Instilling a Culture of Safety in Long-Term Care Settings

What jobs carry a high risk of injury? Common answers to this question include firefighters, construction workers, and police officers. Seldom do nursing employees make the short list, yet they rank among the top 10 occupations for sustaining injuries. Furthermore, if nursing employees are guessed to have a high risk of injury, those working in emergency departments and other acute care settings are identified as having the highest risk; however, data from the US Department of Labor show that nursing assistants (NAs) are more frequently injured and experience more physical violence than any other institutional-based caregiver.¹ In 2004, researchers from the University of Cincinnati published a study that assessed the frequency and context of assaults against NAs by residents.² In the study, approximately half of the 138 included NAs reported having been injured by a resident, with more than one-third of these injuries requiring medical attention. These data indicate that the safety risks for long-term care nursing staff are significant.

Risks in Long-Term Care Settings

When examining the major risk categories outlined by the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health (NIOSH),³ it is easy to see why NAs have such a high risk of injury:

• Physical hazards: A majority of residents are highly dependent on caregivers due to advanced age and the effects of health conditions. Caregivers frequently need to lift and provide other physical assistance to residents, placing caregivers at high risk of sustaining musculoskeletal injuries. In addition, the high prevalence of residents with psychiatric and cognitive disorders subject caregivers to aggressive behaviors that can result in injuries.

• Biological hazards: Advanced age and weakened immune systems cause residents to be at high risk for infection, and the close, regular contact caregivers have with residents exposes them to these infections.

• Chemical hazards: In the course of daily work activities, employees can be exposed to latex, hazardous drugs, and a variety of chemicals.

• Work organization: Short-staffing, shift work, and reliance on overtime are not uncommon in nursing homes. The nature of the work and resident population contribute to chronic stress and its health threats.

Employees of long-term care facilities are not the only ones at risk of injury; these environments also pose considerable safety risks for residents. Older individuals, who constitute the majority of the long-term care population, have a variety of age-related changes to contend with and are often taking multiple medications, placing them at high risk of falls, dehydration, hypothermia, hyperthermia, infection, aspiration, and pressure ulcer development. Altered absorption and elimination of drugs in the elderly heighten the likelihood of adverse reactions. In addition, inappropriate behaviors associated with psychiatric and cognitive disorders reduce the ability of residents to protect themselves against threats and increase the risk of injuries.

Addressing the Problem

To date, piecemeal approaches to addressing safety risks in long-term care settings have been undertaken, primarily involving inservice education programs to teach body mechanics, the safe use of lift/transfer equipment, and perhaps the prevention of pressure ulcers and other complications. Generally, safety risks are identified only after a fall, medication error, or other incident occurs, and the action then commonly taken is to discipline the employee involved. Unfortunately, this method inadequately prepares employees for taking proactive approaches to safety and often discourages them from reporting potential hazards or actual incidents.

In an effort to address this problem and enhance employee and resident safety, the American Association for Long Term Care Nursing has launched a Long Term Care Safety Specialist Certification Program to prepare safety champions within long-term care settings. Program topics include: risks arising from residents’ clinical conditions and measures to reduce them; impact of advanced age on safety risks; assessment and reduction of environmental risks; ergonomic principles; components of a safe lifting and moving program; administrative and organizational support; systems, practices, and monitoring activities; and strategies to create a culture of safety. This 12-contact-hour program includes both core content and strategies for implementing, teaching, evaluating, and championing a comprehensive safety program. It can be taken as a four-part Webinar independent study program. 

The best provider staff, marketing plans, and state-of-the-art recruitment programs mean little if people sustain injuries as a result of safety hazards in the care setting. A comprehensive, systematic approach to safety promotion can result in enhanced health and function of residents and employees, increased consumer and employee satisfaction, and significant reduction in workers’ compensation, litigation, staff turnover, lost work time, and other costs. Creating and sustaining a culture of safety is an essential investment.

Dr. Eliopoulos is executive director, American Association for Long Term Care Nursing, Cincinnati, OH.

References

1. US Department of Labor. Guidelines for preventing workplace violence for health care & social service workers. https://www.dol.gov. Accessed September 28, 2011.

2. Gates D, Fitzwater E, Telintelo S, et al. Preventing assaults by nursing home residents: nursing assistants’ knowledge and confidence—a pilot study.
J Am Med Dir Assoc. 2004;5(2 suppl):S16-S21.

3. Centers for Disease Control and Prevention. NIOSH Workplace Safety & Health Topics. Health Care Workers. www.cdc.gov/niosh/topics/healthcare. Accessed September 28, 2011.