After completing this chapter, you should be able to:
• Determine your risk for encountering a workplace issue that can affect your health or well-being.
• Understand ergonomics and ways to safeguard your musculoskeletal system.
• Understand the experience of making an error and strategize how to manage your experience and do the right thing.
• Know the risk of exposure to hazardous substances.
• Recognize the risk for violence at work and how to reduce your risk.
• Analyze workplace bullying and harassment.
• Create a personal plan to handle workplace problems such as staffing shortages and being assigned (floating) to an unfamiliar workplace.
• Identify useful Internet sites to keep up-to-date with potential workplace issues (e.g., OSHA, CDC, ANA).
A hospital, nursing center, clinic, or physician’s office can be a potential hazard to your future health and well-being. This is especially true if you are not informed. Many nurses are aware of the risk of exposure to infection, but they are not aware of other hazards that exist in health care organizations. Nurses in a health care organization have an increased risk for injury, toxic chemicals, bioterrorism, and violence. How well a health care organization plans and protects workers from occupational hazards is a measure of how safe you can expect to be and what safety measures you need to take as you work. This chapter addresses workplace issues that could potentially affect your health and well-being and addresses what you need to do to avoid injury, occupational exposure, and illness.
Questions to ask When Starting a New Position
As a nurse, when you are preparing to start a new position, ask your new employer to answer the following questions to enable you to evaluate the impact workplace issues will have on your health and well-being:
▪ Is the hospital latex-free? If not, what latex will I be exposed to?
▪ Inquire about availability of patient safety equipment such as lifts, transfer boards, and gate belts. How much will I be lifting, pulling, and tugging? Does the hospital use lift teams?
▪ Ask to see a common patient room. Think about moving around in the room, and ask how much moving of furniture, stretchers, or equipment you will be doing. Will I be using a computer? Is it wall mounted so that I need to stand to type, or will there be a desk to sit at when I need to type?
▪ What is the nursing injury rate for the unit I will be working on?
▪ Is there worker’s compensation in the benefits for the organization? Would I be able to return to work in a light-duty capacity if I am injured? For how long? What are the rules of the state?
▪ Does the organization have an antiviolence program? How does the organization address bullying behaviors and other hostile work situations such as sexual harassment?
▪ Is the organization needleless? If not, what is my exposure risk?
▪ What is the organization’s policy for exposure to infectious agents? Does it include testing, medication, counseling, and follow-up? What is the process for this? (This information can often be found in the employee handbook.)
▪ What is the organization’s tuberculosis (TB) prevention plan? Does the plan adhere to Occupational Safety and Health Administration (OSHA) regulations? How often will I be tested?
▪ Does the organization have an influenza prevention plan? Does it follow the Centers for Disease Control and Prevention (CDC) guidelines?
▪ Is there a plan for handling potentially toxic or infectious substances such as blood, chemoprophylaxis, and suction canisters? What is my potential exposure? Will I receive training in correct handling? Will annual refreshers be offered?
▪ Where will I park? Is the area well lit? Is it patrolled? Have there been any serious events in the past 6 months?
▪ Does the organization provide vaccinations for infections I might be exposed to, such as influenza, chickenpox, and hepatitis B?
▪ Does the hospital have a surveillance plan for multidrug resistant organisms (MRSA, VRE)? Does it follow current CDC guidelines?
▪ How often will I be expected to work “off shift” (shifts other than what I normally work), on-call, or mandatory overtime?
▪ How often will I need to work on a unit other than my assigned unit? How will I be oriented?
Ergonomic Hazards for Health Care Workers
According to the American Nurses Association (ANA), safe patient handling and mobility have become a major safety concern among health care workers (ANA, 2016b), and nurses are considered to be in a profession that puts them at risk for serious musculoskeletal injuries. The most common problems tend to be back and shoulder injuries. Unfortunately, these types of injuries are the most debilitating. Imagine if you cannot raise your arms or reach for things without severe pain. What if you needed help to dress yourself because you lost flexibility in your shoulder joint? What would happen if every step you took resulted in pain in your back and down your leg? What if sitting or lying down did not relieve your distress? These are potential health-related problems of nurses that can be minimized by following safety standards and protocols.
Back Injury
So, what is your risk? That is somewhat unclear, because studies investigating work-related injuries in nursing are sporadic. One study reported that 90% of nurses complain of back pain (Kyung Ja & Sung-Hyun, 2011). In addition, nurses in one study reported changing jobs because of a back, shoulder, or neck injury (Trinkoff et al., 2003). Although this is an older reference, the problem is potentially more serious today because patients are becoming sicker and heavier, and there is more equipment for nurses to work around (including computers and workstations). These factors increase the risk of injury. Back-related injuries reduce the already short supply of nurses, and because there are fewer nurses, the risk for back-related and other musculoskeletal injuries increases. It becomes a vicious cycle.
Why are these injuries so common in nursing? It is simply the nature of the work that nurses do. Lifting, transferring, repositioning, and reaching are the actions that are associated with work-related injuries. Often the configuration of the patient’s room and the placement of furniture, monitors, blood pressure cuffs, thermometers, and other hanging devices contribute to injury, because nurses are required to reach and stretch in nonergonomic positions to perform tasks.
In the past, it was believed that good body mechanics with proper lifting techniques could prevent back and shoulder injuries. However, according to the ANA (2016b), the idea that there is a safe way to lift or turn a physically dependent patient manually is no longer valid. Many of the situations in which nurses are injured involve sudden, quick changes in position with human beings. Therefore, proper body mechanics are not enough to safeguard against injury, because the nurse cannot adjust in a way that fully protects the back. Teaching nurses to use proper body mechanics to lift and turn patients does not result in fewer injuries (ANA, 2016a). Because of the dangers associated with manual patient handling, the current recommendations by the ANA include eliminating manual lifting and using assistive patient-handling devices for lifting, transferring, and turning patients (ANA, 2016a).
It is important that nurses take good care of their backs, even when they are young, flexible, and strong, because aging contributes to the risk for a career-ending injury. Also, as people age, there is a loss of flexibility and increased musculoskeletal instability. Repetitive stress on the structures of the spine, shoulders, and hips can cause small repeated muscle and tendon damage that could manifest in serious debilitating injury. Consider what happened to Sandy.
Sandy was a strong, flexible, and healthy person. She could lift patients in bed, turn them, bathe them, and ambulate them without help. Very seldom did she ask for help. She could stand, walk briskly, and work for 16 hours without a break. And go back the next day. She was proud of her abilities and the fact that she was everything to her patient. She was the one every nurse on the unit loved to work with because of her independence and willingness to help others.
Today at age 50, things are much different. She sits in an office all day wishing for her bedside job. She had to change jobs because she could no longer work at the bedside. Her shoulders, knees, back, and hips all are damaged from chronic stress from the lifting, straining, and reaching she had done during her career.
The ANA has sponsored a program called “Handle with Care” to raise awareness, promote the use of ergonomic equipment and assistive devices, and encourage health care organizations to invest in a safe patient-handling program. In addition, by reducing work-related injuries to nurses, safe patient-handling programs can reduce some of the hidden costs of health care organizations and improve patient care (ANA, 2016b).
What can the nurse do to reduce the risk of serious back injury? First, be aware of the potential risk by assessing each patient’s dependency needs and abilities when deciding what assistive devices to use. Do not move, lift, or turn a dependent person without an appropriate assistive device or help (Fig. 25.1). Next, know what assistive devices are available to you, and learn how to use them properly. If your organization does not have devices readily available, become an advocate for a safe patient-handling program. It is also important to keep yourself fit, and do not ever “tough it out” when you suffer an injury. Make sure you report your injury according to policy, and follow the advice of your health care provider so that your body can properly heal. For more information on ways to promote safe patient handling and prevent work-related injuries, see the following websites: www.nursingworld.org/handlewithcare. At the ANA site, http://www.rnaction.org/site/PageNavigator/nstat__take_action_sph_113.html, you can join the team to fight for legislation to enact laws protecting nurses from harm (ANA, 2016b). Finally, it has been suggested that nurses consider developing a practice for “warming up” and stretching before they start their workday. This is to be followed up by stretching again at the end of a day. Another strategy to maintain a limber, flexible body core is to enroll in a yoga or Pilates program.
Ergonomic Workstations
Many of today’s jobs are performed at a computer work area, often in a “shared” area. This is the case in a hospital setting, where nurses, physicians, and ancillary caregivers frequently use the workstation 24 hours a day. There may be dozens of workers trying to use the same computer workstation almost constantly. Change, variation, and adjustment to fit an individual worker are basic to the well-being of each worker. Workstations should accommodate users of many different heights, weights, and individual needs. Computer vendors must keep in mind that the “typical” nurse is in his or her mid-40s, and letter size and font as well as proper lighting and the avoidance of shadows are vitally important to aid in viewing computer screens.
The successful ergonomic design of an office workstation depends on several interrelated parts, including the task, the posture, and the work activities. The three activities alone can be difficult to handle, but these activities must also interact properly with existing furniture, equipment, and the environment. The combination of the aforementioned makes the picture more complicated. Important parts of the workstation are the chair, the desk, and the placement of the computer (CPU), keyboard, and monitor.
The chair should be padded appropriately, easily adjustable, and have strong lumbar support. Usually, wheels allow easy movement, and armrests may or may not be used because they sometimes cause more problems, depending on the individual needs of the user. Therefore, armrests should be fully adjustable to accommodate the user.
The desk must be wide and deep enough to accommodate the computer’s monitor, keyboard, and mouse, with ample space around the machine to write, use the phone conveniently, and perform all other desktop activities. Keep the area clear of clutter and crowding.
Ideally, the placement of the monitor, keyboard, and mouse would be adjustable for every worker, but because this is rarely possible, the monitor height should be approximately 18 to 22 inches above the desk surface, causing most users to view the screen with slightly lowered eyes. The keyboard should be placed directly in front of the user and the mouse on the user’s dominant-hand side of the machine. Some nursing stations designate certain machines as left-handed mouse machines so that the mouse will not need to be switched numerous times during a shift. Be sure to use a mouse pad to ensure traction, lessening the frustration and continual long movements of the mouse (Critical Thinking Box 25.1). Some individuals wearing glasses need “computer lenses” to make reading the monitor easier and also to screen out blue light, which is associated with a higher incidence of cataracts and macular degeneration (Wood, 2014).
CRITICAL THINKING BOX 25.1What is your workplace environment like? What lift equipment do you have? Have ergonomics been considered? How could you make it better?
Repetitive Motion Disorders
Poor workplace design is often the major source for repetitive motion disorders (RMDs) or cumulative trauma disorders (CTDs). RMDs have been associated with users who work for long periods at poorly constructed or poorly arranged workstations.
Ergonomic design of work tasks can reduce or remove some of the risks. Other solutions may include
▪ Information and training to workers about body positions that eliminate the opportunity for repetitive stress injuries to occur
▪ Frequent switching between standing and sitting positions, reducing net stress on any specific muscle or skeletal group
▪ Routine stretching of the shoulders, neck, arms, hands, and fingers
Workplace Violence: A Growing Concern in Health Care
Witnessing the aftermath of a violent attack on a nurse colleague is a powerful realization that the potential for being harmed by another person at work is very real. As a nurse, you are at risk for harm from co-workers, patients, and families. No matter what the occupation, workplace violence is an ongoing concern in the United States. The nature of health care workers’ jobs puts them at risk for workplace violence, which can result in injury or death (Foley & Rauser, 2012).
Workplace violence is defined by the United States Department of Labor as “an action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats” (n.d.). Nurses often fail to report acts of violence because of a lack of understanding or a belief that “nothing can be changed” (McNamara, 2010). Failure to report risks escalation of the situation until physical violence occurs. In some cases, nurses have never encountered a hostile person before, and they do not understand how to recognize and de-escalate the situation. In other situations, a nurse can have a history of violence and the experience can bring forth images and memories, called post-traumatic stress disorder (PTSD). Anyone who has experienced violence is at risk for experiencing this phenomenon wherein the individual can experience intense emotions such as anxiety, depression, anger, and flash-backs (re-experiencing the initial event) in response to verbal or physical violence.
Recently, a nurse in a large urban hospital was working with a young man who had been hospitalized with chest pain. He had denied any drug use; however, it was found that he habitually used cocaine and also consumed large amounts of alcohol on a regular basis. Once the physician discharged him, the patient grew increasingly agitated waiting for the paperwork for his discharge. He wanted to leave the facility to resume his drug-related behaviors.
The nurse had been working on the unit less than a year after graduation and did not recognize the patient’s increasing agitation. He used the call light to repeatedly summon the nurse to the room asking when he could leave. When she entered the room in response to his fifth call and told him it would be another 30 minutes before she could complete the paperwork for his discharge, he attacked her. Before she was able to summon help, she was assaulted and was seriously injured, requiring surgical repair of lacerations and a head injury. The nurse recovered fully from a physical standpoint but suffered severe post-traumatic stress disorder and was not able to return to her chosen profession. A huge emotional toll was also seen in the rest of the nurses on staff, who were fearful of a similar event happening to them.
In response to incidents such as this, along with other events occurring in the local industry, the hospital administration developed a crisis intervention program. This program taught nurses and other hospital staff how to recognize signs of escalating anger that could result in a violent attack and strategies to de-escalate the situation. Nurses were also taught how to protect themselves during an attack; for example, keeping the door between you and the patient for easy escape. The nurse in the above situation had walked over to the window and the patient was able to barricade the door, which kept her from escaping. Knowing how to recognize an escalating situation and how to defend against an attacker helped these nurses believe they could manage future situations that put them at risk for harm.
Additionally, the hospital instituted a “code white” program. A code white stood for a potentially violent situation, which anyone could initiate if any person became loud or abusive, made threats, or started throwing objects. A code white ensured that resources were available to help de-escalate the situation and that no nurse or any other staff member would be alone with someone who was acting out. Trained volunteers and other staff from the hospital, including security staff, responded to a code white, which would be announced over the hospital’s PA system. It was stressed to nursing staff members that any time they felt unsafe, a code white should be called. The code could be implemented by using the phone system or by pushing a strategically placed alarm button. After instituting the program, there were no further incidents in which nurses were harmed over the ensuing years.
So what do you need to do when you start your first job? First, be familiar with your organization’s policies regarding workplace violence. Next, consider taking a crisis intervention course to become familiar with the signs of escalating violence, such as pacing, using foul language, raising one’s fist, or using threats. Learn strategies to de-escalate anger. Finally, do not ever try to handle a potentially violent person on your own. Use whatever procedures your organization has put in place to defuse situations; for example, call security or call a code white (Fig. 25.2).
Lateral Violence (Bullying) and Other Forms of Workplace Harassment
As a nurse and individual, it is easy to recognize overt violence. Most hospitals have procedures and policies to handle violent events. Less common is recognition and action related to horizontal or lateral violence, which is often called bullying in the workplace; however, these terms are different. Lateral violence refers to violence directed to an individual by another individual who is considered a colleague or equal in terms of job scope, whereas bullying is defined by Kirchner (2009) as “the purposeful exertion of power that is perceived by the victim as physically or emotionally threatening” (p. 177). Most of us believe that the backyard bullies of our childhood will disappear in adulthood. Unfortunately, recent evidence has proven otherwise. Our bullies of childhood tend to grow into the bullies of our adulthood. Consider what happened to Judy:
Judy was excited to start work in the critical care department. She was pleased that the manager had selected her to start there, because she understood the criteria for working in that department as a new graduate were very strict. She had chosen a preceptor from the nurses she knew.
Soon, she found herself to be totally stressed out by work. Always an optimistic, carefree person, she was now nervous and had an onset of migraine headaches. She was not sleeping or eating normally. Her family was very concerned.
At the request of her family, Judy went to see a counselor at the Employee Assistance Program. The counselor helped her identify that other nurses on the unit were bullying her by targeting her and isolating her by their responses to the things she did or said. For example, during shift report, if she asked a question, the nurses at the report table would put down their pens and glare at her or roll their eyes. If she asked for help lifting a patient, everyone would ignore her. The nurse who was the center of the bullying would yell at her in front of everyone for minor transgressions (if she dropped a pill or forgot to write her blood glucose readings on the report board). If Judy made a mistake, everyone would know about it, and the story of the event would grow as it was passed on to others. Judy often overheard these comments and was often angry. The anxiety caused by knowing she would be treated this way every day was impairing Judy’s ability to grow and develop as a new nurse. It was also having a negative effect on her patient care and on her health.
Judy needed to understand better what was happening to her so that she could recognize the signs if she was ever the victim of bullying again. She also needed to develop a plan to manage her current situation. She found a website called the Workplace Bullying Institute (www.bullyinstitute.org) that provides a wide array of helpful information and assistance, including coaching and current legislation. With the help of her counselor, Judy developed an action plan to address her situation. After time off to contemplate her work life, and after she realized the bullying behavior would not be addressed at her current place of employment, Judy found another job in a local hospital and started a new position.
At her new place of employment, Judy found a wonderful mentor and was soon growing as a nurse. Her physical health improved, and with help from her counselor and coach, she was once again a mentally healthy person. Judy had learned from her experience and was determined never to allow a bully to have this level of impact on her again.
You may hear after starting your first position that “nurses eat their young.” Mild forms of hazing activity are common in many professions and can usually be overcome by those who are victims of these behaviors. New nurses may feel the need to prove that they can be counted on to provide safe care for their patients. They may find that their work ethic and skills are being “tested” by other nurses. This type of activity usually lasts for the first weeks of a new position and gradually improves as a new nurse becomes integrated into the work life of the unit.
Experiences Outside Work
• You feel like throwing up the night before the start of your work week
• Your frustrated family demands that you stop obsessing about work at home
• Your doctor asks what could be causing your skyrocketing blood pressure and recent health problems and tells you to change jobs
• You feel too ashamed of being controlled by another person at work to tell your spouse or partner
• All your paid time off is used for “mental health breaks” from the misery
• Days off are spent exhausted and lifeless; your desire to do anything is gone
• Your favorite activities and fun with family are no longer appealing or enjoyable
• You begin to believe that you provoked the workplace cruelty
Experiences At Work
• You attempt the obviously impossible task of doing a new job without training or time to learn new skills, but that work is never good enough for the boss
• Surprise meetings are called by your boss with no results other than further humiliation
• Everything your tormenter does to you is arbitrary and capricious, working a personal agenda that undermines the employer’s legitimate business interests
• Others at work have been told to stop working, talking, or socializing with you
• You are constantly feeling agitated and anxious, experiencing a sense of doom, waiting for bad things to happen
• No matter what you do, you are never left alone to do your job without interference
• People feel justified screaming or yelling at you in front of others, but you are punished if you scream back
• HR tells you that your harassment isn’t illegal, that you have to “work it out between yourselves”
• You finally, firmly confront your tormentor to stop the abusive conduct and you are accused of harassment
• You are shocked when accused of incompetence, despite a history of objective excellence, typically by someone who cannot do your job
• Everyone—co-workers, senior bosses, HR—agrees (in person and orally) that your tormentor is a jerk, but there is nothing they will do about it (and later, when you ask for their support, they deny having agreed with you)
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