrary (McCormick & Maki, 1981). Only through engineering modification resulting in new devices that self-blunt or retract, rather than through changes in personal practice, have needlestick injury rates begun to decline (Perry, Parker, & Jagger, 2003).
The Hierarchy of Controls framework can be applied to a variety of safety hazards. An evaluation identifying the most successful strategies can be implemented in any work setting. Strategies appropriate for home care will differ from those in an emergency room. It is important to work within the specific health care facility to reduce preventable exposures by identifying high risk procedures and devices, and implementing the most effective control measures.
Findings from the ANA Survey on Health and Safety
| In 2000, the ANA conducted an online Staffing Study to collect information about nurses' safety concerns. |
In the late 1990s, nurses reported considerable stress in the struggle to balance increased patient demands and reduced resources. In 2000, the ANA conducted an online Staffing Study to collect information about nurses’ safety concerns. Findings from this study (ANA, 2001a) were powerful because they represented the voice of the frontline nurse. The findings sounded a warning regarding decreasing nurse satisfaction and patient safety. It found nurses were working harder, working extra hours, and were very worried about patient safety. Seventy-five percent of the nurses surveyed expressed concern that the quality of nursing care at their facility had deteriorated over the previous two years. Nurse concerns included inadequate staffing, decreased nurse satisfaction, and patient care delays. The message of declining nurse satisfaction was related to an increase in stress; and this stress was beginning to take a physical toll on nurses who participated in the survey. Nurses reported that they were exhausted, and were skipping meals and break times to give basic care. They reported that overtime was a constant reality, and that they felt pressured to work extra shifts (ANA, 2001a). Nurses were making the connection that the rest of the country was just beginning to make: that there is an inextricable link between the safety of patients and the health and safety of nurses. Good working conditions were beneficial for both patients and nurses. The findings about nurses’ stress, overtime, and declining satisfaction highlighted nurse safety concerns. Yet more information was necessary if an organized and sustained program of education and advocacy was to be designed.
The online survey method was used again by ANA in 2001 to collect information about the health and safety concerns of nurses. The findings were based on responses of over 4800 nurses (ANA, 2001b). Although the limitations of such a survey must be recognized, it did serve as a valuable tool for ANA leaders to assess members’ key concerns and to adjust priorities (time, staff, and financial resources) within organizational initiatives. The opinions expressed validated that ANA was on the right course in identifying safe staffing and patient safety as key "core issues," and in adding nurses’ health and safety issues to the core issues of the national organization. The findings were remarkable not only in relation to the staffing survey released months before, but in the unmistakable call for help from practicing nurses - a call to change the way in which nurses do their work, or nurses will leave these settings that are unsafe for both patients and nurses. Nurses reported job stress, both acute and chronic, as the top health and safety concern, followed by disabling back injuries, and contracting HIV or hepatitis from a needlestick injury. Other responses that garnered double-digit percentages were the threat of being infected with tuberculosis or another disease, sustaining an on-the-job assault, developing a latex allergy, and having a fatigue-related car accident after a shift. Fewer than 20% of respondents felt safe from work-related injury in their current work environment. Over three quarters of the nurses reported that unsafe working conditions interfered with the ability to deliver quality care. These findings point again to the connection between nurse safety and patient safety.
The Link Between Nurse Safety and Patient Safety
Many factors influence both nurse safety and patient safety. This section will discuss national reports about health care safety, measures to protect the environment, and legislative initiatives that suggest relationships between nurse safety and patient safety and show what nurses can do to promote their own safety and the safety of others.
Institute of Medicine Reports
In 1999 and 2000 the nation was riveted by national scientific panels announcing that as many as 98,000 patients may die each year from a medical error (Committee on Quality of Healthcare, 2000). This Institute of Medicine (IOM) report, "To Err Is Human," helped to galvanize support among patients, professionals, and policy makers for a serious systems approach to analyze how care is delivered in U.S. hospitals and the shortcomings of that care. Medication errors, communication gaps, and the influence of human factors on the occurrence of errors were highlighted in this report.
The disciplines of industrial engineering, psychology, and occupational health have studied for some time the influence of human factors on the occurrence of errors; and they continue to study what they call Human Factors Engineering, defined as the study of perceptual, information-processing, and psychomotor aspects of work (Keyserling, 2000). They describe common concerns and everyday occurrences, such as those that nurses described in their reports of staffing shortages and frequent overtime, all of which result in dangerous levels of fatigue. The ANA and other professional nursing groups are working to show the relationship between these high levels of fatigue and patient safety. They are developing recommendations for system improvements that will increase both nurse and patient safety.
In 2004, the IOM (Committee on the Work Environment) released a report, "Keeping Patients Safe: Transforming the Work Environment of Nurses," focused on the nursing environment. The report is especially important for nursing and health care organizations that are struggling to address the staffing shortages that evolved after the turbulent 1990s. This report documents how the current environment is leading to both patient harm and nurse burnout. This document incorporates a systems approach to assess how nurses perform their work and the opportunities that exist to reduce patient error. However, the report does not go so far as to show the connection between risks to patients and risks to nurses. The report does not discuss the effect of poor unit design and extended work hours without adequate rest on the health and safety of nurses. It is hoped that this report will highlight issues related to nurse safety. However, we cannot leave the elucidation of the relationship between nurse safety and patient safety. We must conduct more research on the relationship between injury rates, error rates, and patient and nurse satisfaction. Health care workers themselves need to be asked questions such as: What do you think is occurring? and What could be done to make care safer? In addressing both patient safety and nurse safety, the frontline worker voices need to describe what they see as safety issues.
Occupational and Environmental Health Initiatives
The movement to protect the health and safety of nurses is concurrent with the movement to be environmentally accountable. Nurses care first about the safety and quality of patient care; yet they also care about the health and safety of their nurse colleagues and society at large. Nurses are concerned that the health practices they are involved in will do no harm to the environment around them.
| The movement to protect the health and safety of nurses is concurrent with the movement to be environmentally accountable. |
A variety of resources for protecting the environment are available. The ANA website, www.nursingworld.org provides links to environmental coalitions and initiatives in the Health and Safety section of the website. ANA has developed a "Pollution Prevention Kit for Nurses" to assist staff nurses, nurse executives, community health nurses, and faculty to become active in reducing the toxic pollution created by the health industry (ANA, 2004b). Background information is provided on the science of pollution and environmental protection. The kit provides personal action steps and political action steps to protect communities. Another source of information for health professionals is EnviR.N, (http://envirn.umaryland.edu/), maintained by the University of Maryland School of Nursing. EnviR.N. is dedicated to helping nurses seek accurate, timely, and credible scientific information regarding environmental health and nursing. This site contains a range of information, including a three day faculty development workshop which includes principles of toxicology, epidemiology, and environmental justice. Lectures are available for use, as well as PowerPoint slides for presentations, and bibliographic sources developed by experts in the field. An additional site, the Premier Safety Share site, www.premierinc.com/all/safety/publications/01/04_full_txt.htm includes information on "Green Hospitals," and Hospitals for a Healthy Environment. Green hospitals are those that have made a conscious commitment to environmental awareness in planning, designing, constructing, and operating the hospital. Projects have included nurses linking with environmental advocates and community leaders to reduce waste, minimize pollution, and eliminate the use of mercury-based technologies.
The Policy and Politics of Health and Safety
| The interaction of politics, policy, and advocacy can help to promote a safe working environment for nurses. |
The interaction of politics, policy, and advocacy can help to promote a safe working environment for nurses. This can occur when employees ban together, for example in collective bargaining in states with unions. Labor unions have played a significant role in the health and safety laws of this country (Silverstein, 2000). The term "organized advocacy" describes the collective activity that nurses use to move the health and safety agenda (Foley, 2002). Nurses have marshaled their voices to request protection from health and safety hazards, and will continue to do so as long as there are safety risks. General and specialty professional organizations are highly effective advocates, and serve as another route for organized advocacy.
Good and bad rules just don’t happen. An example of how policy and politics along with professional advocacy and collective action can influence the safety of health care workers was seen when the smallpox program was initiated in the United States. The initial smallpox program was designed to vaccinate thousands of health care workers and first responders to prepare for the release of smallpox as a weapon of mass destruction. The smallpox vaccination campaign that started and halted in 2002 and 2003 was modified as a direct result of scientific analysis and constructive criticism by ANA and other health worker organizations. ANA, other nursing organizations, and worker representatives voiced concerns about the safety of the program from two perspectives: the risk to workers, their patients, and their families from the virus itself; and the risk for those performing the inoculations using needle devices that lacked a safety design. The power of professional credibility and voice changed the outcome of this program.
Nurses often believe they cannot, or should not be political. In reality, nurses are naturals at the skills required to be politically effective, due both to their reputation as being very credible and to their many skills. The public and the policy makers take nurses seriously, and instinctively trust nurses. In addition, nurses have the skills to assimilate a great deal of complex information, process it quickly, and translate it into lay terms. Nurses are skilled in communication, observation, and interactions with people.
To be truly effective, however, nurses need the knowledge and the tools to bring about policy change. Policy is different than politics. Policy has a body of knowledge that can enable the politically novice nurse to be more effective in bringing about change. Learning about policy-related theories and strategies will enable the nurse to work more effectively in a political atmosphere. Coalition building and media advocacy are the building blocks of policy making (Mason, Leavitt, & Chaffee, 2002). The use of the media is crucial for securing support for an issue (Leavitt, Cohen, & Mason, 2002).
Another example of the intersection of policy, politics, and advocacy is the long-term efforts to gain passage of the Needlestick Safety and Prevention Act of 2000. Organized efforts at the state and national levels provided support for this act, which is designed to decrease needlestick injury and was launched at state and federal levels. These plans included regulatory change, education, training, and careful monitoring of implementation. Additionally national and state level ergonomic plans to reduce health care worker injury through education, legislative, regulatory, and voluntary initiatives have increased nurse safety.
| ...nurses need an in-depth understanding of the occupational risks they face and the protective strategies that are available to them. |
Mandatory overtime can also threaten nurse safety. Some states have passed legislation to restrict mandatory overtime, while others have placed limits on the number of hours of overtime overall. The first state to address mandatory overtime since the reports of 2000 and 2001 was New Jersey. Since this New Jersey plan, other states have used a variety of approaches to prevent or reduce mandatory overtime. Federal legislation in this matter is considered unlikely at this time (2004) due to the highly polarized climate of Congress and distractions from issues such as homeland security and a pending national election.
In addition to understanding the political process, nurses need an in-depth understanding of the occupational risks they face and the protective strategies that are available to them. Resources related to these risks and strategies are available from a variety of sources. A review of the ANA website (www.nursingworld.org), provides a historical and current snapshot of ANA’s commitment to health and safety for nurses. Educational programs and instructional materials from ANA include information on blood borne pathogens, TB protection, latex allergies, needlestick prevention laws, SARS, smallpox, and general health and safety guidelines. The American Association of Occupational Health Nurses (AAOHN) publishes a monthly peer reviewed journal (www.aaohn.org/). Specialty nursing organizations have provided members with information on occupational risks unique to their practice arenas. Nurses who work with chemotherapy have the expertise of the Oncology Nursing Society; and emergency department nurses have the advocacy of the Emergency Nurses Association. Other sources of occupational health safety information can be found at government and industry sites. The Premier Safety Share site, (http://my.premierinc.com), has a wealth of information about health and safety issues and is filled with links to NIOSH. DiBenedetto (2003) developed a compilation of occupational health and safety websites useful for the health professional.
Future Trends and Implications
Health care is not standing still. New tests and treatments are continuously being developed and released. Diagnostic procedures are creating new opportunities to identify and treat diseases sooner and in new ways. Every new development presents hope, and possible risks. Currently, what is known about health and safety risks is that the risks will not end. This reality requires continuous work place assessment and a systematic health and safety program. The overview of this OJIN topic on nurse safety by Sedlak provides a starting place for nurses to learn more about the environment in which they work, and how to remain safe in this environment. In addition, there are journal articles to read, programs to attend, and master’s and doctoral programs that can provide a formal education in occupational health expertise.
It is very likely that unsafe work environments will place the very future of nursing at risk. Unsafe environments will have adverse effects on both recruitment and retention of nurses. Nurses do not complain about working hard. In fact, they expect to work hard, and enjoy a great deal of satisfaction when that work makes a difference. However, when that work places nurses at risk, nurses experience dissatisfaction. Nursing can ill-afford to have the image of necessitating work in an unsafe environment at a time when every nurse, newly recruited and tenured, is needed to meet the demands of patients, families, and communities. We are now seeing increased emphasis on safety in the acute care setting environment. However, it is imperative that this focus extends to include long term and home care settings. Long term care workers experience some of the worst mechanical injuries, and home care nurses experience dangers such as needlestick injuries. Fortunately, NIOSH (2003) has recently announced a home health needle safety initiative.
| ...the environment where nurses work can have an effect on the safety of patients as well as the safety of nurses. |
Nurses need to know as much as they can to maintain their own health and safety. It is critically important that nurses support their state and national professional nursing associations. These organizations work tirelessly to assess member concerns and coordinate input into the rules and regulations that will protect nurses. Nurses should be proud and relieved that professional nursing organizations are there to monitor the state and national health and safety horizon and to intervene at a policy level to promote and protect nurses and patients.
There is evidence that the environment where nurses work can have an effect on the safety of patients as well as the safety of nurses. The IOM report, "Keeping Patients Safe: Transforming The Work Environment of Nurses" (Committee on the Work Environment, 2004), thoroughly discusses the relationships between staffing, fatigue, and patient-related errors, and recommends that institutions strive to create "cultures of safety." Additional experience from the occupational health field links the safety climate in a hospital with the type of work environments health care workers experience. What that culture is, and how to achieve it, will be the work of the next decade in the health care environment. Nursing concerns and expertise must be in the forefront of those efforts!
Author
Mary Foley, MS, RN
E-mail: Maryfoleyrn@att.net
Mary E. Foley, MS, RN, is the Associate Director in the Center for Research and Nursing Innovation at the University of California, San Francisco (UCSF), where she is also a PhD student in nursing policy. In 2003, she was a Regents Lecturer at UCSF and Visiting Assistant Professor in the master’s entry program. She is immediate past president of the American Nurses Association. She was previously employed at Saint Francis Memorial Hospital in San Francisco.
Ms. Foley has been active in the health care policy arena, writing and lecturing about health care policy, improving the workplace, promoting safe care, and worker health and safety. Foley was named for the second year as one of the top 100 "most powerful" in U.S. health care system by Modern Healthcare. She was appointed to the California Tuberculosis Elimination Task Force in the Department of Health Services from 1993 to 1994, the Mayor’s HIV Task Force for the City of San Francisco in 1989, and California’s RN Special Advisory Committee on the Nursing Shortage for the Department of Consumer Affairs in 1989. She is a member of the Glide Clinic Oversight Board. She also serves as a project consultant for the Training for the Development of Innovative Control Technology (TDICT) Project, which brings together health care workers, product designers, and industrial hygienists to better design and evaluate medical devices and equipment.
Foley has held numerous elected and appointed positions with the ANA at both the state and national levels. She currently serves on the ANA Political Action Committee as Vice Chair, and has been elected ANA/C Vice President. She was an official representative from the United States at the 1997, 1999 and 2001 meetings of the International Council of Nurses (ICN). She continues as a member of the National Patient Safety Foundation Board of Directors and as an advisory member of the Partnership for Patient Safety (p4ps). Her professional organizational involvement began with the National Student Nurses Association (NSNA), where she served as president in 1974-1975.
Foley received her nursing diploma in 1973 from New England Deaconness Hospital School of Nursing, her BSN in 1976 from Boston University School of Nursing, and her Master’s of Science in Nursing Administration and Occupational Health from the University of California in San Francisco in 1994.
Article published September 30, 2004
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