Identifying nursing hazards in the emergency department: A new approach to nursing job hazard analysis

https://doi.org/10.1016/j.jsr.2005.10.018Get rights and content

Abstract

Introduction

It is widely acknowledged that nurses are crucial components in healthcare system. In their roles, nurses are regularly confronted with a variety of biological, physical, and chemical hazards during the course of performing their duties. The safety of nurses themselves, and subsequently that of their patients, depends directly upon the degree to which nurses have knowledge of occupational hazards specific to their jobs and managerial mechanisms for mitigating those hazards. The level of occupational safety and health training resources available to nurses, as well as management support, are critical factors in preventing adverse outcomes from routine job-related hazards. This study will identify gaps in self protective safety education for registered nurses working in emergency departments as well as for nursing students. Furthermore, this study reviews the nature and scope of occupational nursing hazards, and the degree to which current nursing education and position descriptions (or functional statements) equip nurses to recognize and address the hazards inherent in their jobs.

Method

This study has three parts. First, a literature review was performed to summarize the nature and scope of occupational nursing hazards. Second, the safety components of position descriptions from 29 Veterans Affairs (VA) hospitals across the United States were obtained and evaluated by an expert panel of occupational health nurses. Finally, an expert panel of occupational health nurses evaluated the degree to which nursing accreditation standards are integrated with OSHA's list of known emergency department hazards; and a separate expert panel of occupational health nurses evaluated the degree to which current VA emergency department nursing position descriptions incorporated hazard recognition and control strategies.

Conclusion

Ultimately, prevention of job-related injuries for nurses, and subsequently their patients, will depend directly on the degree to which nurses can identify and control the varied occupational hazards specific to jobs. Neither accreditation standards nor position descriptions adequately integrate common occupational hazard recognition and control strategies, nor do they adequately prepare nurses to identify and control hazards specific to nursing. A research approach that specifically addresses the current lack of formal on-the-job training for nurses regarding job-related hazard recognition and avoidance strategies is presented.

Introduction

It is widely acknowledged that nurses are a crucial component of the U.S. healthcare system, holding about 2.3 million jobs (U.S. Department of Labor, 2004). Nurses are employed in virtually every kind of healthcare setting. The wide range of practice settings include public health (national, state, and county level), skilled nursing facilities, community-based residential care centers, hospitals (public, private, and teaching), clinics, urgent care centers, offices, industrial (occupational) settings, acute care through tertiary care institutions, and home healthcare. In this sense, nurses are often the linchpin component of modern healthcare connecting quality healthcare practices to patient safety across a wide continuum of care.

It is therefore no surprise that the acquisition and maintenance of a nurse's skill set and its application across healthcare settings require advanced and detailed education from accredited and standardized curricula. In addition, to optimally protect the safety and health of nurses requires professional credentialing procedures, opportunities for continuing education, and supportive and informed management structures and cultures (including worksite-specific hazard recognition and avoidance capacities). Toward this end, major professional nursing associations have recognized the hazards faced by nurses as part of their jobs. For instance, the Association of Operating Room Nurses (AORN) includes in a position statement on workplace safety: “AORN further supports the Environmental Protection Agency (EPA), National Institute for Occupational Safety and Health (NIOSH), Occupational Safety and Health Administration (OSHA), and state and local regulations that promote workplace safety in the preoperative environment” (AORN, 2005). Generic hazard areas for nurses have been identified by both OSHA (see below) as well as by occupational health nurses to include: biological/infectious disease, chemical risks, environmental/mechanical risks, physical risks, and psychosocial risks (Rogers, 1997).

Section snippets

Purpose

The primary purpose of this paper is to investigate two empirical questions: (a) the degree to which occupational safety and health control strategies are taught in accredited nursing schools; and (b) the degree to which nursing position descriptions incorporate occupational hazard recognition and control by nurses, supervisors, and administrators.

This paper is organized in three sections. First, we briefly summarize the research literature regarding nursing occupational hazards. Second, we

Characteristics of nursing hazards

As a large and complex enterprise, the healthcare industry is characterized by both highly skilled and credentialed professionals with sophisticated technological equipment and procedures. In addition, the healthcare industry operates within and is subjected to both governmental and external reviewing and accrediting bodies as well as a rapidly changing legal environment. The U.S. Department of Health and Human Services (DHHS) reports that the healthcare industry is the second fastest growing

Occupational Safety and Health Administration (OSHA) list of principle hazards to nurses

OSHA lists several specific hazards faced by the ED nurse. The following are the principle exposures specific to ED nurses according to OSHA (Department of Health and Human Services, 2004a):

  • 1)

    Bloodborne pathogens

  • 2)

    Hazardous chemicals: (e.g., Ethylene Oxide, spilled medications, carcinogenic materials, noxious fumes, and flammable liquids)

  • 3)

    Slips/falls: high traffic and compact treatment spaces are a combination for risk

  • 4)

    Latex allergy: (e.g., reaction to gloves made from natural latex and/or materials

Nursing hazard example – percutaneous Needlestick Incidents (NSIs)

To better describe the nature of the nursing safety issue, one can characterize the frequency and severity of specific nursing exposures. Of all healthcare workers, arguably nurses (RNs and LPNs) are at most risk for needlestick incidents. In fact, the annual rates of occupational blood exposure were highest for nurses and midwives (6.5 per 100 compared to 3.5 of overall), and nurses tend to be exposed 4.27 times more often than physicians (Denis et al., 2003). Ippolito et al. (1997) found that

Job hazard avoidance — nursing education and organizational training

As illustrated by the hazards listed above, occupational nursing hazards are numerous, varied, and complex. Historically, efforts to address safety and health in healthcare settings have focused on developing skills that optimize patient safety and health rather than the safety and health of healthcare workers themselves. Occupational injury/illness has not been a priority. Moreover, where there have been changes in nursing safety practices, these changes have occurred only after a significant

Nursing core competencies and the national league for nursing accrediting commission

Today, there are many professional levels of nursing education including associate's degrees, diploma programs, and bachelor's, master's, and doctoral degrees. All accredited academic nursing programs are required by the National League for Nursing Accrediting Commission (NLNAC) to meet stringent academic requirements. Accreditation offers a profession several advantages, including quality assurance and consistency in the curriculum across various academic and professional programs. As such, it

NLNAC rating analysis methodology

To better address the degree to which the NLNAC accredited nursing curriculum prepares nurses to identify and control known occupational hazards, four raters were selected and trained to rate the extent to which the NLNAC core accreditation requirements accommodated hazard recognition and control strategies into the curriculum. The raters of the study were selected based on their multifaceted nursing careers of greater than 20 years and a nursing specialization of greater than 10 years in

Nursing position descriptions (PDs) – methodology and analysis of DVA PDs

The second empirical question posed in this paper is: To what degree are emergency department (ED) nurses expected to manage their own safety vis-à-vis requirements that are integrated into their position descriptions (PDs)? In other words, we were interested in finding out whether and to what degree hospitals incorporate known characteristics of OSH hazards into an ED nurse's PD, thus making safety the direct responsibility of the ED nurse as well as the responsibility of the nursing

PD rating analysis methodology

To investigate the degree to which an ED nurse's PD incorporated safety principles, we performed a similar cross tabulation to those performed in Table 1, Table 2 above. The authors first reviewed standardized Office of Personnel Management (OPM) nursing PDs and U.S. Department of Veterans Affairs (VA) generic nursing “functional statements.”4

An alternative administrative control – job hazard analysis

Typically, safety professionals respond to and control OSH exposures with a combination of engineering, administrative, and personal protective equipment (PPE) controls. There are abundant engineering and PPE controls available and used by healthcare professionals such as lift assists, safer needles, needle-less IVs, a variety of gloves and goggles, and other PPE. However, the degree to which administrative controls are used is less clear. Common administrative controls include job rotation and

Recommendations for further studies

From the morbidity data presented above and from anecdotal evidence, we know that nurses experience an increasingly hostile, complicated, and stressful work environment. To complicate the forecast for ED nurses, it appears as though nurses may be inadequately prepared in nursing school to recognize, evaluate, and control many of the hazards inherent in the ED; nor does it seem that nurses have much of a formal charge to know about or to protect themselves from ED hazards as the paucity of OSH

Phase I — ED nurse survey

First, we propose to develop a survey for ED nurses using a series of expert panels and focus groups. The main objective of the survey would be to query ED nurses in order to identify their beliefs and professional socialization regarding existing hazards on the job and perceptions of individual responsibility. For example, the survey would identify for both management and nurses: (a) professional socialization in terms of injury; (b) specific sources of stress; (c) sources of job satisfaction

Phase II – A new job hazard analysis for ED nurses

As described above, the JHA is believed to be an underutilized administrative tool in the battle to reduce the frequency and severity of nursing exposures. However, without an acceptable, peer-reviewed model to replicate, and given scant experience in the literature, the development of a comprehensive JHA instrument is indicated. Using data from Phase I, a pilot JHA instrument would be developed. The JHA would then be applied to a sample of ED nurses across the United States. This group of ED

Conclusion

Both academic nursing institutions and hospitals and clinics agree that occupational safety and health is an important element of their business goals and responsibilities to their students, employees, and patrons. OSHA has identified at least 12 categories of specific hazards inherent in the job descriptions of ED nurses. Yet, neither academia nor industry appears to optimally prepare nurses to identify and to successfully avoid job-related hazards. Therefore, constructing a JHA specific to ED

James D. Ramsay PhD, MA is an associate professor of safety sciences at the Indiana University of Pennsylvania. Dr. Ramsay is currently the chair of the healthcare section of the National Safety Council, and is a member of the Academics Practice Specialty within the American Society of Safety Engineers.

References (29)

  • L.A. Chiarello

    Selection of safer needle devices: A conceptual framework for approaching product evaluation

    American Journal of Infection Control

    (1995)
  • S. Ando et al.

    Associations of self estimated workloads with musculoskeletal symptoms among hospitals nurses

    Occupational and Environmental Medicine

    (2000)
  • American Nurses Association [ANA]. (2004, May 24). 2001 Health and Safety Survey. Nurses cite stress and overwork as...
  • Association of Operating Room Nurses [AORN]. (2005, April 5). AORN Position Statement on Workplace Safety [On-line]....
  • Committee on Quality of Healthcare in America, Institute of Medicine

    To Err is Human: Building a safer health system

    (2000)
  • A.B. de Castro

    Handle With Care: The American Nurses Association's campaign to address work-related musculoskeletal disorders

    Online Journal of Issues in Nursing

    (2004)
  • M.A. Denis et al.

    Risk of occupational blood exposure in a cohort of 24,000 hospital healthcare workers: Position and environment analysis over three years

    Journal of Occupation and Environmental Medicine

    (2003)
  • Department of Health and Human Services [DHHS], Centers for Disease Control and Prevention [CDC], National Institute...
  • Department of Health and Human Services [DHHS], Centers for Disease Control and Prevention [CDC]. (2004b, December 20)....
  • M. Friend et al.

    Fundamentals of occupational safety and health

    (2003)
  • S.G. Gerbrich et al.

    An epidemiological study of the magnitude and consequences of work related violence: The Minnesota nurses' study

    Occupational and Environmental Medicine

    (2004)
  • G. Ippolito et al.

    Prevention, management, and chemoprophylaxis of occupational exposure to HIV

    (1997)
  • Kuhn, W. (1999). Managing aggressive patients in a high-stress environment [On-line]. Available:...
  • M. Lagerström et al.

    Occupational and individual factors related to musculoskeletal symptoms in five body regions among Swedish nursing personnel

    International Archives of Occupational Environmental Health

    (1995)
  • Cited by (28)

    • Critical care nurses' perceptions of the outcomes of working overtime in Canada

      2017, Nursing Outlook
      Citation Excerpt :

      For health care workers, musculoskeletal disorders have been found to be related to hours of work per day and per week (Trinkoff, Le, Geiger-Brown, Lipscomb, & Lang, 2006). Beyond musculoskeletal injuries, Ramsay et al. (2006) found the emotional exhaustion that often accompanies overtime hours to be related to decreased immune function, hypertension, cardiovascular problems, physical exhaustion, and insomnia. In a report prepared for the U.S. Department of Health and Human Services, overtime was associated with poorer perceived general health, increased injury rates, greater illness, and increased mortality in 16 of the 22 studies reviewed (Caruso, Hitchcock, Dick, Russo, & Schmit, 2004).

    • Workplace hazard identification and management: The case of an underground mining operation

      2013, Safety Science
      Citation Excerpt :

      Ramsay et al. (2006) investigated hazard analysis in the US nursing profession and found that although nurses are exposed to a number of hazards on a daily basis the core competencies within their accreditation and training they failed to mention a requirement to demonstrate competence in hazard identification or control. Industries and professions such as nursing, dental health, mail deliveries, nano-technology, manufacturing, construction and mining are identified in the literature raising the importance of good hazard identification in the workplace as a preventative injury mechanism (Bentley and Haslam, 2001; Ramsay et al., 2006; Schulte & Salamanca-Buentello, 2007; Biggs et al., 2006; Reinhold and Tint, 2009). However, for example, in Australia training in hazard identification is limited and predominantly the work of consultants.

    • Non-violence-related Workplace Injuries Among Emergency Nurses in the United States: Implications for Improving Safe Practice, Safe Care

      2012, Journal of Emergency Nursing
      Citation Excerpt :

      The unpredictable and urgent nature of emergency care creates challenges that require task-specific, tailored prevention strategies that are feasible to implement in the ED environment to help mitigate the occurrence of non–violence-related injuries among nurses. Research supports multidimensional programs that include input from staff, are tailored to the range and specificity of tasks, and are implemented by well-trained multidisciplinary teams.6,10,18,25-28 The Model of ED Workplace Safety identifies 4 components that should be considered in the development and ongoing assessment of workplace safety initiatives: (1) safety policies and training programs, (2) access to safety equipment and postexposure control measures, (3) optimal staffing levels, and (4) leadership commitment.

    View all citing articles on Scopus

    James D. Ramsay PhD, MA is an associate professor of safety sciences at the Indiana University of Pennsylvania. Dr. Ramsay is currently the chair of the healthcare section of the National Safety Council, and is a member of the Academics Practice Specialty within the American Society of Safety Engineers.

    Frank Denny is the Program Manager, Occupational Safety and Health for the Dept. of Veterans Affairs. Prior to VA, Mr. Denny was employed as an Industrial Hygiene Compliance Officer for OSHA. He has over 30 years of occupational safety and health experience. Mr. Denny provides occupational safety and health policy recommendations, guidance, and educational support for VA.

    Kara Szirotnyak, MSN, MPH,COHN-S, is a program manager for Occupational Health, Workers' Compensation and Patient Safety programs for the Dept. of Veterans Affairs. Her current interests include providing safe work environments for patients and employees, “limited lifting” programs for nurses and the safe handling and moving of patients, care and treatment of injured employees, medical surveillance examinations.

    Jonathan Thomas is a senior researcher in the Research and Statistical Services Group of the National Safety Council and is adjunct faculty at Roosevelt University, teaching courses in research methods and statistical analysis.

    Elizabeth Corneliuson MS, RN, COHN-S, HEM is a Wisconsin regional coordinator for Hospital Preparedness under a HRSA grant. She has served on the NSC research and healthcare committees for the past eight years and has over twenty years of Occupational Health and Safety experience. She has served as adjunct facility for the UW Whitewater Safety Studies Program and Center for Healthcare Environmental Management through ECRI.

    Kim L. Paxton MSN, ANP, APRN-BC is Assistant Professor of Nursing at Cardinal Stritch University in Milwaukee Wisconsin, where she teaches in the Nursing ADN, BSN, and MSN programs. Professor Paxton is a practicing Emergency Department Nurse Practitioner at the Wisconsin Heart Hospital and Aurora Kenosha Medical Center.

    View full text