Transformation of health and safety practices in the nursing profession

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The nursing world of work continues to evolve.  In light of changes in the health care system, the patient population characteristics and the society in general, nurses are faced with unique challenges despite which they continue to strive for better healthcare for all. Nurses are situated in close proximity to the patients and hence directly experience any patient-related changes in practice, be it a new legislation that urges to reduce wait-times and improve wound care, or a new regulation that affects the general public, such as the smoking ban. The environment in which nurses work has been recognized as an important place to not only prevent disease and promote health in nurses, but also instrumental in sustaining quality patient care.

A Healthy Work Environment is a practice setting that maximizes the health and well-being of nurses, quality patient/client outcomes, organizational performance and societal outcomes” (RNAO HWE Best Practice Guidelines). Creating a healthy work environment is not merely an ideological construct; rather, it has firm and evidential underpinnings. A culture of safety is one component of the evidence that leads to a healthy work environment and nurses have a pivotal role in keeping themselves and patients safe. One need only to reflect over the past 15 years at such sobering events as Acquired Immunodeficiency Syndrome (AIDS), severe acute respiratory syndrome (SARS), aggressive nosocomial infections, and increased violence to distinguish the permanent changes nurses and organizations were obligated to make in the last decade to protect themselves and equally important the patients or clients they care for. Many aspects of the response to AIDS and SARS are worth remembering as they led to innovations such as needleless systems, personal protective gear, and improved isolation products, to protect nurses and other health care workers.

The work of nurses is sometimes portrayed as a fragile balancing act between caring for oneself and others. The hazards of nursing work can impair health both physically and mentally. The resulting health impacts include musculoskeletal injuries, frequent infections, changes in mental health, and cardiovascular and metabolic disorders. Musculoskeletal injuries among nurses and health care workers continue to be the major source of disabilities and time loss at work (Health Canada, 2012). Nurses had a rate of absence due to illness or disability nearly twice the rate for all other occupations and higher than all other healthcare occupations in 2010.

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Ontario reported approximately 147,000 nurses for 2012, of these 96 per cent of Ontario’s nurses, or 108,500 were women, and four per cent, or 4,500, were men (College of Nurses Ontario). In Ontario, nearly one-third (33 per cent) of nurses reported experiencing high job strain. Job strain results when the psychological demands of a job exceed the worker’s discretion in deciding how to do the job (Health Canada, 2012). Approximately two-thirds of nurses in Ontario (65 per cent) reported that their jobs were highly physically demanding. The figure for all of Canada’s nurses was 62 per cent (Health Canada, 2012).

Along with the physical strain nurses are under, the last decade has also revealed persistent levels of workplace violence. Workplace violence includes physical aggression, sexual violence, verbal or physical, and psychological violence including bullying (RNAO, BPG Preventing and Managing Violence in the Workplace, 2009). Governments have responded favourably with legislation to protect nurses and other workers against violence through the introduction of Bill 168 which requires employers to develop, implement and maintain a workplace violence policy and program.

A key driver to the transformation of health and safety practices in the nursing profession has been federal and provincial legislation. For example, a number of regulations across Canada followed the Tobacco Act that impacted the manufacture, sale, labelling and promotion of tobacco products. Provincial legislation prohibiting smoking in enclosed workplaces later evolved in order to protect workers from exposure to second hand smoke. It is hard to imagine that at one point in time you could be working on a Cardiac floor, providing health teaching on the impact of smoking and effect it has on the heart, and then documenting on the patient in a smoke-filled nursing station.

In addition to federal and provincial legislation, the global epidemic of Severe Acute Respiratory Syndrome (SARS) in 2003 pushed medical infrastructure to the limit. SARS outbreaks greatly impacted Canada’s largest city, Toronto.  SARS placed heavy pressures on Toronto’s public health and health care system.  The region’s health care professionals, as frontline workers vital to controlling the disease, were at heightened risk for contracting the disease, and under considerable physical and psychological stress. Many patients required intensive care, hospitals had to close, elective procedures were cancelled, and procuring adequate types and quantities of supplies to combat the disease was difficult. SARS also placed unprecedented demands on the public health system, challenging regional capacity for outbreak containment, surveillance, information management, and infection control. (www.phac-aspc.gc.ca/publicat/sars-sras/naylor/1-eng.php)

Through the SARS experience, the employers’ legislated responsibility to maintain a safe work environment was greatly challenged. Many issues involving occupational health and safety surfaced from N95 respirator availability and applicability, to proper mask-fit testing and use. Workers rights such as the right to refuse unsafe work and right to know about health and safety hazards in their workplace were debated and tested.

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To better understand how nurses feel about the changes in nursing health and safety practices throughout the last decade, a group of nurses from Public Services Health & Safety Association and the Registered Nurses’ Association of Ontario, put together a survey asking nurses to share their experiences and perspectives on the changes in nursing practice. Participants were asked about the changes observed related to health and safety practices in the nursing profession and what are some of the influential events and system developments that led to these changes.  The respondents provided an insightful look at the evolution of health and safety practices in nursing in the last decade.   Seven experienced nurses who lived through the changes shared their thoughts on the strengths and areas for improvement related to workplace health and safety in the nursing profession.  Respondents’ years of nursing experience in Canada ranged from 13 – 34 years. Most of the nurses reported diverse nursing experience and had worked in a variety of setting, including Pediatrics, Intensive Care, Emergency, Obstetrics, Gerontology, Occupational Health, Medical Surgical, Urgent Care Clinics, Administration, Public Health, Community and Long-term Care, and specialized care clinics.   Their responses fall into six broad themes, including infection prevention and control; workplace violence and bullying; smoke-free workplace; technology; general workplace safety; and looking forward.

Infection prevention and control

SARS certainly came out as the most significant event, “a turning point to increasing nurse’s safety,” according to one participant, among all related events and changes.  Participants have reported an increase in awareness and emphasis on hand hygiene; increased and appropriate use of personal protective equipment (PPE); regular mask-fit testing for health care staff; screening of respiratory symptoms; and stronger partnerships with the local health units, Ministry of Health and Long-Term Care, as well as the World Health Organization.  Some participants noted that the downside of introducing these practices is the time it takes to get it done right!  Handwashing between patients is critical, as is additional screening of patients for infectious diseases but the nurses are required to complete these tasks within their already busy days.  The tragic events associated with the global SARS pandemic made most employers realized that they have responsibilities when it comes to staff safety.  Completing a screening for patients, particularly in the time with emerging antibiotic resistant organisms and acute respiratory illnesses, nurses are not only concerned about their patients, but also their own health and wellbeing.

Workplace violence and bullying

There were times when nurses accepted physical and verbal abuse as part of their job. The place of work has evolved for nurses with more nursing care being provided in patients’ homes.  This heightens nurses’ awareness about safety because of the increased risks associated with working away from a controlled healthcare facility environment.  Today, the nurses felt that in most workplaces, workplace violence and bullying is not being tolerated.  This is a result of continued education and awareness raising in workplaces.

Smoke-free workplace

Smoke-Free Ontario Act went into effect in 2006, and aims to protect Ontarians from exposure to second-hand smoke by banning smoking in workplaces, enclosed public spaces and also in motor vehicles where a child under the age of 16 years is present.

Although the survey participants acknowledged the benefit of creating smoke-free workplaces for all involved, some felt it is important to note that nurses, as a result of this ban, have been given more responsibilities with screening patients and asking if they would like smoking cessation aids.

Technology – cannot live with it, cannot live without it

For the most part, advances in technology, in the form of electronic charting and online learning have certainly improved the overall working lives of nurses.  A common concern is that introducing rapid technological changes has led to nurses spending much of their time learning how to operate the technology, then operating the technology which can sometimes become a barrier to spending more one-one-one time with the patient.  An insufficient number of charting stations and malfunctioning computers are some of the troubles nurses experience with technology.

General workplace safety

Overall, workplace safety is much more of a priority now in places where nurses work and care for patients.  One nurse recalls how back in the day, no PPE was worn while caring for a patient who was hemorrhaging; and nurses mixed chemo drugs themselves without hoods.  In some workplaces, nurses lacked a clear definition of where their duties ended and did everything from bathing a patient to plunging the toilet.

Looking forward

The nurses felt that overall, there has been great progress and a general consensus around creating healthy and safe workplaces.  Employers recognize that when nurses have the opportunity to provide care in a safe and healthy work environment, everyone involved benefits, including the nurse, patient and their family.  Some of the challenges and barriers to sustaining healthy and safe environments for nurses is the fact that nurses themselves need to actively participate to upkeep the new and innovative practices.  This places more time pressures on the nurses who find it difficult to cut back on patient-nurse time.

The nurses called for appropriate and adequate education on safety measures being implemented.  At times, a new practice is introduced and nurses find themselves struggling trying to understand the rationale behind the intervention. Good examples of successful program implementation are the RNAO best practice guidelines on Professionalism, Fatigue Management and Conflict Management.

It was recommended to continue to break the silos between healthcare subsectors to work together on developing and successfully implementing standardized tools that address healthcare system challenges.  Communication is still fragmented and information sharing, particularly around resources, tools and databases, is difficult.  It is still common to see great ideas and innovative solutions remain within one organization while many others are seeking answers and left trying to reinvent the wheel.

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Although a number of valuable interventions and practice changes have been introduced in healthcare workplaces, some are done without a proper evaluation.  This is important when we want to understand the effectiveness and areas for improvement.

Every professional in the health care system plays an important role in caring for the patient and assisting them in achieving better health.  However, nurses are in a very special place when considering their proximity to the patient and ability to connect everyone in the circle of care.

Recommendations

Keeping nurses safe and healthy is a natural extension of providing quality care.  Every worker has the right to be free from harm.  Commitment to high standards of professional practice doesn’t mean bearing the burden of risk, but rather managing risk for better outcomes.

Nurses and employers need to work together to eliminate occupational injuries, illnesses, and fatalities.  Bringing about further change requires strong collaboration.  Efforts need to heighten awareness, promote knowledge mobilization, and support ongoing engagement.

Nurses have the responsibility to raise health and safety concerns and the right to be part of the solution.  Employers have the duty to invest in their workforce.