Designing Research to Change Policy:  Achieving Safety in the Health Care Work Environment

Jane Lipscomb, RN, PhD, FAANFounders Day Research LecturerWork and Health Research CenterUniversity of Maryland School of Nursing

Acknowledgements:

Work and Health Research Center Jeanne Geiger Brown Jeff JohnsonJoan KannerKate McPhaulCarla StorrAlison Trinkoff

Matt London, NYS PEF Earl Dotter, Photo Journalist

Our Partnerships

NY PEF, CSEA, NYSCOPBA (labor unions) OMH, OASAS, OCFS, DOL (state government) ARI (architectural consultant)

WA 1199 NW/SEIU (labor)

IL UIC IL/IN HC/SEIU (labor) Addus Health Care

The Burden of Work-Related Illness and Injury

6,500 job-related deaths from injury/yr 13.2 million nonfatal injuries/yr 60,300 deaths from disease/yr 862,200 illnesses/yr $171 billion

Leigh JP, Arch Intern Med. 1997

Incidence Rates of Nonfatal Occupational InjuriesHCSA sector and private industry, 2003-2006

Incidence Rates of Nonfatal Occupational IllnessesHCSA sector and private industry, 2003-2006

Incidence Rates of Nonfatal Occupational Injuries and IllnessesHCSA subsectors and private industry, 2003-2006

The Global Shortage of Health Care Workers

Link Between Work Environment and Patient Safety (IOM Report, 2004)

L. Aiken, Univ. of Pennsylvania

Onerous Nurse Workloads and Chaotic

Environments: Errors Waiting to Happen

Two Case Studies: Research Designed to Change Policy

Evaluation of Workplace Violence Prevention Interventions in Social Service Settings (R01-OH007948 )

Blood Exposure and Primary Prevention in the Home Care Workplace (R01-OH008237)

CDC/NIOSH Definition(CDC/NIOSH Current Intelligence Bulletin, 1996)

Workplace violence: violent acts,including physical assaults and threats of assault, directed toward persons at work or on duty

Facts about Workplace Violence:

3rd leading cause of death in the workplace

NCVS – Over 1.7 million assaults on working people annually (mental health workers’ risk is nearly 4x that of all HCW)

In 2002, 43% of all non-fatal assaults on workers which resulted in lost work days occurred in the healthcare sector

Healthcare patients commit 48% of all non fatal attacks in the workplace

Verbal Hostility/Bullying

Threat of Assault

Threat w/Weapon

Assault

Fear/Anxiety Stress/Vigilance

Injury

Lost-time Work Injury

“Iceberg” of Workplace Violence

Magnitude of the Problem

NCVS – 1.7 million assaults on working people annually (Duhart, 2002)

60% of non-fatal assaults resulting in lost work days occurred in the healthcare sector (BLS, 2007)

Up to 100% of staff report verbal and/or physical assault/year in acute care, varying by setting (Bensley 1997, May 2002)

Ave. Annual Rate of AssaultAve. Annual Rate of AssaultSelected OccupationsSelected OccupationsNational Crime Victims Survey, US DOJ 2001

Occupational Rate/1000

Physician 16.2

Nurse 21.9

Technician 12.7

All industry combined 12.6

Mental Health professional

68.2

Mental Health custodial 69.0

Mental Health other 40.7

Friedman, NEJM 2006Friedman, NEJM 2006Friedman, NEJM 2006Friedman, NEJM 2006

Violence and the Mentally Ill

Attributable risk – 3-5%

Violence independently correlated with several factors among mentally ill Hx of victim of violence, Homelessness Poor medical health

Sx of mental illness rather than the Dx

Risk factors for violence in health care? Client Factors: Under the influence of drugs or alcohol History of violence certain psychotic diagnosis Access to firearms

Staffing Factors: Working alone Working when understaffed Lack of staff training Lack of policies for preventing and managing crises

Environmental Factors: Poor environmental design Inadequate security, lighting Unrestricted movement of the public

Literature Review:Intervention Evaluation Training

Lehman (1983) VA Hospital + Infantino & Musingo (1985) + Carmel and Hunter (1990) - Parks (1996) - Goodridge et. Al. (1997) +

Post-incidence debriefing Flannery et.al. (1998) + Matthews (1998) -

Literature Review:Intervention Evaluation Other strategies

Drummond et. Al. (1989) - +Hunter& Love (1996) +Arnetz & Arnetz (2000) -

Comprehensive ProgramLipscomb et al. (2006) +/-

Policy/RegulationPeek-Asa et al. (2007) +/-

ATC Patients’ Profiles 2003-2004

• 33% criminal justice history

• 40% homeless

• 34%/80% mental health history

• 79% 2nd substance abuse

Environmental Survey Checklist (Murrett, ARI)

Working in isolation, hidden areasSurveillance cameras, mirrors, view

panelsAccess control Security hardware, alarm systems

Crowding Recreation areas Lighting, noise Objects/furnishings as weapons Sharp edges, hard surfaces

Staff Focus Groups: Findings

Staffing, especially evenings Food – poor quality causes tension Intake – can stress out clients Need more info on clients’ histories Fights over phones and personal items Building complaints, crowding, layout Patients w/ MH issues: staff training; # of

MH providers

Staff Survey Findings (N=355)

68% report that patients threaten staff at least a few times/month

52% report that they defuse potential violence at least a few times/month

21% say they aid a co-worker being threatened at least a few times/month

1% say they are hit at least a few times/month

Staff Survey Findings (N=355)

51% say they often or always review the patient history at first visit

71% say they often or always are clear about what procedures to follow when they face potential violence

76% report they completed VIP training in past year

Staff Survey Findings (N=355)

Staff assaults were significantly associated with: High risk profile of patient population:

OR = 1.25 (95% CI- 1.05, 1.48) “Having a clear procedure for clients to make

their concerns known to staff”

OR = 0.54 (95% CI- 0.31, 0.94)

Violence prevention strategies explained 17% of the variance in verbal aggression; while the direct care environment contributed an additional 3%.

NYS Violence Standard All public employers must evaluate their workplaces to

identify violence-related risk factors Union reps and employees must be included

Key program elements Incident reporting and recordkeeping List of risk factors Risk-reduction measures Training Must be in writing if have >20 employees

Enacted June 2006

Case Study – Marty SmithMurdered by client while on a home visit

46 year old experienced Social Worker

Employer: Non-profit mental health services provider

Service: Mental Health Crisis Intervention

Environment: Clients’ homes

Clients: Mentally ill living at home

Union: SEIU NW1199

….and Accompanied Visits

“I'm quite sure the supervisor would have accompanied me, …I know that but I also know that for her to come with me it's an hour out it's an hour there and it's an hour back and then if she has a meeting and she can't come when I come that's a hassle, you know.”

Homicides

NY1998

MI2001

MD2002

KS2003

WA2005

Child removal/CPS X X

Unfamiliar or new Provider

X X

Mental Health Crisis(involuntary commitment)

X X

Lack of information(Criminal History)

X X X

Visiting Alone X X X X X

The Marty Smith Act (2007) will:

provide annual safety training for all community mental health workers;

ensure that crisis intervention workers will not have to go out alone on high-risk home visits;

ensure better access to

case files for situations

that might be dangerous. 

   

Two Case Studies: Research Designed to Change Policy

Evaluation of Workplace Violence Prevention Interventions in Social Service Settings (R01-OH007948 )

Blood Exposure and Primary Prevention in the Home Care Workplace (R01-OH008237)

Occupational Groups of Healthcare Workers Exposed to Blood/Body Fluids (CDC NaSH 6/95-12/01)

Percent reduction in needlestick injuries for major safety device categories

23%

76% 66%

Up to 88%

0

20

40

60

80

100

%reduction in injuries

IV NeedlessSystems

Self-bluntingphlebotomy

needle

Phlebotomyneedle with

add-on safetyfeature

Winged steelblood collection

needle with sliding sheath

EPINet Centers for Disease Control and Prevention

Decline in HBV Cases Among Healthcare Workers Following Vaccination

0

4,000

8,000

12,000

16,000

20,000

1983 1991 1995

OSHA mandates HBV vaccination

17,000

800

This regulation had the greatest impact in eliminating HBV transmission among healthcare workers.

Mahoney F et al. Archives of Int Med 157 (1997): 2601-2603

Blood Contact Rates* among RNs (N=794) and PCAs (N=980) providing care in the home

PCA RN

Sharps 3.8 12.6

Non-sharps 6.0 16.3

Any BBP exposure 8.1 26.7

* (injury per 100 FTE)

Compared with a rate of 16/100 FTE among hospital-based RNs (Trinkoff et al, 2007)

Typical job activities and exposure to blood

Odds Ratio (95% CI)

RN PCAChange dirty linens 1.7 (1.2, 2.4) 1.6 (0.7, 3.4)

Handle sharps 1.4 (0.9, 3.2) 7.4 (4.1, 13.3)

Change wound dressings 2.5 (1.6, 4.1) 6.3 (3.4, 11.6)

Empty wound dressings 2.1 (1.4, 3.1) 8.5 (4.0, 18.0)

Insert/care urinary catheter 1.6 (1.1, 2.3) 6.9 (3.0, 15.7)

Colostomy care 1.6 (1.2, 2.4) 4.9 (2.1, 11.2)

OSHA BBP Standard (1991/2000)

“applies to all employers who have employees with reasonably anticipated exposure to

blood and other potentially infectious materials”

Should this standard apply to

unlicensed health care personnel

providing care in the home?