Excellent article found here: http://www.medscape.com/viewarticle/818437?nlid=45543_785&src=wnl_edit_medp_nurs&uac=123963FX&spon=24
The Risky Business of Nursing
Laura A. Stokowski, RN, MS
January 14, 2014
Nursing is a physically and psychologically demanding profession. It may not be the most dangerous profession in the world, but it might have the distinction of being associated with the broadest range of workplace hazards and threats to health and well-being. From needlestick and sharps injuries to musculoskeletal damage; assault; infectious disease transmission; and exposure to harmful chemicals, drugs, and radiation, the profession of nursing supplies no shortage of ways to get injured or sick on the job. Moreover, the list goes well beyond physical illness and injury to psychological harms associated with stress, compassion fatigue, bullying, and incivility in the workplace.Precisely because of the myriad ways to suffer harm in the conduct of nursing practice, we have no firm statistics on the overall frequency of workplace injury of all types in nurses and work settings. Furthermore, we know from studies of individual hazards that these events are often underreported by nurses. Some notion of the scope of job-related injury and illness is provided by data gathered by the US Department of Labor's Bureau of Labor Statistics, which consistently ranks healthcare among the jobs with the highest rates of injury.[1]
When the phrase "culture of safety" first came into use, it was aimed at patients rather than nurses, and to this day, the emphasis on nurse safety doesn't come close to approaching that of patients. This is perhaps natural, considering that patients are already sick and vulnerable to errors and accidents. Yet, a short-sighted failure to address nurse safety can have consequences for patient care.
Nurses who are ill or injured often miss work -- or worse, attempt to work while suffering pain, some degree of incapacity, or even with a communicable disease, a phenomenon known as "presenteeism." Presenteeism is associated with low productivity, more medication errors and patient falls, poorer quality of care, and costs estimated at $2-$13 billion annually.[2] Increasingly, injuries originating in the workplace area are compelling nurses to leave the profession altogether as a result of career-ending disability.
This article will review the current state of the most common nursing workplace hazards and injuries, and what is being done to prevent them. At the end of this article is a short survey to find out about your personal experience with workplace hazards and injuries. For an overview of the different types of injury, see our slideshow, Safety for Nurses in the Workplace.
Musculoskeletal Injuries
Most patients can be lifted and moved without injury if proper body mechanics are used. Is this statement true or false?
If you haven't taken a safe patient handling class for a while, you might think that this statement is true. In fact, it is a myth, the perpetuation of which is responsible for countless occupational musculoskeletal injuries to nurses and other healthcare workers. The truth is that there is no such thing as safe manual lifting, regardless of body mechanics, and that every episode of manually lifting, turning, or transferring patients can result in microinjuries to the spine.[3] The nurse might not feel the effects immediately, but these cumulative microinjuries can eventually result in a debilitating condition.[3]
Musculoskeletal injuries (also called "ergonomic" or "overexertion" injuries) are common among workers in all healthcare settings, from acute care hospitals to long-term care and ambulatory facilities. Wherever there are patients, there are opportunities to become injured in the course of care. Nurses, nurses' aides, orderlies, and attendants suffer these injuries at a rate much higher than the general population of workers, even those in construction, mining, and manufacturing.[4]
Patient handling tasks, such as transferring patients from bed to chair or commode, and repositioning patients in bed, are blamed for most of the sprains and strains to the neck, shoulders, and lower back experienced by nurses. However, the manual load involved in lifting and transferring patients is not the only source of muscle strain. Tasks that involve bending over the patient, such as bathing, performing procedures, or pushing wheelchairs and gurneys, also contribute to cumulative injury.[5]Static load, caused by working or standing in a nonergonomic position, can strain the muscles as well.[6] Consequently, even nurses who don't routinely lift or move heavy patients can suffer back and neck pain.
The problem of musculoskeletal injury is exacerbated by the aging and increasingly overweight patient population, yet in many settings, nurses do not have the tools needed to safely lift and transfer these immobile patients. A survey of critical care nurses revealed that less than one half of employers supplied patient lifting equipment, and injury rates were higher when lifting equipment was not available.[7] Many nurses try to prevent musculoskeletal injuries during patient handling by "keeping themselves fit," but this is another myth about safe patient handling.[3] If you are "fit," you may be more likely to be asked to lift patients or be part of a patient lift team, providing more opportunities to be injured.
The elimination of unsafe patient handling has been a long-time goal of the American Nurses Association (ANA). The ANA recently convened a multiprofessional group of experts to reexamine the issue of safe patient handling and mobility. The outcome was the development of a set of national overarching standards[8] for what is required to implement a safe patient handling and mobility program in all healthcare settings, Safe Patient Handling and Mobility.
"We can't afford to lose nurses to preventable injuries at a time when more people are able to access healthcare services," says Adam Sachs of the ANA. One of the core principles outlined in the standards document is investment in safe patient handling technology, locating it conveniently, and making sure staff know how to use it. "Safe patient handling technology isn't important just for keeping staff healthier," says Sachs. "It also preserves the dignity of patients. It's awkward and embarrassing when it takes a dozen people to move a morbidly obese patient."
Sadly, no federal law yet exists to protect nurses and other healthcare workers from injury caused by patient handling, although safe patient handling laws have been passed in 11 states to date. The Nurse and Health Care Worker Protection Act of 2013 if passed, would require a national safe patient handling, mobility, and injury prevention standard to reduce injuries to patients, nurses, and other healthcare workers.
Needlestick and Sharps
A few decades ago, a needlestick or sharps injury was the most feared workplace hazard in nursing. This fear was primarily founded on the risk for acquisition of HIV, a risk that was responsible for the institution of universal precautions in healthcare. In 2000, Congress passed the Needlestick Safety and Prevention Act to increase protection to healthcare workers from HIV, hepatitis B virus, hepatitis C virus, and other bloodborne pathogens. The law requires employers to institute work practice controls and safer needle technology to eliminate or minimize exposure to bloodborne pathogens from needlestick injuries.
Whether the law made a significant difference in the rate of injury to healthcare workers was the subject of a recent study at the University of Virginia.[9] Researchers reviewed injury data collected from 85 hospitals in 10 states between 1995 and 2005. Injury rates were calculated, and a national change in injuries and associated costs following the national legislation was estimated. They found that a precipitous drop in injury rates by more than one third occurred in 2001, immediately following the legislation, and this was sustained through 2005. Concurrently, the proportion of injuries from safety-engineered devices nearly tripled. They estimated that the annual reduction of more than 100,000 needlestick and sharps injuries was associated with cost savings of $69-$415 million.
A big part of a needlestick safety prevention program involves the use of technology that is designed to protect healthcare workers. Safety-engineered devices include self-sheathing or retractable needles, scalpels, finger-prick lancets, and blunt-tipped surgical and other needles or needleless systems for administering intravenous medications. Safer devices are designed to be active (safety feature requires activation by the user) or passive (safety feature is automatically triggered).
Animations that show how different safety-engineered sharp devices work are available on the Occupational Safety and Health Administration (OSHA) Website.
It is imperative that the staff who will be using safety-engineered devices are involved in the evaluation and selection of devices for purchase; otherwise, compliance can be jeopardized if the devices do not perform at the desired level.[10]
Despite the existence of a federal law and subsequent improvements, needlestick and sharps injuries continue to occur in healthcare, particularly in operating rooms, where injury rates from suture needles, scalpels, and syringes continue to increase.[11] Factors found to be associated with the occurrence of needlestick injuries include lower registered nurse skill mix, a lower proportion of experienced staff, and heavier patient loads, suggesting that adequate staffing is necessary to prevent needlestick injuries.[12]
Hazardous Drugs
Do you handle any hazardous drugs in your workplace? If you have to think about it, you might be unknowingly exposing yourself to harm. Hazardous drugs are used in many different inpatient and outpatient settings, and not exclusively for the treatment of cancer.
According to Ann Walton, lead author of "Safe Handling: Implementing Hazardous Drug Precautions,"[13] when nurses are asked about hazardous drugs, those that come to mind are chemotherapy (antineoplastics). However, many other drugs administered to patients pose significant health risks to nurses. The National Institute for Occupational Safety and Health (NIOSH) defines a hazardous drug as having 1 or more of the following characteristics: carcinogenicity, teratogenicity or other developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity or structure, and toxicity profile in a new drug that mimics an existing drug determined hazardous by the above criteria.[14]
In addition to many chemotherapy drugs, several other drugs should be handled as hazardous substances, including some anticonvulsants (oxcarbazepine and carbamazepine), antivirals (trifluridine), some estrogens (estrone, estradiol), progestins (medroxyprogesterone acetate), some contraceptives (estrogen-progestin combinations), cell stimulants (palifermin, tretinoin) and even bone resorption inhibitors (zoledronic acid). This list is by no means exhaustive. A sample list can be found at NIOSH, although patient care units and healthcare facilities are encouraged to maintain their own current list of hazardous drugs used in their settings, because new drugs are always being developed.
Acute symptoms of hazardous drug exposure can include skin irritation, sore throat, cough, dizziness, headache, allergic reaction, diarrhea, nausea, and vomiting. Other reported adverse outcomes as a result of exposure include fetal loss, congenital malformations, infertility, and increased cancer risk.[15]
In her experience teaching nurses about hazardous drugs, Walton finds that nurses are now paying more attention to education about the dangers of handling hazardous drugs and protecting themselves from exposure. "That said, many nurses still find work-arounds to protective behaviors, and often seem alarmed and surprised by the potential sequelae of hazardous drug exposures. Nurses outside of oncology are less likely to be educated about hazardous drugs."
She explains the possible mechanisms of exposure to hazardous drugs in the course of providing care. "Nurses can be exposed to hazardous drugs when handling them; transferring between containers; spiking and unspiking bags; priming intravenous tubing (if a closed system device is not used); connecting or disconnecting syringes from an injection port; and even by touching surfaces, floors, or contaminated medical equipment."
Nurses may not be aware that they can also be exposed when they come in contact with the excreta of a patient who has been administered a hazardous agent. Walton offers the following advice about the handling of the biological waste of patients receiving hazardous drugs. "Healthcare providers, formal and informal, rarely think about hazardous drug exposures from urine, stool, and emesis. In the healthcare setting, workers should use 2 pairs of chemo-safe gloves and a chemo-safe gown, cover the toilet with a plastic-backed absorbent pad when flushing, and wear a mask when splashing is possible for 48 hours after hazardous drugs are administered."
Hazardous Chemicals
The bad news is that if you work in healthcare, you are exposed to hazardous chemicals.
This isn't exactly "news." We know we are exposed, and that dangerous chemicals end up in our bodies. A few years ago, Physicians for Social Responsibility in partnership with the ANA and Health Care Without Harm released "Hazardous Chemicals in Health Care",[16] a report detailing the first-ever investigation of chemicals found in the bodies of healthcare professionals. The inquiry found that all physicians and nurses tested had toxic chemicals associated with healthcare in their bodies. At least 24 individual chemicals were detected in each participant, 4 of which were considered by the Environmental Protection Agency to be priority chemicals for regulation. These chemicals are associated with chronic illness and physical disorders.
This knowledge hasn't yet prompted the removal of all hazardous chemicals from healthcare or the substitution of safer alternatives. Among the hazardous chemicals still used widely in hospitals are cleaning products, disinfectants, sterilants, and floor care products that contain toxic active ingredients, such as ammonia, chlorine, phosphates, alkylphenol ethoxylates, volatile organic compounds, formaldehyde, phenolic compounds, propellants, and petroleum solvents. In specific areas of the hospital, workers can be exposed to glutaraldehyde, ethylene oxide, formaldehyde, paraformaldehyde, methyl methacrylate, Freon, peracetic acid, or waste anesthetic gases. Pesticides, rodenticides, and fungicides are also used in hospitals.
Most exposures occur by skin and eye contact or by inhalation, and are associated with a broad range of acute and chronic health effects. Nurses can suffer acute asthma attacks from exposure to chemicals in the environment. Pregnant nurses can face additional risk to their unborn babies from exposure to chemicals, as evidenced by a recent study showing that sterilizing agents increased the risk for spontaneous abortion in pregnant nurses.[17]
OSHA is taking steps to increase safety by improving the quality and consistency of information about chemical hazards in the workplace. Do you remember "Material Safety Data Sheets?" We were supposed to read them, and somehow, being aware of the danger, we would be able to protect ourselves. OSHA has now revised itsHazard Communication Standard to provide a common and coherent approach to classifying chemicals and communicating hazard information. The original standard was called "Employee Right to Know"; the new standard is "Employee Right to Understand."
Education is good, but even better is avoiding exposure in the first place. It is unlikely that hospitals and other healthcare facilities will ever be able to remove all hazardous chemicals, but attempts should be made to use safer alternatives where possible. Nurses need to demand this. Many resources are available, such as Health Care Without Harm's Guide to Choosing Safer Products and Chemicals: Implementing Chemicals Policy in Health Care.
Radiation
Radiation exposure may be the most insidious hazard in healthcare. It's invisible and odorless. You can't be sure whether you have not been exposed, so what is there to report? The effects may become apparent long after years of cumulative exposure, and impossible to connect with an occupational injury.
Radioactive materials and ionizing radiation have many diagnostic and therapeutic uses in patient care. Sources of radiation exposure include holding patients for portable radiography or fluoroscopy procedures and taking care of patients who are undergoing nuclear medicine therapy, such as brachytherapy. Nurses spend more time in close contact with patients than any other healthcare worker, so when radiation is present, nurses are likely to be exposed. Working around ionizing radiation requires nurses to be constantly vigilant and stringently follow established safety procedures. Badge and ring dosimeters are available for long-term monitoring of radiation exposure.
Typically, nurses who regularly work nearby sources of radiation are trained in radiation safety. However, some nurses may not be aware of the extent of their exposure to radiation. For example, neonatal intensive care nurses often hold babies still during portable radiograph acquisition in the neonatal intensive care unit. A recent study[18] that evaluated the radiography films of neonates for the presence of adult fingers found that of 230 radiographs audited, 30 (13%) contained adult fingers directly in the x-ray beam, representing a significant source of occupational exposure for these neonatal nurses.
The possible effects of radiation exposure can be acute (eg, erythema, dermatitis, nausea, vomiting, diarrhea, weakness, death) or chronic (skin cancer, bone marrow suppression, congenital defects in offspring).
Nonionizing radiation (laser) is also used in healthcare. A laser produces an intense, highly directional beam of light and has many different applications. The most common hazard associated with laser beams is thermal injury to the skin or eyes.
During electrosurgical procedures with a laser, the thermal destruction of tissue produces smoke (a "surgical plume") that can pose an inhalation danger to surgeons, nurses, anesthesiologists, and other staff. The surgical plume contains toxic gases, such as carbon monoxide, polyaromatic hydrocarbons, and other gases, the inhalation of which are associated with upper respiratory irritation and mutagenic effects.[19] Although the actual health risks of inhaling surgical plume have yet to be quantified, studies have found viable cellular, bacterial, and viral material in plume.[20] Smoke evacuators are recommended for the control of surgical plume.
Infectious Disease
Needlestick injuries and bloodborne pathogens tell only part of the story in occupational exposure of infectious diseases. Although most of the attention on infectious disease transmission in healthcare has been directed at patients rather than nurses, in truth, many of the same practices that protect patient-to-patient transmission will also protect patient-to-nurse transmission.
Nurses spend more time in close proximity to patients that any other healthcare provider. If unprotected, nurses can acquire infections through the skin and mucous membranes (by needlestick or sharps injury, or direct contact), ocular contact, the respiratory tract (by inhalation) or the gastrointestinal tract (by hand-to-mouth transmission). A review of the literature from 1999 to 2008 identified the pathogens known to have infected nurses in the course of patient care[21] (Table).
Table. Pathogens Known to Have Caused Work-related Infection in Nurses
Bordetella pertussis
Cytomegalovirus
Helicobacter pylori
Hepatitis A, B, C, or E virus
Human herpes virus
HIV
Human parvovirus
Influenza virus
Measles virus
Methicillin-resistant Staphylococcus aureus
MERS coronavirus
Monkeypox virus
Mumps virus
Mycobacterium bovis
Mycobacterium tuberculosis
Rubella virus
Salmonella species
SARS coronavirus
Streptococcus pyogenes
Vancomycin-resistant enterococci
Varicella zoster virus |
MERS = Middle East respiratory syndrome; SARS = severe acute respiratory syndrome
The number of different pathogens that have infected nurses exceeds the number identified for veterinarians, dentists, sex workers, and waste collectors.
The deadly outbreak of severe acute respiratory syndrome (SARS) in 2003, the threat of avian influenza, the recent pandemic influenza, and the emergence of drug-resistant strains of tuberculosis have increased concern among healthcare providers about occupational risk associated with respiratory pathogens.[22] We were reminded of the SARS outbreak last summer, when it was reported that a 41-year-old Filipino nurse contracted the Middle East respiratory syndrome (MERS) coronavirus and died in a hospital in Riyadh, Saudi Arabia.[23] Several other healthcare workers have subsequently contracted the virus but developed only mild illness. The emergence of the deadly MERS virus reinforces the point that nurses must be protected from potentially transmissible illnesses at all times, not only when infected patients have been identified, flagged, and placed in isolation.
Understanding of aerosol transmission of respiratory viruses has expanded accordingly, although infection control practices have not always kept pace. The World Health Organization differentiates aerosol transmission according to particle size. Droplets are > 5 µm in diameter, and airborne particles are ≤ 5 µm in diameter; both can carry viral RNA.[24] During breathing, coughing, or aerosol-generating procedures, particles containing viral pathogens do not exclusively disperse by airborne or droplet transmission, but are spread by both methods simultaneously.[25] Despite the advancing science, protection of nurses in the clinical setting is hampered by insufficient levels of compliance with hand hygiene, availability and use of personal protective equipment, and low rates of healthcare worker vaccination.
Assault and Violence
If you have been a nurse long enough, then at least once in your career you have been yelled or cursed at, hit, grabbed, scratched, kicked, or bitten or had something thrown at you. Depending on where you work, you may have enough stories about the hostilities directed at you by patients, families, and visitors over the years to scare off even the most determined of student nurses.
Healthcare workers experience the highest rate of nonfatal assaults and violent acts in the workplace, and most of these are perpetrated against nurses.[26] Although threatening behavior and violence can occur in any healthcare setting, the highest rates typically occur in emergency departments and inpatient psychiatric units. In a recent study of emergency department nurses, 76% of nurses reported having experienced verbal or physical abuse in the past year.[27]
Two of the biggest barriers to preventing nursing workplace violence are tolerance and underreporting. Some nurses and administrators believe that suffering abuse from patients and visitors is "just part of the job." Other nurses fail to report these incidents because they are confused about what constitutes abuse or assault. Reporting policies and procedures may be unclear, or nurses who might otherwise report these incidents hesitate to do so because they perceive a lack of support from managers. The failure to prevent workplace violence has many negative consequences, including higher turnover, increased use of sick time, and stress-related illness among the nursing staff.[28] Furthermore, violent acts or the threat of violence compromises the nurse's ability to provide safe and compassionate care.[29]
Nurses have a right to be safe at work. Healthcare facilities should have a zero-tolerance policy and effective programs for the prevention of violence against nurses. Nurses can help to protect themselves by becoming educated about violence in healthcare settings. The Centers for Disease Control and Prevention and NIOSH have developed a free online course for nurses called "Workplace Violence Prevention for Nurses." This program explains risk factors for workplace violence, behavioral warning signs of violence, communication and teamwork skills to prevent and manage violence, resources for injured nurses, and steps to implement a comprehensive violence prevention program. The course is free for nurses and awards 2.6 hours of continuing nurse education.
