Nursing Safety

The latest health and safety survey from the American Nurses Association (ANA) makes it clear that the efforts to protect nurses from occupational injuries remain a crusade-in-progress� The survey indicated that hospitals appear to be safer workplaces today than 10 years ago, when the last ANA survey was conducted� Safe needle devices and patient-lifting equipment are more available today than a decade ago� However, responses of more than 4500 RNs that participated in the ANA 2011 Health and Safety Survey indicated the same top three concerns were identified by the 2001 participants and in slightly higher percentages:

• 74 percent cited the effects of stress and overwork (versus 70 percent in 2001)� • 62 percent cited disabling musculoskeletal injury (versus 59 percent in 2001)� • 43 percent cited contracting an infectious disease (versus 37 percent in 2001)�

The 2011 survey revealed that 64 percent of RNs work for hospitals that provide patient assist devices� Fifty-six percent of 2011 respondents indicated they experienced musculoskeletal pain related to or made worse by their jobs� Eighty percent worked despite musculoskeletal pain� Slightly less than 15 percent reported suffering three or more work related injuries within a year� Just 21 percent of respondents in 2011 listed fear of contracting HIV or hepatitis from a needle-stick event, down from more than 40 percent from the 2001 survey� Only six percent of 2011 respondents

BOX 1.1 TOP 10 OSHA CITATIONS FOR 2011-2012

Health Services Industries (All Categories)

• Bloodborne Pathogens (1910�1030) • Hazard Communication (1910�1200) • Formaldehyde (1910�1200) • Recordkeeping Forms (1904�0029) • Medical Services and First Aid (1910�0151) • Maintenance, Safeguards, and Operational Features for Exit Routes (1910�0037) • Electrical Systems Design, General Requirements (1910�0303) • Electrical Wiring Methods and Components (1910�0305) • Personal Protective Equipment, General Requirements (1910�0132) • Annual Illness/Injury Summary (1904�0032)

TABLE 1.1 OSHA Comparative (Nonfatal) Incidence Rates for 2011

indicated concern about latex allergies, as glove alternatives are more available than in 2001� Ten percent of 2011 respondents voiced concern about their exposure to hazardous drugs and other toxic substances� Awareness of hazards appears to be the key reason for increased concerns� Eleven percent of respondents reported a physical assault within the past year, which was down from 17 percent in 2001� However, more respondents ranked assault risks as a top three nursing concern in 2011 than in 2001�

The ANA, in collaboration with a national working group and other professional organizations, recently released Safe Patient Handling and Mobility: Interprofessional National Standards� The 40-page outline contains eight evidence-based standards to prevent injury� The standard should provide a foundation for establishing a culture of safety for all caregivers and patients� An interprofessional work group established the standards that apply in any healthcare setting� The standards call for establishing a culture of safety, which includes ensuring safe levels of staffing, creating a nonpunitive reporting environment, and developing a system for communication and collaboration� Other standards address (1) implementing a safe patient handling and mobility program, (2)  using  ergonomic design principles to provide a safe environment of care, (3) obtaining safe patient handling technology, (4) creating processes for educating, training, and maintaining personal competence, (5) integrating patient-centered assessments, care planning, and technology, (6) requiring safe patient handling while considering reasonable accommodations and post-injury return to work policies, and (7) establishing a comprehensive evaluation system� The publication also includes a glossary of terms and appendices containing tools and resources�

Nurses play a critical role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing countless other tasks to ensure patients receive high-quality care� Nurse vigilance at the bedside must remain the key element in ensuring safety� Assigning nurses an increasing numbers of patients eventually compromises nurses’ ability to provide safe care� Several seminal studies have demonstrated the link between nurse staffing ratios and patient safety� The nurse-to-patient ratio is only one aspect of the relationship between nursing workload and patient safety� Overall nursing workload is likely linked to patient outcomes as well� Determining adequate nurse staffing is a very complex process that changes on a shift-by-shift basis, and requires close coordination between management and nursing based on patient acuity and turnover, availability of support staff and skill mix, and many other factors�

A recently conducted survey indicated a large number of American, British, and Chinese nurses feel that hospitals are falling short in keeping patients safe, according to a recent survey of 900 nurses from the three countries� Although nearly all nurses said that their hospitals had programs in place that promote patient safety, they questioned their impact� About 40 percent of nurses described their hospital as safe and less than 60 percent believed that patient safety efforts in their hospital were effective� They said access to technology, heavy workload, communication with patients and doctors, and punitive systems for reporting errors were at the core of the problem� The survey was conducted by GE Healthcare and the American Nurses Association� Some 90 percent said they felt most responsible for patient safety� A large majority of nurses see data, technology, and innovation as key to identifying early warning signs and alerting staff� Many nurses said that there was a lack of feedback between patient safety data and the nursing staff� The results also suggest that moving away from a culture of punishment for poor practice could help to improve matters� About 40  percent of nurses rated their hospital as excellent at communication with the patient� Only about 30 percent indicated their hospital was excellent at communication between staff�

The International Board for Certification of Safety Managers (IBFCSM) was founded in 1976 as a not-for-profit credentialing organization, and operated for some time as the Board of Certified Hazard Control Management (BCHCM)� The Board offers qualified working healthcare professionals including nurses the opportunity to earn their Certified Healthcare Safety Professional (CHSP), Certified Healthcare Emergency Professional (CHEP), or Certified Patient Safety Officer (CPSO) credential� Many healthcare professionals hold more than one credential� The Board offers CHSP and CHEP credential holders the opportunity to add the healthcare Fire Safety Management (FSM) designation to their primary certification� The IBFCSM motto, Individual Credentials-The Key to Upgrading the Profession, reflects the impact that individual certifications have on improving organizational safety and hazard control functions�

Safety must focus on developing processes or systems that can help prevent harm and loss� An uncorrected hazard or hazardous situation could contribute to an event resulting in property damage, job interruption, personal harm, or adverse health effects� The process of controlling hazards may require development of written policies, plans, or procedures� Never consider safety as a program but as a function of the organization� The safety function must connect with organizational structures and operational philosophies�

The term “program” is derived from the French word “programme,” which means agenda or public notice� We can also refer to the Greek word “graphein,” which means to write� When used with the prefix “pro” it became “prographein,” which means to write before� Many organizations develop written safety programs to satisfy organizational mandates or to demonstrate visual compliance with regulatory requirements� Written plans, policies, and procedures should direct the hazard control function� The word “function,” first used in the early 16th century, denotes the concept of performance or execution� A function can relate to people, things, and institutions� A function

BOX 1.2 BASIC SAFETY PRINCIPLES

• Correcting causal factors results in better use of human and material resources� • Placing individual blame leads to organizational problems being ignored� • Data collection provides the foundation for effective analysis of hazards� • Safety efforts must address poor and hazardous behaviors� • Communication and human relation skills remain key to achieving safety results� • Hazard control focuses on accomplishing the job with safety� • Hazard control functions as a quality tool when integrated into all job functions� • Good hazard control and efficiency function as partners within an organization�

BOX 1.3 SEVEN VALUES OF EFFECTIVE SAFETY

• Never-Ending Process • People Focused • Leadership Driven • Operational Priority • Benefits Everyone • Reduces Organizational Losses • Prevents Human Harm

can refer to serving a designated or defined role in some manner� A function can also relate to participation in an ongoing cultural or social system� Considering hazard control as a function of the organization elevates its priority in the minds of everyone�

Many healthcare and medical organizations fail to outline specific safety and hazard control responsibilities in their plans, procedures, directives, and job descriptions� The concept of responsibility relates to a person’s obligation to carry out assigned duties in an efficient, effective, and safe manner� Senior leaders must ensure that managers, supervisors, and frontline nursing personnel understand the importance of their assigned safety responsibilities� Senior leaders must ensure that job descriptions address safety responsibilities inherent with each job position� Safety efforts will yield results when leaders encourage participation and hold key managers accountable� Senior leaders and hazard control managers must learn to focus on the hazards, behaviors, and risks that pose the most potential harm�

Nursing supervisors must possess the knowledge and experience to provide hazard control guidance to those they lead� First-line supervisors occupy a key hazard control position in many organizations� This position of trust can require supervisors to conduct area inspections, provide job training,

BOX 1.5 SENIOR MANAGEMENT RESPONSIBILITIES

• Develop, sign, and publish an organizational safety policy statement • Describe key expectations related to accomplishing safety-related objectives • Ensure that all organizational members can explain the major objectives • Develop methods to track progress and provide feedback to all organizational members • Require managers and supervisors to visibly support established objectives

BOX 1.4 REASONS FOR INEFFECTIVE SAFETY EFFORTS

• Safety efforts focus on activities instead of behavioral elements� • Safety problems and issues are not addressed using a systems approach� • Senior leadership fails to define the organizational safety philosophy� • The organization focuses primarily on compliance and accreditation issues� • Physicians in many situations do not participate in safety efforts and become an

obstacle� • Safety education and training programs focus too much on simply documenting

attendance� • Performance-and objective-based training and education are rarely provided� • Competition is allowed to exist among safety program elements (e�g�, patient vs�

worker safety)� • Leaders many times fail to address or deal with turf kings and queens with their own

agendas� • Lack of good coordination results in poor “buy-in” by organizational leaders� • Senior leadership does not communicate goals and objectives to all levels� • Effective accident investigation techniques are not implemented� • Root cause analysis methods are used only for patient safety, not all safety events� • The facility believes a “one-size-fits-all” safety program approach will work�

ensure timely incident reporting, and accomplish initial accident investigations� Supervisors in many healthcare settings possess little control over factors such as hiring practices, working conditions, and equipment provided to them� Supervisors must understand the role that human factors can play in accident prevention and causation� They must ensure that each person they supervise understands the behavior expectations of the job� Some organizations require employees to sign a safe work agreement� Such an agreement requires the individual to commit to working safely and to adhere to organizational policies or procedures� Supervisors must ensure that frontline personnel can access all safety-related directives, plans, policies, and procedures�

Nursing supervisors must explain work rules and behavioral expectations to all new or transferred employees� Supervisors must never tolerate individuals that encourage others to disregard work rules or established procedures� When disciplining an individual, do so in private, but always document the facts� Senior leaders, managers, and supervisors must set an example for others� They must discourage poor behaviors by reinforcing the importance of acceptable behaviors� Never confuse correcting a behavior with undertaking needed disciplinary action� When correcting an unsafe behavior, always state the facts about the situation but limit personal opinions� Use statements that begin with “I” but never use “they” statements� Take time to recognize good behaviors by using positive reinforcement� Keep in mind that some individuals may not recognize a hazard or hazardous situation� Some may recognize a hazard but not possess the ability to deal with it� Too many injuries occur when a person recognizes a hazard but fails to respect its potential for causing harm�

Employee engagement occurs when an individual personally feels their connection to their position or job� This engagement also refers to their personal commitment to the success of the organization�

BOX 1.7 BEHAVIOR CORRECTION PROCESS

• Step 1 – Identify the unsafe action • Step 2 – State concern for worker’s safety • Step 3 – Demonstrate the correct and safe way • Step 4 – Ensure the worker understands • Step 5 – Restate concern for personal safety • Step 6 – Follow up

BOX 1.6 NURSING SUPERVISOR RESPONSIBILITIES

• Enforce work rules and correct unsafe or at risk behaviors • Implement mandated safety policies and procedures for their areas of responsibility • Provide job-or task-related training and education • Immediately report and investigate all accidents in their work areas • Conduct periodic area hazard control and safety inspections • Ensure proper maintenance and servicing of all equipment and tools • Lead by example and personally adhere to hazard control requirements • Conduct safety and hazard control meetings on a regular basis • Work with organizational hazard control personnel to correct and control hazards • Ensure all personnel correctly use required personal protective equipment (PPE)

Employee engagement can contribute to individual satisfaction and personal mental wellness� Engaged employees also help improve the productivity, morale, and motivation of others� Today, many organizations realize the need for balancing work demands with a person’s family and other life issues� When off the job, organizational members serve in a variety of roles including as a volunteer, caregiver, and parent� Understanding employee engagement helps leaders and hazard control managers deal with the complexity of human behaviors� Conflicting responsibilities can lead to role misunderstandings and work-related overloads, which can impact organizational objectives, including hazard control efforts�

Classifying and defining hazards can vary greatly depending on a number of factors, including type of industry, process, or operation� For example, mechanical energy hazards can involve components that cut, crush, bend, shear, pinch, wrap, pull, and puncture� Biological hazards can include pandemic, bioterrorism agents, bloodborne pathogens, and infectious waste� Chemical hazards include substances such as solvents, flammable liquids, compressed gases, cleaning agents, and even disinfectants� Physical hazards can include risks posed by fire, radiation, machine operation, and noise� Environmental and ergonomic hazards include slip, trip, and fall hazards, walking and working surfaces, lighting, and tasks with repetitive motions� Psychosocial hazards address issues such as workplace violence, work-related stress, sleep deprivation, mental problems, chemical dependency, alcohol abuse, and horseplay on the job�

Hazard identification requires the identification of hazards, unsafe conditions, and risky behaviors� Hazard anticipation relies on human intuition, training, common sense, observation, and continuous awareness� To identify hazards, rely on the use of inspections, surveys, analysis, and human recognition reporting� Hazard identification efforts should focus on unsafe conditions, hazards, broken equipment, and human deviations from accepted practices� Require supervisors or unit safety coordinators to conduct periodic area inspections� These individuals should understand hazardous areas and the workers better than anyone� However, supervisors can fall prey to inspection bias, which results in poor survey results� Many supervisors conduct limited ongoing inspections

BOX 1.8 WAYS TO PROMOTE SAFE BEHAVIORS

• Requiring everyone to walk the talk, also known as “modeling” • Rewarding people when appropriate • Recognizing people for making good efforts • Correcting unsafe behaviors in a positive manner • Learning to deal with behaviors and not attitudes • Motivating through a focus on promoting trust • Educating others to increase their understanding • Presenting the “why” of something • Encouraging people to become engaged and to participate • Empowering subordinates to make decisions • Coaching by promoting teamwork and individual improvement • Consulting to provide guidance from a short distance away • Coordinating to allow people to buy in and take ownership • Leading and motivating others to achieve goals by focusing on the process • Promoting better listening to learn from others

as part of their daily job duties� Periodic inspections and surveys can focus on critical components of equipment, processes, or systems with a known potential for causing serious injury or illness� Some equipment inspections help meet preventive maintenance requirements or hazard control plan objectives� Safety standards can mandate that qualified persons periodically inspect some types of equipment, such as elevators, boilers, pressure vessels, and fire extinguishers, at regular intervals� Establish the frequency of inspections by considering the scope and type of the hazardous operations� Many hazard control plans fail to provide sufficient guidance about how to conduct hazard surveys, inspections, and audits� Inspections, audits, and hazard surveys can only help identify hazards when conducted properly� Providing a checklist to an untrained person can result in his or her failure to properly identify hazards or unsafe conditions� General checklists serve as tools that guide an inspection process� These documents do not contain information about all potential hazards� The effective use of demand response checklists will also require some type of education or training� Demand response checklists address specific operations and complex job processes such as the operation of robotic systems or the control of hazardous energy�

Conduct education and training sessions about how to conduct inspections� Periodic inspections provide opportunities for hazard control personnel, line supervisors, and top managers to listen to the concerns of those doing the work� Inspections should accurately assess all environments,

BOX 1.9 HEALTHCARE OCCUPATIONAL HAZARD CATEGORIES

• Biological hazards include bacteria, viruses, infectious waste, and bloodborne patho gens� • Chemical hazards can pose a variety of risks due to their physical, chemical, and

toxic properties� • Ergonomic and environmental hazards include repetitive motion, standing, lifting,

trips, and falls� • Physical hazards include things such as radiation, noise, and machine-generated

hazards� • Psychosocial hazards include substance abuse, work-related stress, and workplace

violence�

Note: Some hazards may fit in more than one category.