Chapter 26 SAFETY AND PROTECTION
Safety is a basic need of every individual throughout their lifespan. People are constantly exposed to environmental hazards that endanger safety and, while many individuals are able to maintain a safe environment independently, factors such as age or illness may reduce the ability to protect against them without assistance. Most incidents that cause harm are preventable, and nurses require the knowledge and skill to identify the potential hazards in any situation within any environment where client care takes place. Maintaining a safe environment includes preventing accidents such as falls, scalds, burns, cuts and ingesting poisons and preventing fires, injury from chemical hazards and harm from cross-infection. It is an integral part of nursing care to carefully assess clients to determine their ability to protect themselves against accidents and hazards and to become aware of clients who are particularly at risk of being harmed by them. The planning, implementation and evaluation of safety measures to prevent harm to clients is an integral part of all aspects of nursing care. Identifying and minimising threats to safety in the workplace is an essential component of a process directed towards providing and maintaining a safe environment and protecting all of those within it.
I have worked in aged care for over 5 years now and I love it. Before the no-lift policy came in I thought I was going to have to give it up because I was getting backache and by the end of the day it was quite bad. The no-lift policy has made such a difference — I’m still busy but the work seems so much lighter now that we don’t manually lift the residents. At the end of the day, yes, I’m tired, but I feel really good about the work I do and I rarely get any problem with my back now.
Safety may be defined as freedom from danger and the risk of psychological or physical injury. For clients to be safe and feel safe the nurse needs to ensure that there is a safe environment in which to work and provide client care. Nurses work with clients in a range of environments that include hospitals, clinics, schools, long-term care facilities and clients’ homes. A safe environment maintains protection of clients, staff and all other people who may be within it. A safe environment is one in which:
Nurses must assess the environment for threats to their clients and their own or other people’s safety, then plan and implement the measures necessary to reduce, or when possible totally eliminate, actual or potential hazards and the risk of harm.
Part of assessment means identifying individuals who are most at risk from hazards in the environment. All clients should be assessed for factors that may affect their ability to recognise hazards and to protect themselves from harm. Clients who are receiving medical or nursing care may be either temporarily or permanently affected by a physical, psychological or emotional impairment that interferes with the ability to recognise, avoid or protect themselves against environmental dangers.
The ability to avoid danger depends on being aware of it, and to be aware people must be able to perceive, interpret and react appropriately to sensory stimuli. People are provided with information about their surroundings through the senses. For example, the sense of smell warns of the presence of smoke or noxious fumes. Any alteration to the efficiency of any one of the five senses (taste, smell, hearing, vision or touch) may significantly reduce the ability of clients to detect and protect themselves from danger. This then may significantly increase the potential for a mishap or accident. In addition to impaired sensory organs, other factors affect the ability of clients to perceive and protect themselves from harm, including age, reduced mobility or cognitive awareness, reduced capacity for communication and intellectual, mental or psychological impairment.
The very young and very old are at particular risk of accidental injury, but each stage of human development poses its own risks to safety. Very young infants are totally dependent on others for their safety. They must be protected against infection, accidents and exposure to extremes of temperature. Toddlers and young children have not learned to distinguish between safety and danger and are therefore constantly exposed to hazards as they explore and learn about the environment. They are vulnerable to accidents because many hazards are not obvious to them; for example, they may ingest poisonous substances such as cleaning fluids if the substances are not stored out of reach in childproof containers; they may wander into a swimming pool that is not safely behind a childproof fence; they may place plastic bags on their heads if bags are left within reach.
School-age children are exposed to a wide range of new experiences. They begin to participate in more activities away from home, such as playing a sport, visiting at a friend’s house or riding a bike around the local park. Nurses can play an active role, alongside parents and teachers, in teaching and reinforcing safety measures such as what to do if approached by a stranger, observing road safety rules and wearing protective sports clothing, such as a safety helmet when riding a bicycle, skateboard or scooter.
Adolescents are at the challenging developmental stage of moving from dependence to independence and allowing their own adult personality to emerge. This is a stressful process for many adolescents and, in an attempt to cope with the tension and emotional discomfort that sometimes occur, they may participate in risk-taking behaviour. This may be the time when they start smoking, drinking alcohol and/or consuming other types of drugs. The risks to safety often result from these behaviours because they damage the body and impair the ability to make rational decisions. Smoking and consuming alcohol and other drugs are known risks to health, but they also increase the potential for incidents such as drug overdose, falling, drowning or vehicle accidents. Adolescence is also the time when physical changes promote the desire for sexual activity. If appropriate precautions are not planned and taken, sexual activity presents the possibility of sexually transmitted infections, unplanned pregnancy and emotional distress.
Not all adolescents take part in these behaviours. Many have a strong grasp on, and accept and practise, the rules and laws that are designed to protect everyone in the community; for example, don’t drink and drive, don’t drink alcohol and swim, wear a seatbelt in the car. Young people in the years leading up to and during adolescence can be kept safe from these specific dangers if they receive appropriate information and guidance about how to say no to drugs, choices about abstinence from sexual activity or how to practise safe and effective birth control. They need to be able to discuss and ask questions about these issues in an environment where they feel comfortable to do so. Nurses are frequently in the position to practise health promotion by teaching safety measures, answering questions and facilitating discussion with adolescents in the health care setting.
Young and middle-aged adults tend to be at a level of risk according to their lifestyle practices. For example, a high-fat diet, smoking and lack of exercise increase the risk of respiratory and cardiovascular disorders and cancer. The types of leisure activities indulged in, particularly sports, are often linked to injury in this age group. Workplace injuries are also common, particularly in males and particularly among tradesmen. The risk of being involved in a motor vehicle accident also remains significant (Australian Bureau of Statistics 2005).
As a normal part of ageing, older adults may experience physiological changes, including decreased muscle strength, diminished sensory acuity and slowed reflexes. Many older people adapt successfully and modify lifestyle practices to accommodate the physical changes of ageing, but statistics indicate that getting older does increase the risk of accident and injury. For example, injury from falls becomes much more common in adults over age 65. The rate of individuals needing medical attention as a result of falls is higher in residential care and hospital settings than in the community generally (National Ageing Research Institute 2004).
Abuse of older people is a safety issue that nurses need to be aware of when assessing clients. Elder abuse, particularly of those who have dementia, is sometimes related to the actions of family carers who are so tired and stressed by the hard and constant work of caring that their tolerance level reaches zero. Carers are often ashamed or too embarrassed to ask for help, and clients often do not have the courage or privacy needed to speak out about what is happening to them (Faye & Sellick 2003). Nurses must be alert for signs and symptoms of abuse when assessing clients (see Chapter 23) and recognise when family carers might need interventions such as regular periods of respite.
Mobility enables people to protect themselves against many environmental hazards and maintain their own safety. The inability to initiate, coordinate or perform motor activities reduces the capability to physically move away from dangerous situations and potential injury. Individuals who are unsteady on their feet, for example, as a result of a neurological disorder, a debilitating illness or from the effects of medication, are more vulnerable to injury from loss of balance and falling.
Impaired awareness or consciousness can reduce the ability to perceive, interpret and react to people, objects or situations in ways that maintain safety. For example, a person with Alzheimer’s dementia may walk across a busy road or touch a hot oven because they fail to perceive these things as potentially harmful. The risk of injury to self or to others is significantly increased if a person is confused, disoriented or suffers from memory lapses; for example, clients with head injuries, those under the influence of chemical substances and those with dementia or serious psychiatric illnesses. They need the nurse and all members of the health care team to work together to ensure that they are protected from harm or from harming others.
Clients who are unable to perceive danger because they misinterpret environmental cues or do not understand, see or hear verbal or written warnings or instructions are at greater risk of injury. Clients who have a language barrier or experience any communication impairment, such as aphasia for example, may not have the ability to report dangers they observe or to ask for help.
Any alteration in the brain’s ability to interpret what is happening in the environment places a client at greater risk of harm. Interference with developmental processes or changes in brain function can also cause behaviour that is not based on clear and logical decision making. This may result in clients being a threat to their own safety.
Sometimes clients may have a condition that leads them to harm themselves. Examples of self-harming behaviour include self-inflicted wounds such as cuts or burns, ingesting or injecting poisonous substances, or inserting objects into body orifices. Close monitoring is required in such cases to protect the client from self-harm (see Chapter 45). Behaviours such as these have been associated with what mental health nurses might call ‘disabling distress’ — behaviour that results from serious unresolved anxiety (Watkins 2001). Any circumstance or condition that increases anxiety may interfere with a person’s normal pattern of behaviour. It does not, in most situations, lead to self-harm, but it is not uncommon for anxiety to lead to feelings of utter panic. People who are anxious or experiencing feelings of panic can sometimes react to situations with such intensity that clear thinking and logical responses to what is happening are impossible. These individuals may experience levels of anxiety so severe that it affects their perception of, and ability to react appropriately to, the threat of harm. (Chapter 13 discusses nursing responses to anxiety and panic.)
The goal of nursing practice in relation to the need for safety is to prevent injury or harm. Nurses need to assess potential risks then plan interventions that can prevent accidents that are often the cause of injury or harm to clients. The nurse assessing potential risks to safety in relation to young children or at-risk clients living at home needs to check the entire house and garden area. Organisations responsible for community health frequently have assessment tools designed to aid the assessment of home safety. Clinical Interest Box 26.1 provides an example of one part of an assessment tool used to assess home safety. The example provided relates to checking for safety risks in a home kitchen.
CLINICAL INTEREST BOX 26.1 Example of a home safety assessment tool
Nursing interventions need to be considered in relation to the level of risk that a client faces and the impact of the intervention on social benefits and enjoyment of life. People balance risk against the pleasure or sense of achievement they will gain when they make choices about what activities they will pursue throughout life: there is a level of risk in many leisure and work activities. Whenever possible, clients should continue to be given the opportunity to consider the risks they face and make informed choices about which interventions are in their best interests. For example, a nurse visiting a client at home may be very concerned about the number of times the client has tripped over a lively pet dog. The nurse may consider the potential for serious injury is high but, even when the risks and possible outcomes are explained, the client may choose to live with the risk of tripping over the dog again and suffering an injury rather than losing the pleasure and sense of security provided by the pet.
Often risk assessment presents difficult decisions; for example, the person who has swallowing difficulties and is at risk of choking may prefer to take the risk of eating and drinking substances they enjoy, even when they increase the risk of choking. Decisions are especially difficult when the person who is at risk is deemed not competent to make an informed decision, as may be the case with people who have intellectual or cognitive impairment (Clinical Interest Box 26.2). The nurse should discuss risk assessment issues with other members of the health care team and clearly document all related discussions with the client in situations such as these.
CLINICAL INTEREST BOX 26.2 FRANK AND MARY’S STORY
Frank cared for his wife, Mary, coping very successfully for more than 10 years as her Alzheimer’s dementia gradually worsened. For the whole of the 42 years they had been married, Mary had gone for a walk almost every day. She walked for an hour or more each morning. She continued to do this as her memory became less reliable and she occasionally got lost. Frank and other neighbours sometimes had to drive around the district until they found her.
Frank became increasingly worried about Mary’s safety as she became more confused, particularly after she was knocked down on a pedestrian crossing by a car and suffered some nasty bruising. She spent a couple of days in hospital after this incident and when she came home Frank tried to keep her happy in the house or garden, or by walking with her.
Frank found walking with Mary difficult, as she liked to walk a long way and she wanted to walk alone; she shouted at him, yelled out and repeatedly tried to push him away. She even gesticulated angrily at him when he walked behind her at a distance, which he continued to do for over 6 months. Frank worried constantly that Mary would walk in front of a car again before he could reach her and stop her.
The problem was that if Mary did not go for her walk she was very agitated and cried a lot during the day and did not sleep very much during the night. She would spend the rest of the day after a walk happily pottering about in the house and garden, and she hardly stirred at all during the night.
Frank and Mary had two daughters and one son. Together with the health care team they all discussed the risks for Mary and the impact of forcibly stopping her from walking. It was discussed how, if Mary were able to decide for herself, she would choose to take the risk of another injury in order to enjoy the lifetime habit of regular long walks. Although some of the health care team were unsure, there was no conflict within the family about the decision.
Mary continued her daily walks for another 18 months until she could no longer physically manage to do so. During this time she sustained a range of minor injuries, once when she walked into the path of a cyclist, and falling twice, on the second occasion fracturing an arm. After Mary died, Frank reflected on the choice that was made. He was quite certain that, if faced with the same difficult decision, he and his family would make the same choice again.
(story told by Frank, 77, carer of Mary, who had Alzheimer’s dementia and died aged 76)
It is the nurse’s role to assess the client and the client’s environment for hazards that are a potential cause of injury, whether the environment is in the home or in a health care facility. Infective microorganisms present a significant threat in health care settings (the safety and protection measures needed to deal with this risk are addressed in Chapter 25). Some of the other most common causes of injury or harm result from thermal injuries, contact with sharp objects, poisons and pollutants, and falls.
Protection from burns and scalds includes protecting clients from the threat of fire and also from everyday risks of thermal injury. Burns or scalds can result from exposure to flame, hot liquids or objects, electrical or gas appliances, or from overexposure of the skin to the direct hot rays of the sun. Serious damage may also occur when the body tissues are exposed to extreme cold. (See Chapter 48 for information about the first aid management of burns, scalds and heat and cold trauma after exposure to the natural environment.)
Any client with impaired circulation or loss of physical sensation or who is confused or taking medications that alter mental awareness is at increased risk of a thermal injury, of which injuries by heat are the more common. The tissues of the very young and the elderly are less robust than those of other age groups and this places them at particular risk of damage by thermal injury. Measures to reduce the risk of thermal injuries include:
CLINICAL INTEREST BOX 26.3 Safety measures recommended for senior citizens to prevent fire inside the home
Children are at particular risk of thermal injury. Not all people recognise areas of risk and the nurse can play an important role in health promotion by educating clients and families about safe practices; for example, the nurse may need to educate parents about ways to prevent thermal injuries to children (Box 26.1).
Fire is a constant risk in a health care institution because of the presence of many highly combustible materials such as oxygen and cleaning solvents. Employers at health care institutions have a responsibility to conduct programs in fire prevention and safety for all staff members. Fire drills and in-service updates are held periodically in health care institutions so that all personnel can practise the emergency procedures. This usually includes an annual practice of the evacuation procedure for the facility. Nurses have a responsibility to be aware of fire prevention precautions and to practise fire safety and evacuation measures when the opportunity is offered. Nurses should refer to the facility’s fire safety policies and protocols regarding their specific responsibilities in the event of a fire. The knowledge needed to promote fire safety includes knowing the:
Three elements are necessary to start and maintain a fire — combustible material, heat and oxygen. A combustible material is anything that will burn, such as paper, textiles, flammable liquids or furniture. Heat sufficient to ignite the combustible material may originate from a lighted match, a live cigarette, a spark or from friction. If the other two elements are present, there is sufficient oxygen in the atmosphere to support combustion. Fire extinguishers contain water or a chemical, and act by either cooling the burning substance or by cutting off the supply of fuel or oxygen. There are various types of fires (such as flammable liquid fires or electrical fires), with different types of fire extinguishers used for each. Every nurse should be familiar with the use of each type of fire extinguisher.
While methods of extinguishing fires are commonly aimed at reducing heat and excluding oxygen, methods of preventing fires are directed towards controlling combustible materials and heat. Measures to prevent fire include:
The sharp objects most likely to cause cuts or puncture wounds in a health care setting are needles used for testing a client’s blood glucose level or for administering an injection, and glass ampoules that contain medication. Measures to prevent injury from needles include:
In the event of an injury from a sharp object, such as a needle-stick injury, the incident is reported immediately and documented on an incident report form (see Chapter 20). The level of risk of an infection being transmitted via the needle-stick injury is assessed and the individual treated in accordance with the policies of the health care facility. (See Chapter 25 for information concerning protective measures after possible exposure to blood-borne microorganisms.)