"Safety Comes First" should be more than a slogan

Protect employees to improve retention and patient care

[Editor's note: This is the first of a two-part article that discusses the safety of home health employees. This month, we look at the types of workplace hazards home health employees face in patients' homes. Next month, we look at specific actions to take when an employee reports an unsafe situation and how improving employee safety can affect recruitment and retention of employees.]

Imagine showing up at your workplace and having to run full speed back to your car to escape being mauled by a dog, or arriving at work only to be greeted at the door by a gun pointed at your face.

Two of Attorney Robert Markette's clients did not have to imagine either of these hazardous situations because they experienced them. "Luckily, the nurse was able to outrun the dog, and the home health aide was able to back away from the patient's door and get to her car," says Markette. "But both of these situations demonstrate the unique employee safety challenges faced by home health agencies."

Needlesticks, falls on slippery floors, and injuries from lifting patients are hazards faced by health care workers in all settings. Hospitals, nursing homes, and other health care facilities control the safety of the workplace with processes and resources that employees can easily access.

Take the hazards faced by hospital-based or other facility-based nurses and aides and add family violence, working in isolation, traveling in high-crime areas at night, aggressive pets, and unsanitary environments, and you have a good picture of the challenges faced by home health managers who want to ensure a safe workplace.

Workplace safety for home health differs from workplace safety in other health care settings, admits Robyn R.M. Gershon, MSN, DrPH, associate dean of research resources and professor at the Mailman School of Public Health at Columbia University in New York City. "The workplace for home health nurses and aides is the patient's household, which is not regulated by anyone," she says. This location puts home care staff members at higher risk for hazards than other health care workers, she says.

Unsafe household conditions reported by 738 registered nurses who participated in a 2008 survey included animal hair (74% of respondents), cigarette smoke (72%), excessive dust (58%), vermin (44%), and unsanitary conditions (43%). The threat of violence was also frequently reported, says Gershon, one of the study authors.1 When home health aides are surveyed, their concerns focus more on violence in the house and neighborhood, drug use in the home, guns in the home, or aggressive pets. "Aides are also in the homes for longer periods of time, up to 12 hours at a time, so they are exposed to more interaction with family, neighbors, and friends," she says. "Aides in urban areas are frequently using mass transit late at night and walking through areas that might not be safe," she points out.

Although ensuring employees' safety is a challenge in home health, it is important to take every step possible to do so, says Gershon. "Studies have shown that employee safety is directly correlated to employee injuries, adverse medical events, and to employee job satisfaction and retention," she says. "Other studies have also shown a correlation between the safety of the home health employee and the quality of patient care," she says. It's not surprising to learn that patient care can suffer if an employee does not feel safe, she says. "A nurse or aide who feels threatened in a home might cut a visit short, skip a visit, or choose not to perform some tasks that agitate a patient or family member," she explains.

Develop reporting process

The first step to take to ensure employee safety is to develop clear policies regarding employee safety and make sure all employees are aware of the importance management places on employee safety, Markette suggests. "Employees should know whom they should contact about unsafe conditions at a patient's home," he says. Be sure employees understand that they don't have to wait until there is violence or an accident or injury. "In every case in which an employee or patient is harmed, there were warning signs," he adds. This means that any concern expressed by an employee must be taken seriously, he points out. "Have a process in place to receive the complaint, investigate the complaint, and communicate your decision regarding action needed to address the complaint," he says. "It is important that every concern expressed by an employee be investigated, even if the supervisor doesn't see it as an issue," he says.

Once an agency manager has a policy and process in place, be sure to educate staff members, suggests Norma R. Anderson, RN, MSN, CNL, DNP(c), nurse educator, University of San Francisco School of Nursing and author of "Safe in the City," a study of workplace danger in home health.2 "Preventing injuries to workers through yearly safety training and daily reminders about safety is important," she says. "Employees need to feel valued and know that safety is of utmost importance," she adds. Ongoing education and incorporation of safety discussions into team meetings and conversations between supervisors and employees is one way to create a culture of safety, she adds.

Part of the education about employee safety is to emphasize the need for employees to stay alert and tuned into their instincts about different situations. "Clinicians who feel 'invincible' or blind to the potential risks can be a danger to themselves," points out Anderson.

RNs are more likely to report concerns about safety, Gershon says. "A nurse will not hesitate to tell a supervisor that she needs a sharps container in the home or that she wants a safety needle to use," she says. "Aides are less likely to report concerns, because they may believe the complaint will put their job at risk," she adds. Also, because aides spend longer periods of time with the patient and family, the aide may become so accustomed to the environment that he or she doesn't recognize risk, she says. "It's important that aides maintain their awareness of potential dangers, so they don't find themselves in a hazardous situation," she points out.

Part of safety training should include discussions of the importance of being aware and tools that can help in dangerous situations, says Gershon. Escape plans, lists of agency personnel who can be contacted for assistance, and cell phones are a few tools nurses and aides should have. "I'm a big believer in making sure that all aides have cell phones, even if the agency has to provide pre-paid phones for them to use in an emergency."


1. Gershon RRM, Canton AN, Raveis VH, et al. "Household-Related Hazardous Conditions With Implications for Patient Safety in the Home Health Care Sector" J Patient Saf. 2008; 4:227-234.

2. Anderson, NR. "Safe in the City" Home Healthcare Nurse. 2008; 26: 534-540.


For more information about employee safety, contact:

• Norma R. Anderson, RN, MSN, CNL, DNP(c), Nurse Educator, University of San Francisco School of Nursing, 2130 Fulton Street, San Francisco, CA 94117-1080. Fax: (415) 422-5618. Email: normaranderson@msn.com.

• Robyn R.M. Gershon, MSN, DrPH, Associate Dean of Research Resources, Professor, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 938, New York, NY 10032. Telephone: (212) 305-1186. Fax: (212) 305-8284. E-mail: rg405@mail.cumc.columbia.edu.

• Robert W. Markette, Jr., Attorney, Gilliland & Markette, 3905 Vincennes Road, Suite 204, Indianapolis, IN 46268. Telephone: (317) 704-2400 or (800) 894-1243. Fax: (317) 704-2410. E-mail: rmarkette@gillilandmarkette.com.