From the Massachusetts Nurse Newsletter
October 2006 Edition
By Lee Ann Hoff, RN, PhD
and Craig Slatin, ScD, MPH
University of Massachusetts Lowell
The UMass Lowell PHASE in Healthcare research project, funded by the National Institute for Occupational Safety and Health, has been a five-year study of health disparities among health care workers. The case study and focus group research addressed our questions about how health care system restructuring has affected the health and safety of workers. Our partnership with the MNA provided us with the opportunity to learn about the working conditions nurses face in a range of health care settings. Nearly 50 MNA members—including many elected leaders, local unit leaders, occupational health advocates and staff nurses who were primarily employed in hospital environments—participated in a series of seven focus groups on the following topics: general health and safety; violence and abuse; diversity and discrimination; post-injury return to work experience; and healthcare system restructuring. Outlined below is a summary of the findings.
Summary of findings
A. Work-related injury, illness, violence and abuse
Types and source of injury: These include direct bodily harm and threats to health such as HIV infection from needle sticks, sharps and bodily fluids of patients; exposure to hazardous materials; and muscular-skeletal disorders traced to heavy lifting, inadequate equipment, and too few staff for lifting very heavy patients. Nurses attributed frequent URIs, chronic fatigue and spastic bowel, too short staffing, double shifts and mandatory overtime. One nurse described the work environment as a “merry-go-round turned to high” and so, to avoid falling off “you have to increase the speed at which you work.”
The categories of assault and abuse included physical—but non-life threatening—attacks, life-threatening violence, and verbal and emotional abuse. Violence and abuse occur across practice settings, with patients as primary perpetrators and direct care staff as the primary targets. Nurses attribute increasing assaults and abuse to lack of preventive programs and management support; inadequate staffing and security measures; admission of patients with histories of violence without adequate security; the “free flow of people [into healthcare facilities]; and increased aggressiveness of patients and families; short staffing; and long waits for service leading to patient frustration.
Abuse included verbal attacks by physicians and the emotional toll of “constant negative evaluations” by management, labeling them as “malingerers” if injury was not physically apparent, and humiliating them in front of patients and other staff.
Impact of stress and trauma on physical and emotional health: The stress emanating from the fast pace, overtime, noise from telemetry, fear of potentially dangerous patients, and chronic fatigue is insidious, although out of the nurse’s immediate awareness. But it is also cumulative—eventually revealing itself in conditions such as dental pain, sleep deprivation, compromised immune system, and subsequent increased vulnerability to infections and injuries from various exposures. As one nurse said, “Nursing is just one shortcut after another, and many shortcuts are unhealthy for the nurse and patients.”
Nurses distinguished the trauma from abuse in relation to the cognitive status of the perpetrator: If the patient is impaired, it is easier to excuse the assault. Yet, there is a tendency to interpret assaults in health care settings as “part of the job” unlike, for example, recognizing assault in a supermarket as a “criminal act.”
For example, when a nurse complained about a patient who committed a sexual assault, a supervisor said, “We can’t do anything … he has a right to be here [until a court order is obtained].” Similarly, in a dramatic and life-threatening hostage situation, management was apparently oblivious to the emotional toll the event had on the nurse who was trying to bring a violent patient under control in order to save lives. She pressed the nurse to continue in her care-giving role with, “Hurry up, let’s go” … and with no opportunity offered for post-incident debriefing or support. Also noted was a class difference in management’s response to the assault of workers, with more attention paid, for example, if the assaulted victim was a physician.
Disparities among workers at risk: Overall, direct care workers are at greatest risk of injury, especially nurses and nursing assistants, although this varies according to type of injury, language, ethnicity and class. The upward age trend and accompanying decreased physical stamina among nurses (95 percent female) puts them at greater risk of injury from stressors of short staffing, heavy workloads, long shifts and many years of work. Although nurses note less frequent injury of managers and physicians—“They don’t see it [e.g. heavy lifting] as part of their job”—chemical injury and exposure is perceived as “the great equalizer” because, regardless of job description, “The fact that you were in the building, breathing on a regular basis was your risk factor. But the way you were treated varied on the basis of what your status was.”
B. Reporting behavior, policies and management attitudes
Overall, reporting may be formal (following agency policies), or informal, encompassing the communication process between workers and management, and among workers themselves. Whether or not nurses follow explicit reporting policies depends on a variety of factors, including: type and seriousness of injury; attitudes of management; cognitive status of perpetrator; socioeconomic status of the worker; formal supports; and threat to job stability following the report of an injury. Among these factors, most influential is the severity of injury—regardless of source—that is marked by the need for immediate medical treatment, physical incapacity to continue working because of injury, and/or threat of serious illness such as HIV/AIDS or Hepatitis C from needlestick or sharps injury.
Nurses tend not to report an injury perceived as “self-inflicted” or accidental (e.g., bumping one’s head), whereas physical assault by patients are more often reported, although such reporting is complicated by the cognitive status of the perpetrator.
This is a significant factor in a nurse’s attempt to find meaning in what happened and take appropriate follow-up steps after injury. It refers to the widespread differentiation in medical and public health arenas between “intended” and “unintended” injuries. If the perpetrator is cognitively impaired, there is a propensity to accept the injury as “part of the job,” as exemplified by the following statement: “But he’s demented, you know.”
Delayed reporting occurs when the perceived seriousness of the injury or subsequent pain may not be apparent until days after it occurred. Reporting behavior is also complicated by a policy requirement to cite a “specific instance” of injury which is not possible in cases of the “cumulative” effect of some injuries. For such insidious injuries, some nurses attribute their “collapse” to “getting old, tired and [working] too hard.”
Reporting is inherently connected to management attitudes and any prospects of compensation for injury. Nurses noted their cynicism about the complexity of reporting procedures and management’s response to reporting. They described experiences with workers’ compensation policies as generally negative and their perception of its inherent unfairness. One called it a “system riddled with red tape and aggravation” and requiring “jumping through hoops to see a doctor.” Nurses also noted their lack of educational preparation to deal with safety and workers’ compensation issues prior to joining the workforce and/or being injured on the job.
Nurses cited management indifference, blatant victim-blaming or even hostile rebuke of nurses who file reports. For example, management sent a nurse-educator to “teach somebody what, obviously, they did wrong” implying, “You really did it yourself,” “You don’t know what you’re doing,” or “It’s in your head, you’re overreacting or you must have psychiatric problems.”
Another nurse said that the nurse manager would “rip up the incident reports” and verbally attack nurses for “trying to cause trouble.” In an instance of verbal abuse with no physical injury by a surgeon, management indifference was exemplified with “He’s like that,” or “He talks to everybody that way … it’s like a no-win situation.”
Overall, nurses said that “lack of support is almost worse than the illness or what happened to you.” When the burden of responsibility for documenting an injury is on the injured party instead of the agency, nurses felt re-abused by the system. They also cited the money that could be saved by solving the occupational health problems versus legally intimidating the injured worker.
In a similar vein, they cited “throwing away experienced nurses” [instead of buying latex-free gloves, for example]. Rather than dealing with the workers’ compensation system, a nurse said that it’s easier to “just take Motrin and go on working.”
On the other hand, one nurse acknowledged the chaos of the situation and said, “We put ourselves in harm’s way” [in contrast to others who assert themselves]. Still another said, “Adaptation is a terrible thing: you do it because it’s expected. And eventually you don’t even realize how bad it is for you.”
Look for the second part of this article in the November/December edition of the Massachusetts Nurse.
Acknowledgements: MNA member focus group participants; focus group coordinator Evie Bain; and PHASE team members Kathy Sperrazza, Eduardo Siqueira and Beth Wilson, for their assistance with this research.
Authors: Lee Ann Hoff, a nurse-anthropologist, has authored several books on crisis and violence, and is a co-investigator of the UMass Lowell PHASE research project. Craig Slatin is principal investigator of the PHASE project and associate professor at UMass Lowell.
For information on the methodological facets of this project, contact leeann.hoff@comcast.net.
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