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By Gary Evans, Medical Writer
In the current political climate, the Occupational Safety and Health Administration (OSHA) has no realistic way forward to achieve its goal of issuing a proposed standard to protect healthcare workers from violence, a former OSHA director tells Hospital Employee Health.
“I don’t think that is going to happen,” says David Michaels, PhD, who is now a professor of public health at George Washington University in Washington, DC.
In the interim, hospitals should step up efforts to protect workers from a threat of healthcare violence that is increasing amid a national opioid epidemic.
“Hospitals certainly don’t need a standard or a regulation to make sure their workforce is protected,” Michaels says. “The growing opioid epidemic has raised the level of concern in the hospital community — you have people looking for drugs. We have had this issue of workplace violence in health settings for a long time, but I believe it has gotten worse in many ways.”
Appointed by former President Obama, Michaels left OSHA last year after a seven-year term as assistant secretary of labor — the longest tenure of any director in the agency’s history. As his term closed with the ascendancy of the Trump administration, Michaels directed OSHA to pursue a regulation to prevent violence in healthcare. After opening a request for information in 2016, OSHA announced on Jan. 10, 2017, that it would promulgate a federal regulation to protect healthcare workers from violence.1
In a statement at the time, Michaels said, “I am pleased to announce, as one of my last actions, that OSHA will grant [healthcare union] petitions and will commence rulemaking to address the hazards of workplace violence.”
OSHA was prompted to pursue rulemaking by a government watchdog report that found lost days due to violent injury in healthcare were five times higher than other industries overall. The report noted that the nation’s mental health system is in disarray, as the dearth of psychiatric facilities drives patients into other healthcare settings.
“The number of nonfatal workplace violence cases in healthcare facilities ranged from an estimated 22,250 to 80,710 cases for 2011, the most recent year that data were available from all three federal data sets reviewed,” the Government Accountability Office (GAO) reported.2 “The most common types of reported assaults were hitting, kicking, and beating. The full extent of the problem and associated costs is unknown, however, because according to related studies GAO reviewed, healthcare workers may not always report such incidents.”
In the accounts reported, there is no shortage of grim details by assaulted workers. Yet, as urgent as the problem is, even when the OSHA rulemaking process begins, it takes years to move through the bureaucracy of hearings and review necessary to enact regulation. Until the political winds change, the duty falls to healthcare facilities, a setting where Michaels once worked himself.
“The first 13 years of my career I worked at Montefiore Hospital in the Bronx,” he says. “I wasn’t directly involved in the employee health service, but I worked very closely with them. So, I have a particular focus on healthcare and hospital workers.”
In that regard, as this issue went to press, Michaels was scheduled to appear among the keynote speakers at a national conference on patient and worker safety. While violence is a compelling occupational threat, the epidemic of worker injuries takes a grinding daily toll in healthcare.
“Many healthcare institutions haven’t yet recognized the link between patient safety and worker safety,” he says. “Many of them that have recognized the link have only made small steps toward the problem.”
Still, as data accumulate, healthcare may finally reach a tipping point where the patient benefits of safe lifting and mobility will justify investment in programs to protect workers from injuries.
“We are able now to link safely mobilizing patients with protecting healthcare workers,” says Susan Gallagher, PhD, RN, a bariatric nurse, safe patient-handling consultant, and speaker. “Our concern is how do we protect healthcare workers and still maintain patient safety? There is a link between the two; we are seeing it more and more in our research.”
Patient mobility initiatives have really come to the fore in the last few years, generating more data on improved health outcomes.
“A patient-handling program designed 10 years ago didn’t even have provisions for this,” she says. “Now we know there need to be special accommodations in critical care to get sicker patients up and out of bed early. It reduces the length of stay and readmissions. The patients just have better outcomes.”
Employee health professionals are critical to these efforts, and have spearheaded some of the more effective programs, she adds.
“In my experience, it is employee health and occupational health that have brought on the most successful safe patient-handling programs,” Gallagher says. “These are individuals who see what really happens in the workers’ lives. They really want to make a difference.”
Of course, reducing costs in the form of workers’ comp claims are very much a part of the equation, but employee health most directly addresses the “humanistic aspect” of worker injuries, while getting the secondary gain of improving patient safety, she says.
While employee health is in a critical role, the ultimate success of any program to protect healthcare workers depends on the support of leadership.
“I think that the most important players in this are the CEOs, boards of trustees, and directors,” Michaels says. “What we are talking about here is culture change, and that has to come from the top.”
Healthcare can learn from the business models of other industries, where occupational safety is linked closely with productivity and profits.
“Workplace injuries are evidence of the absence of operational excellence,” he says. “If workers are being injured, the work isn’t being done correctly.”
Reasons for that may include understaffing or the lack of proper equipment, but the result is that healthcare has “random injuries higher than most every other sector — it’s higher than construction workers,” Michaels says.
“That is often surprising to people, especially in the healthcare industry,” he adds. “They don’t realize it is such a dangerous industry for their workers.”
In addition, in part because many hospitals are not-for-profit institutions, workers’ compensation costs are “very high, particularly in nurse and nurses’ aides who suffer debilitating back injuries,” he notes.
This problem is likely to get worse before it gets better because hospitals are seeing an influx of heavier patients and many do not have the equipment in place to deal with them, Gallagher says.
“About 20% of nurses in any given day — one out of five — are having discomfort related to an occupational injury,” she says. “It impacts not only their professional lives, but personal lives as well.”
Much as with violence, a severe patient-handling injury is an event that goes beyond the bedside, affecting the immediate families and surrounding communities of injured nurses.
“That’s what we find when we really sit down with nurses and ask them how their work impacts their lives,” Gallagher says. “Last week a woman said to me, ‘I can’t even wear the clothes I used to wear to work. I can’t wear anything if I have to reach over my head to put a shirt on.’”
Hospitals should consider forming a bariatric task force or at least an ad hoc committee, as facilities may underestimate the level of obese patients under care.
“You have to do a point-prevalence [review],” she says. “How many patients are admitted on any one day that weigh 300 to 600 pounds? How many weigh 600 to 1,000 pounds? Shockingly, right now we are seeing a lot of patients in that 600- to 1,000-pound range.”
In addition to information on patient population, assess the various lifts and equipment to make sure they are compatible with patient room installations, she adds.
“I have a photograph I just took in the last 10 days in a facility that has a ceiling lift that accommodates 500 pounds hanging over a toilet that accommodates 200 pounds,” she says. “That is not compatible. We need to know all this information ahead of time and then in planning address the gaps.”
If possible, set up a simulation room so healthcare workers can practice working together to lift and mobilize patients, Gallagher recommends. This can help workers prevent injuries when a real situation arises, while testing equipment and lifts to see what works best in a given scenario.
“You can look at scenarios like what happens if the patient falls in the bathroom — which is very different from an open space,” she says. “It helps us understand how to learn the nuances of the tools before we are put in that very stressful situation.”
Indeed, the stress of working with bariatric patients can exacerbate toxic behaviors like bullying, she adds. For example, an experienced nurse may tell co-workers it is easier and faster to move the patient manually. Though these workers may have been trained to use safe handling equipment, they may feel pressure in the moment. It takes “moral courage” to defy a more experienced co-worker, she says.
“What if it they get the patient up off the side of the bed without the equipment, and then the patient falls?” she says. “Now we have a patient event and potentially an injured nurse. It’s important for not only bariatric nurses to have moral courage in what they do, but for all safe patient-handling professionals.”
Such scenarios should be discussed openly and the situations when equipment should be used clearly understood.
“It’s a crucial conversation,” she says.
1. OSHA. Prevention of Workplace Violence in Healthcare and Social Assistance. Fed Reg 2016-29197, Dec. 7, 2016. Available at: http://bit.ly/2hB5gL5.
2. GAO. Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence. GAO-16-11: Published Mar. 17, 2016.
Financial Disclosure: Medical Writer Gary Evans, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Kay Ball report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.