designing research to change policy: achieving safety in the health care work environment
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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?
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