March 14 kicks off Patient Safety Awareness Week, an annual recognition of the essential need to improve safety in all settings.
For nurses, awareness about patient safety impacts every aspect of their work. From medication prescriptions and delivery, to diagnoses and follow up, to ambulatory safety and safety of those who are bedridden, to the treatment of conditions and issues that affect virtually every area of the body, nurses place safety at the very top of the list of what they do.
No matter how careful healthcare workers are and how much they prioritize patient safety, there’s always room for improvement. And the numbers are alarming when it comes to the widespread impact errors have. According to the World Health Organization, as many as 4 in 10 patients are harmed in primary and outpatient healthcare situations across the globe. Of the harm done, more than three-quarters of the cases are preventable and the most harmful errors fall under medication use, prescriptions, and medical diagnosis. Even treatment in some of the highest income nations with excellent healthcare isn’t entirely protective. One in 10 patients suffers harm in a hospital setting in these countries and almost half of those errors are preventable.
Organizations including the Center for Patient Safety and the Institute for Healthcare Improvement (IHI) advocate for attention to common ways where patients are harmed during healthcare treatment. Resources such as the Patient Safety Essentials Toolkit from the IHI can help nurses and nursing teams assess their typical workflow and make changes that can have a big impact on outcomes. From the SBAR (Situation-Background-Assessment-Recommendation) technique to better communication, even small adjustments in the way a unit operates can improve patient outcomes and safety for both patients and staff.
The opportunity for improvement is extensive. According to the WHO, patient harm occurs on many levels and in varied settings. From medication error to infection prevention practices to radiation errors or unsafe injection practices, the potential for mistakes occurs across the spectrum of care. It can also include harm such as falls and other unintentional injury.
As a nurse, educating yourself about the latest evidence-based safety practices is always good professional development, as is learning new skills. Take courses, read journals, and investigate what other healthcare settings are doing successfully. Promote safety practices on your unit and advocate for opportunities to learn more about protecting your patients at work, whether that’s through speakers, seminars, or with hands-on education and projects.
What is one thing you can do to elevate your own practice this week?
It’s my first day on the job as an occupational health nurse at one of the largest automobile factories in America. The Tesla Fremont factory encloses 5.5 million square feet and has around 15,000 workers on site at any one time. At the moment I’m hired, the factory is in overdrive to meet quotas and workers are pulling five twelve-hour shifts per week.
I’m overwhelmed by the factory floor. Spinning robots, automobile bodies on overhead assembly lines, herds of forklifts, and an incredible noise assaults my senses. The floors are covered with painted walkways, traffic safety barriers, and bollards to separate vehicles and pedestrians. Every 20 feet or so there is a sign on the floor stating “HEADS UP, PHONES DOWN” to encourage safety in this dangerous environment.
I’m working for a subcontractor. Tang and Company is a provider of occupational health services for 40 years serving such disparate industries as petroleum production, electrical generation, construction, and automobile manufacturing. They provide drug testing, respiratory mask fitting, employee health surveillance, safety education, and first aid services with the goal of keeping workers healthy and productive.
Most of my career has been in emergency room and ambulatory care. I feel well prepared for the clinical part of this job. I’m not so well prepared for some of the other functions. Fortunately, my employer has a well designed training program. I’m interested in the population health aspect. Mitigating the dangers in the workplace requires data. What are the injuries? How are they happening? What can be done to prevent them in the future? The benefits to the employees are obvious. Nobody wants to be injured on the job. The benefits to the employer include increased compliance with regulatory bodies and rules such as OSHA, FMLA, ADA, DOT, HIPAA, etc. The employer also enjoys decreased costs associated with insurance, lost production, potential fines, and the staggering expense of caring for the injured worker. In 2017, the cost of workplace injuries was $161.5 billion. This includes lost wages and productivity, medical cost, and administrative cost.
During my training period I’m instructed on how to perform routine workplace tests such as drug and alcohol testing, respiratory mask fitting, spirometry, and hearing tests. I work
Fast Facts about Occupational Health
Occupational health nurses work in a variety of settings to keep workers healthy and safe.
The typical occupational health nurse would be baccalaureate prepared and may have an advanced degree.
This nurse might enter the field with experience in community health, emergency room, critical care, or ambulatory medicine.
There are certifications available for ADN-prepared nurses, BSN-prepared nurses, and advanced practice nurses wishing to enter the field.
closely with EMTs, Physician Assistants, LVNs, and ancillary personnel working to keep the clinic running. The EMTs are trained to respond to workplace incidents on the factory floor. They are ready at a moment’s notice to respond to medical emergencies in the vast reaches of the factory. Typical responses I’ve seen so far are falls, cuts, and even a heart attack. They respond with a shoulder carried first aid pack, oxygen, and an AED.
Medical care beyond first aid is provided by physician assistants on site or through a video conferencing system. The range of services is pretty broad. Management of repetitive motion injuries, evaluation and treatment of traumatic injuries, and referrals for non-occupational conditions are typical. The clinic is well stocked with equipment and supplies, an EKG machine, nebulizer machines, various notions and potions for symptomatic relief of sprains, headaches, and bruises. The goal is to keep the factory moving with healthy workers.
Each day is a new and interesting experience. My nursing skills are being used productively and I’m learning about this expanding and well-paying field of nursing.
Especially since the #MeToo Movement began, sexual harassment has been in the spotlight. We spoke with nurses who have been harassed, legal experts, and nursing professionals to determine what you should and can do if this happens to you.
Celia,* RN, a longtime hospice nurse, remembers it like it was yesterday. A younger man, at least younger for hospice, had been admitted with terminal cancer. While Celia says she recalls other nurses talking about the patient having made “inappropriate comments,” she had never experienced it herself.
Until she did.
The patient had been angry and struggling with what he deemed the unfairness of dying young and leaving his wife and child—and knowing that he wouldn’t be able to take fun trips or do things with his daughter. Because he had a trach, which requires frequent suctioning and medication, he felt like the staff was treating him like a leper—when actually, they were simply following all safety precautions.
“Once trach care was completed, I sat down, took my gloves off, and offered him a hand to hold—this is standard practice between hospice staff and patients, and it’s not frowned upon,” says Celia. At the time, the patient held her hand, cried, and expressed gratitude for the time to talk. “I felt we had a nice, professional, and therapeutic rapport.”
A few weeks later, a couple of days after Christmas, Celia was caring for the patient, and he asked if she was married. When she responded that she was in a long-distance relationship, he asked how she took care of her sexual needs—and asked using inappropriate, graphic sexual language.
Celia replied, “One—that is none of your business. And two—It’s not appropriate conversation between a patient and a nurse!” Then, Celia calmly informed him that this was harassment and abuse. With one word to her managers, she told him, she would never have to be his nurse again. She says that the patient was contrite and apologized. Celia passed it off as a one-time thing and let it go.
Unfortunately, that wasn’t the end of the harassment. After a couple of weeks, Celia was the patient’s nurse again. While taking care of his trach, she talked with him. When he could speak, they discussed their favorite kinds of music. She recalls, “It was a nice interaction, as I grew up in a musical home, and discussing this was special to me.”
Near the end of the treatment, though, everything changed. The patient told her lots of things that he would like to do with her sexually, in graphic detail.
Celia recalls, “I was horrified. I was angry. I felt nauseated. I felt ashamed about my body, and I wanted to cry. I was shaking, inside and out.”
She told the patient that he was so far out of line. He was shocked that she was so rattled and tried to justify it by saying that it was a compliment. Celia left his room immediately.
The first thing she did was post on the staff’s white board that she would no longer care for this patient. When she calmed down, she emailed her managers and then communicated with them in person the next day.
Celia’s managers were supportive. She never saw the patient again, and he left the facility a few days later.
Harassment is Prevalent
A Medscape.com survey published last year revealed that the majority of nurses—71%—say that they had been sexually harassed by a patient. Of those responding, 90% were female nurses, 10% male.
But male nurses get harassed as well. They may, however, be even less inclined to report it. In the same survey results, it states, “By gender, female nurses…were much more likely to say they had been sexually harassed than their male counterparts (73% for female nurses vs 46% for male nurses).”
No matter the gender of the nurse who experiences it, sexual harassment is wrong. That said, how do you decide if what a patient is doing or saying is sexual harassment?
If it Looks Like a Duck and Quacks Like a Duck
According to Trista Long, RN, DNP, MBA, ON-C, a nurse manager for an inpatient med/surg unit with Blessing Health System, it is easy, most times, for nurses to differentiate between behavior that is appropriate or inappropriate. “The first sign of inappropriate behavior is when patient’s actions or conversation makes the nurse uncomfortable. Patients who are making inappropriate comments will first ‘test the waters’ by making inappropriate jokes or mild comments to gauge the nurse’s response. If the nurse dismisses the comment, the patient will likely continue with the inappropriate conversation or actions.”
If a patient exhibits inappropriate verbal behavior, it’s often easy to recognize, says Long. “Nurses know what crosses a line and what doesn’t,” she says. Because of the physical nature of nursing, however, Long says that inappropriate physical behavior can sometimes be more difficult to recognize.
“I often tell my staff that—again—inappropriate touch is anything that makes them uncomfortable…it’s no different than being in public and having someone touch you inappropriately. Just because you are in a hospital does not give another person the right to touch you,” explains Long. “Most patients will want to hold your hand or touch your arm, but they will not go any further than that. An action or remark could be considered harassment if the nurse directs the patients to stop, but that direction is ignored.”
“A ‘reasonable person standard’ is generally used to determine if conduct is motivated by prurient interests or for a person’s sexual gratification,” says Debra W. Levin, counsel in the health law group at Brach Eichler. She previously served as counsel to the New Jersey State Board of Medical Examiners and was the Assistant Section Chief responsible for legal services provided to more than 50 licensure boards, including the New Jersey Board of Nursing. “If a reasonable person would be offended, then it can be determined to be sexual harassment. Because the standard is subjective, it is often hard to determine.”
“Sexual harassment is generally any unwanted sexual direct or indirect physical contact or comments. Of course, some physical contact may be more overtly ‘sexual’ than other contact, but much of the time, the intent will be evident,” says Jessica T. Ornsby, LL.M., Esq, managing attorney with A+O Law Group. “A good rule of thumb is whether the contact is objectively appropriate under the circumstances. For example, if a nurse is taking a patient’s blood pressure, is it necessary for the patient to place his or her hand on the nurse’s thigh? Probably not. But if a nurse is helping a patient into bed, that patient may need assistance stabilizing himself/herself and may rest his or her hand on the nurse in a way that would otherwise not be necessary.”
She adds, “Sexual harassment is basically a step down from sexual assault. If the action/contact involves force or any kind of penetration, that is most likely assault and should be addressed accordingly.”
What to Do if It Happens to You
Suppose a patient sexually harasses you. What do you do?
“Experts believe that sexual harassment is significantly underreported in health care. For that reason, I believe the best defense for nurses starts with reporting these types of incidents,” says Jennifer Flynn, CPHRM, risk manager at Nurses Service Organization. “No matter who the harasser—whether it be a supervisor, coworker, or a patient—nurses can take steps to address harassment in their workplace.”
“While working in a hospital, the first step is for the nurse to address the behavior. The nurse should tell—not ask—the patient to refrain from the inappropriate comments or actions and to stop immediately. The nurse should then report the behavior to his/her manager so that the leader can be aware. If the behavior stops, it typically will not need to go further,” says Long. “It is imperative that the nurse set boundaries with the patient immediately once s/he recognizes the behavior. If the action is severe or violent, the nurse should report it immediately, and the leader should address it. If the nurse is uncomfortable caring for the patient, the patient can be reassigned to another nurse. There have been times when I have assigned only male nurses to a patient who was harassing the female nurses.”
There may be times in which a patient won’t stop. In this case, Long says that the leader should talk with the patient and stress that the behavior won’t be tolerated and must cease. “If the behavior continues or if the nurse is uncomfortable caring for the patient, the patient should be reassigned to another nurse, and the leader should engage the Risk Management Department and/or the Security Department to assist. Many times, a Security Officer will be asked to speak with the patient and direct them to stop the behavior. Since they are often in uniform, it can be a show of added authority and the behavior will stop. If it does not, the Risk Management Department can speak to the patient and explain any legal consequences to their continued inappropriate behavior,” says Long.
Ornsby says that each work environment, ideally, should have some kind of policy with regard to sexual harassment. “Nurses should make note of these policies and earmark them for future reference,” she says. “If the policy does not specify to whom to report the incidents—ask. If a patient’s behavior…is making you uncomfortable or causing you to feel unsafe, leave the situation immediately. Your personal safety and well-being are the most important. Federal laws on sexual harassment apply regardless of whether the harassment is taking place at a hospital or a doctor’s office.”
Levin agrees that health care organizations should have policies in place. “Larger or licensed facilities may have staff to counsel the patient regarding harassing behavior. Additionally, in regard to patients, the patient can be transferred to another’s care, a chaperone can be provided, and the patient can be counseled. In dramatic situations, the patient can be discharged/terminated from the practice or facility. State-specific laws apply that govern termination of the doctor/patient relationship/discharge so that the patient is not abandoned, and there is a transition of care,” she says.
The American Nurses Association has challenged nursing professionals to end sexual harassment in the workplace by adopting a zero-tolerance policy. “Much has been written lately about the importance of nurses engaging in self-care. Not tolerating sexual harassment is an integral component not only for self-care, but also for self-respect, vital for professional effectiveness. Speak up when sexual harassment occurs and facilitate a civil work environment,” Flynn says.
The Bottom Line
“If the organization is not responsive to the nurse’s claims, s/he should consult legal counsel or their union. No one should be subjected to sexual harassment in the work place,” says Levin.
Long says that harassment, whether physical or verbal, has been perceived in health care as “part of the job.” But it’s not and never should be seen as such. “It is never acceptable to be harassed by anyone at any time. Nurses are an integral part of the health care team and should command the same respect as every other profession,” says Long. “Unfortunately, nurses have been depicted in a sexual manner for ages and that has demeaned the profession. Being a nurse does not negate my rights as a human being to not be verbally or physically assaulted.”
“I took an oath to care for others, but that does not mean that I have to sacrifice my physical or mental well-being,” Long adds.
There have been increasing claims of nurses being sexually harassed. Some male nurses have reported being harassed; however, more than 50% are female nurses. The harasser may be male or female, and the victim may be of the opposite sex or the same sex as the harasser. Sexual harassment is not acceptable and unlawful. It can affect a person’s emotional and mental health, as well as lead to significant stress and anxiety.
The U.S. Equal Employment Opportunity Commission (EEOC) states that “harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person’s sex. For example, it is illegal to harass a woman by making offensive comments about women in general.” Sexual harassment is defined as unwelcome behavior of sexual advances, a request for sexual favors, and other verbal or physical conduct of a sexual nature that explicitly or implicitly affects an individual’s employment, unreasonably interferes with an individual’s work performance, or creates an intimidating, hostile, or offensive work environment (EEOC).
Types of sexual harassment include:
Telling lewd jokes, or sharing sexual anecdotes;
Making inappropriate sexual gestures;
Staring in a sexually suggestive or offensive manner, or whistling;
Asking sexual questions, such as questions about someone’s sexual history or their sexual orientation;
Making sexual comments about appearance, clothing, or body parts;
Making offensive comments about someone’s sexual orientation or gender identity;
Inappropriate touching, including pinching, patting, rubbing, or purposefully brushing up against another person.
Whatever form the sexual harassment may take, it is important that it is recognized, and that prompt action is taken against the harasser. Preventing sexual harassment and taking proactive steps to deal with harassment that does occur is especially critical.
Here are eight steps to protect yourself from being sexually harassed:
Be informed about the definition of sexual harassment.
Be knowledgeable about institutional policies regarding sexual harassment.
Take an active role in fostering a work environment free from sexual harassment.
Attend sexual harassment prevention courses or training.
Report the harassment to your supervisor immediately, or to a higher authority if your supervisor is the harasser. Consult with your human resources office and government agency if necessary. Never be afraid to report a comment, action, or gesture by somebody that made you feel uncomfortable.
If possible, speak with the individual directly and inform him or her that you feel the behavior is inappropriate.
Seek support from family members, friends, colleagues, or your state nurses’ association.
Document the harassment in writing as soon as possible.
A healthy work environment is empowering for both the employees and the administrators. It creates a culture of safety, which is paramount for performance. While it applies to every industry, it is especially true for the health care sector.
Medical workers are exposed to a lot of challenges, including health and safety challenges, and therefore it is even more important to create a culture of safety within the organization. This, in turn, helps to create a patient-centered team that performs with a sense of professionalism, involvement, efficiency, transparency, and accountability.
In the United States, health care is the fastest-growing industry. It employs more than 18 million workers and almost 80% of health care staff are women. So it is not just the hazards on the job that the health care workforce needs to worry about; the fact that the sector employees such a large number of females makes it even more vulnerable to violence and stress.
The video below speaks volumes of the physical consequences nurses often experience in terms of workplace violence.
It is pretty obvious that the job related injuries and workplace violence are the reasons that make health care a very dangerous profession, especially for direct patient care professionals. The Occupational Safety and Health Administration (OSHA) estimates that there were 253,700 reports of work-related illness and injuries in hospitals in 2011. This means 6.8% such illness and injuries for every 100 full-time health care staff. And according to a study of emergency departments, 12.1% of emergency nurses are subjected to physical violence over an average week of work. Worse still, in almost 97.8% cases patients were the perpetrators. The problem is even more acute for mental health workers.
Besides, data indicates that direct patient care professionals are more likely to get hurt on the job; it is almost double the rate of employee injuries (including construction workers) in private industry. Most common injuries suffered by nurses are related to falling down, running into something, and overexertion. Illnesses are usually caused by needle-sticks, infectious diseases, back pain, coming in contact with toxic and allergy-causing substances, and so on.
Sounds scary, doesn’t it? The good news is that it’s possible to prevent or at least reduce such workplace health and safety hazards for nurses. Follow these 3 tips to ensure workplace health and safety.
1. Be Careful of Sharp Objects
According to the Centers for Disease Control and Prevention, annually 385,000 sharps-related injuries occur among health care workers in hospitals. Needlestick or other sharp objects that health care workers are usually vulnerable to expose them to blood-borne pathogens. This is one of the major serious health and safety hazards experienced by nurses.
Nurses and other medical professionals have, for long, fought to make it compulsory to use safe needles in hospitals and health care centers. Today, it is mandatory by law for such medical organizations to use needles with safety caps, apart from using gloves, masks, eye protection, and gowns to prevent puncture wounds. The Needlestick Safety and Prevention Act also requires employers to maintain a sharp injury log and take proper steps to reduce health care professionals’ exposure to such injuries.
If your hospital or medical center fails to use safe needles as required by the federal law, discuss the issue immediately with the authority. In addition, be careful while drawing blood from patients, especially those suffering from contagious diseases. The risk of injury is especially higher when working a double shift, at the end of a shift, and/or when staffing is low.
2. Use Proper Gloves to Avoid Latex Allergy
Latex allergy continues to be another key health hazard for health care workers. You need to use latex gloves while providing care to patients in order to prevent coming into contact with toxic and allergy-causing substances. Unfortunately, the powder that these gloves contain are toxic enough to cause a rash on your hands. Some of these incidents can be so severe that you can even suffer from anaphylactic shock.
Even if someone doesn’t develop latex allergy soon after using these gloves, there are always chances of developing them later, especially after prolonged use. According to Dr. Phillip Farthing, a medical doctor and an experienced Tampa medical malpractice lawyer, nurses have the right to ask their employers for powder-free gloves.
If, unfortunately, you have to continue working with powdered gloves, make sure you follow these safety guidelines:
• Thoroughly wash and dry your hands soon after removing the latex gloves.
• Don’t use oil-based lotions, especially those containing palm oil, coconut, lanolin, and mineral while at work, as these oils will eventually break down the glove barrier.
• You should preferably wear cotton liners or synthetic gloves along with your latex gloves particularly for work that gets your hands wet.
If you already have latex sensitivity, it will become even more challenging for you to avoid further exposure. If the symptoms get worse, speak to your employer immediately and don’t forget to consult a doctor.
3. Don’t Tolerate Workplace Violence
According to OSHA, nurses are highly vulnerable to workplace violence, and such incidents are more likely to occur at times of high activity like meals and visiting hours or when staffing is low. Nurses working alone in remote locations as well as in high-crime areas are also susceptible to assault and violence. But before discussing that, let’s understand the nature of workplace violence in the health care industry.
The definition of workplace violence according to the National Institute of Occupational Safety and Health (NIOSH) is as follows: It is the “physically and/or psychologically damaging actions that occur in the workplace or while on duty.” Such workplace violence is further classified into 4 categories:
• Violence caused by customer/client (i.e., patient or patient party)
• Criminal intent
• Personal relationship
Unfortunately, there is no federal law requiring workplace violence protections for nurses. That said, many states are now bringing regulations and/or have enacted legislation to prevent workplace violence.
There are few things hospitals and health care centers can do to prevent such incidents, and installing security systems to control access is definitely one of them. In addition, nurses and other health care workers must be diligent. Familiarize yourself with and be careful of patients who have a history of violent behavior, drug or alcohol intoxication, and/or dementia. Moreover, when working in an unsafe situation, have an escort (such as a security personal or even a fellow worker) who can raise alarm if your patient becomes aggressive.
It is no secret that health care workers are more vulnerable to safety issues than any other professionals. Nurses are exposed to various challenging situations and/or health/safety hazards since the first time they step into a medical facility. But there are ways to minimize and even prevent such risks and both the medical facilities and the healthcare workers must take responsibilities to ensure workplace safety. Be vigilant always and follow the guidelines provided by OSHA and other administration to make this constantly variable environment safe for all.