| Washington Watch | Vital Signs | Issues Update |
Every day in the United States, 9,000 health care workers sustain a disabling injury on the job, according to Linda Rosenstock, MD, MPH, director of the National Institute for Occupational Safety and Health (NIOSH). Dangers of particular concern to nurses are latex allergies and needlesticks; other threats include back injuries and violence in the workplace. “We have, as a nation, underestimated the occupational hazards for health care workers. This is an enormous health and economic problem,” said Rosenstock at the recent Caring for Those Who Care Conference, held in Washington, DC, by the ANA and the International Council of Nurses in late August.
Uniting nurses from 14 countries, the conference provided a comprehensive two-day look at the threats to nurses’ health and safety and the measures being taken to address them. Earlier in the month, the third Frontline Healthcare Workers Safety Conference, also held in Washington, DC, examined these same issues. Both conferences were well attended and garnered national media coverage, indicative of the growing interest in the health and safety of care providers.
The ANA and the state nurses associations (SNAs) have led this charge, working throughout the year with government agencies, manufacturers, legislators, and other health care organizations to confront some of the most pressing threats to nurses. Here’s a brief update on what’s being done to abate these hazards.
“When we wear latex gloves, we are exposing ourselves and our patients,” Mohamed Yassin, MD, said at the Caring for Those Who Care Conference, “and there is no cure.”
Although there is no cure, some relief is in sight. Ongoing lobbying by the ANA spurred NIOSH, the Food and Drug Administration, and the Occupational Safety and Health Administration (OSHA) to take action. For example, last year, NIOSH released an alert to warn employers that their employees may be at risk for latex allergy and recommended a ban on powdered latex gloves as the most effective way to stem the growing number of latex allergies acquired by health care workers and consumers.
The FDA weighed in on the issue by mandating that all medical products, including latex gloves, be labeled as of September 30, 1998, and that the words “hypoallergenic” and “powder-free” be eliminated from packaging to avoid misleading health care workers. Outlining ways to minimize risk and protect those who are already sensitized, OSHA is currently working on a second draft of a Hazard Information Bulletin. The ANA made comments specific to nursing that will be included in the final draft for review. While pleased with the development of the bulletin, the ANA is concerned that it isn’t enforceable and is urging OSHA to develop and issue a standard that would mandate that employers protect their workers.
In May, the ANA, along with the FDA, American Medical Association, Centers for Disease Control and Prevention, and several other groups, took the message on latex allergy to thousands of health care professionals via a teleconference viewed at more than 7,000 sites nationwide. In addition, the ANA has been successful in influencing some latex glove manufacturers to develop nonlatex synthetic alternatives and low-protein, powder-free, latex gloves, according to the ANA’s occupational health and safety specialist Susan Wilburn, MPH, BSN, RN. Advertisements for these gloves are beginning to appear.
The ANA also has joined forces with SNAs to ensure that provisions for latex-sensitive employees are incorporated into bargaining contract language. And the ANA has helped the SNAs to propose state legislation. The Oregon Nurses Association, for example, was a pioneer in introducing legislation calling for the exclusive use of low-protein, powder-free latex gloves for use in health care facilities. While the legislation didn’t pass, it played a significant part in alerting the public to this health risk. The Nebraska and Wisconsin nurses associations also have supported this type of legislation, and similar bills have been introduced in Indiana, Minnesota, New York, and Pennsylvania.
Occupation-related back pain affects 38% of nurses. Yet only one-third have reported it, Bernice Owens, PhD, RN, told attendees of the Caring for Those Who Care Conference. At the same time, 12% of those affected are thinking of leaving nursing because of back pain. Lifting patients, the predominant cause of back injuries, oversteps NIOSH’s guideline, which states that a 51-pound stable object with handles is the heaviest amount that can be safely lifted.
“The good news is that most work-related musculoskeletal disorders can be prevented by a sound ergonomics program,” Charles N. Jeffress, OSHA’s assistant secretary of labor, said at the Frontline conference. The Occupational Safety and Health Administration is developing an ergonomics standard mandating that employers develop programs that include manual lifting procedures. It also has produced videos on ergonomics, both general and specific to nursing homes, which the U.S. Department of Labor says lead all other workplaces in injury rates. (To order the videos, $60 each, call the National Audio Visual Center at [703] 605-6186.)
The ANA has worked with the Minnesota Nurses Association (MNA) to develop ergonomic language to be included in collective bargaining contracts. Some of this work resulted from a landmark MNA study that found a link between health care restructuring and increased injuries among nurses. The majority of the injuries reported were related to either patient transfer or “head, neck, or back,” and sharps. The MNA used the results of the study to successfully bargain for new language in contracts with the hospitals in the study. This will help nurses identify situations in which they face risk of injury or illness.
Nursing homes and hospitals hold the dubious distinction of being the sites of almost two-thirds (64%) of nonfatal workplace assaults, according to the Bureau of Labor. “Many nurses who are victims of abuse feel it reflects a performance failure on their part, but it’s not—it’s a reflection of the increase in shift work, and working alone,” Canadian Nurses Association President Linda Kushnir Pekrul, MscA, BSN, RN, stated at the Caring For Those Who Care Conference.
“Nurses need to be more assertive ... we have to put a price on our lives and our health care,” Lenore Mrkwicka, MA, RGN, assistant general secretary of the Irish Nurses Organization, said at the same conference. “The acceptance by many nurses that this is par for the course has to be changed.” She pointed out that while 47% of nurses in Ireland said they were physically assaulted by a patient during their career, less than 3% took time off as a result of an assault.
In a recent study initiated by the Colorado Nurses Association (CNA), more than 30% of the nurses in seven SNAs who responded to the survey reported having been the victims of workplace violence in the previous year. Most had been assaulted by patients, and 72% are staff nurses.
“Just as we are advocates for safe and quality health care for our clients, we must be champions for creating a safe work environment for ourselves,” said Victoria Carroll, MSN, RN, and Karen Morin, DSN, RN, recently in The American Nurse (September–October 1998). Carroll chaired the CNA’s Task Force on Workplace Violence, and Delaware Nurses Association member Morin tabulated the survey results.
While OSHA published voluntary guidelines for health care workers and employers to minimize the risks of violence on the job more than two years ago, not all employers have instituted them. Alarmed, the SNAs have moved forward with legislative remedies to workplace violence in Minnesota, New Hampshire, Ohio, and Washington that would either increase penalties against people guilty of assaulting a health care worker or establish task forces to study workplace violence.
According to Janine Jagger, PhD, MPH, director of the International Center for Health Care Worker Safety, the use of passive devices, such as self-sheathing blood-drawing needles, would prevent at least 75% to 80% of the more than 800,000 needlesticks that occur in the United States annually.
Yet, many hospitals nationwide have either refused to stock these devices or they purchase inferior ones without nurses’ input, placing their employees at risk for contracting diseases such as HIV and hepatitis C through needlesticks.
The Occupational Safety and Health Administration issued a bloodborne pathogen standard in 1991 to force employers to use “engineering controls” to prevent injuries. “However,” Wilburn said, “no one has ever been cited for not having these needles, so there is a fear that the standard is not being followed.” The ANA is pushing OSHA to inspect and ensure compliance for safe devices, and OSHA recently published a formal request for information from industry experts, including the ANA, to learn what the experts think is the best way to prevent needlesticks.
The association also is urging the FDA to act. At the Frontline conference, Wilburn asked, “Is there any threshold [for the number of health care workers’ deaths] before the FDA will act?”
One nurse who suffered a devastating needlestick injury has told her story at several ANA events this year. Lynda Arnold, RN, was infected with HIV following a needlestick while working as a nurse in a small community hospital in Lancaster, Pennsylvania, in 1992. Her injury could have been prevented if a safe needle device had been available and she had been taught how to use it. Arnold started the Campaign for Health Care Worker Safety in 1996 to encourage hospital administrators to provide safe needle devices. So far, about 600 administrators have signed a pledge to purchase safe devices.
Arnold joined country music superstar and registered nurse Naomi Judd at a press conference held in conjunction with the ANA’s convention in June to draw attention to this preventable problem. Judd contracted hepatitis C from a needlestick when she was a practicing nurse.
The ANA has worked closely with Representative Pete Stark (D-CA) and Senator Henry Reid (D-NV) to develop legislation, and has lobbied members of Congress to support the House (HR 2654) and Senate (S 2054) versions of the Health Care Worker Protection Act. This would mandate education and training programs to inform health care workers about the risks associated with bloodborne pathogens and the use of safer needle devices. The legislation also would ensure that safety medical devices are reviewed by the FDA for their efficacy and quickly made available. And finally, the legislation would make the use of safer needle devices a condition for hospitals’ participation in the Medicare program. Both bills are pending in committee.
“The key ... [to reducing the number of needlestick injuries] is continual training on how to use safer devices, and removing unsafe devices,” ANA First Vice President Mary Foley, MS, RN, stated at the Frontline conference. “Nurses need to be involved in the selection and implementation of new devices and these devices must be intuitive and passive.”
While 2% or less of a typical hospital’s waste stream must be incinerated to protect public health and safety, hospitals routinely burn 75% to 100% of their waste, often including materials that prove to be deadly. For example, a broken mercury thermometer might be tossed in the red bag. When incinerated, mercury from the red bag is released into the environment as dioxins, potentially causing impaired vision, hearing, taste, and smell. In low doses, dioxins, which are known carcinogens, cause reproductive, endocrine, and immune systems problems. Ted Schettler, MD, MPH, who spoke on the topic at the Caring for Those Who Care Conference, believes that’s why medical waste incinerators are the third leading source of dioxin emissions in the United States.
Besides dioxins, “Hospitals are responsible for 10% to 20% of the mercury released into the environment,” Schettler said.
According to Health Care Without Harm, a nonprofit organization that aims to reduce hospital pollution with which the ANA has worked closely, the Environmental Protection Agency (EPA) released the first federal standards and guidelines in August 1997 to regulate hospital and medical waste incinerators. Existing facilities have three to five years to comply.
In the meantime, the ANA is using an EPA grant to address the problem. The association developed a “Pollution Prevention Kit” for nurses to use in their hospitals and introduced it at the ANA convention in June. More than 200 nurses at the convention pledged to return to their facilities and educate their co-workers and administrators about the dangers of poor indoor air quality. To order a kit, call ANA Publications at (800) 637-0323.
One nurse who has been spreading the word about toxic waste for years is Holly Shaner, MS, RN, who started a waste recycling program several years ago at the Vermont hospital where she works. Today, as the environmental health coordinator at that hospital, the Vermont Nurses Association member runs a dioxin-free medical waste management program that pays for itself.
Shaner offered tips on addressing the problem: “Rethink product choices—request no PVC (polyvinyl chloride) or mercury products. Put someone in charge of the program. Make education annual and mandatory. Establish collection sites for mercury and battery waste.”
Pollution isn’t just an outdoor problem for hospitals—a “chemical soup” is also simmering inside. Fumes from high-level disinfectants such as glutaraldehyde, surgical smoke from tissue being cut, vaporized, or coagulated, and waste gases from anesthetic agents compromise the quality of indoor air and the health of patients and workers. At the Caring for Those Who Care Conference, Kay Ball, MSA, RN, CNOR, said that nurses have greater exposure time to these harmful pollutants than other health care workers. “How many of you were exhausted after working in a recovery room all day?” asked Ball. “You were tired because patients exhale anesthesia gases and expose health care workers.”
Glutaraldehyde, a sterilizing agent for instruments, especially those used in gastroenterology, is not regulated. Although there is no permissible exposure limit for glutaraldehyde, exposure to small amounts of the fumes can cause serious respiratory and dermatologic problems. Surgical smoke, or laser plume, can also cause respiratory problems along with burning, watery eyes, nausea, and viral contamination and regrowth, warns Ball. She predicts that as surgery becomes more mobile, there is a greater risk for exposure to surgical smoke and disinfectant chemicals.
Steps are being taken to lessen these dangers. After the ANA and the Association of Operating Room Nurses lobbied Congress to urge OSHA to take action on the hazards of laser plume, OSHA wrote a white paper and is currently gathering feedback on it from health care organizations and professionals. It will publish a more formal document based on this input. The National Institute for Occupational Safety and Health also recently issued a hazard about laser plume. While these government agencies decide what further action to take, Ball recommends that nurses educate their colleagues, patients, and physicians’ offices about the potential dangers, wear high filtration masks, and use smoke evacuators.
The need for more attention to the health and safety of nurses was best summarized by U.S. Surgeon General David Satcher, MD, who during his keynote address at the Caring for Those Who Care Conference said that while there is no question that nurses worldwide take care of their patients, there is concern over whether they are taking care of themselves. He urged: “The nurses of the world need to stand together, whether it’s a needlestick, chronic back injury, or violence. Nurses must take care of themselves in order to care for their patients.”
Michelle Slattery is a public relations specialist at the American Nurses Association.