Nurse mortality study looks at workplace hazards

Calls for more occupational health interventions

A multistate study of mortality patterns among female nurses calls for redoubled efforts to reduce workplace hazards, but at the same time acknowledges that budget cuts and downsizing are diminishing the ability of hospital occupational health departments to implement and evaluate preventive measures.1

The study examined causes of mortality among 50,000 registered and licensed practical nurses in 27 states using the National Occupational Mortality Surveillance database of death certificates. Researchers calculated proportionate mortality ratios (PMRs) for selected causes of death among female nurses compared with all workers (including housewives) and with other white- collar workers. Two age groups of nurses were included: working age (less than 65) and older (65 years and older).

Generally, the study found excess deaths among nurses of working age in both comparison groups for viral hepatitis, suicide, cancer of the nasal cavities, and drug-related causes. Among older nurses, deaths due to chronic myeloid leukemia were excessive. PMRs for breast and colon cancers, diabetes, and heart disease varied by comparison group.

Most of the study’s findings are not new, says lead author Lucy A. Peipins, PhD, who was a National Institute for Occupational Safety and Health epidemiologist when she conducted the study. Now an epidemiologist for the division of health studies at the Agency for Toxic Substances and Disease Registry in Atlanta, Peipins says her goal was to determine whether problems identified in the past continue to be problems.

"And the answer is yes, some of these are still issues and need to be worked on," she tells Hospital Employee Health.

‘We need occupational health staff’

Peipins says widespread downsizing of hospital occupational health and nursing staff adds to her concerns.

"When there are fewer nurses and more work to do, there also is less focus on health concerns of individual nurses when they have many patients to see. Safety programs, surveillance programs, industrial hygiene programs, and occupational health programs are essential to monitor these kinds of patterns. More surveillance is needed. We need occupational health staff to identify the barriers to immunization and [use of] universal precautions, to determine what safety equipment is needed and what might prevent nurses from using it.

"When we identify these constraints, we can begin to work on them. We need structured programs to do this. I’m worried that increasing cutbacks will make it more difficult for nurses to comply, and cutbacks in occupational health programs just exacerbate those conditions," she says.

The study focuses mainly on outcomes associated with occupational exposures identified for nurses in the workplace, such as:

• biological hazards, including viral hepatitis, tuberculosis, and human immunodeficiency virus (HIV);

• chemical hazards, including cytotoxic drugs and anesthetic agents;

• physical hazards, including ionizing radiation, needlestick injuries, and patient handling;

• psychosocial hazards, such as stress and shift work.

Data analysis showed substantially elevated PMRs for viral hepatitis (death certificates did not specify types of hepatitis) among working-age nurses in both occupational comparison groups. Hepatitis exposure, primarily through needlesticks, has long been an issue for HCWs and still is, Peipins notes.

Occupational HIV infection among HCWs also occurs primarily through needlestick injuries, but the data showed no excess of HIV deaths among working-age nurses. However, "any possible excess may not be represented in these data because of the latency of 10 to 15 years between HIV infection and mortality," the study states.

While the number of TB deaths was small, PMRs were elevated for working-age nurses, especially compared with other white-collar workers. Peipins points out that occupational risk rises with increased exposure to patient populations such as correctional institution residents, low-income groups, alcoholics, and drug users.

Leukemia deaths higher than expected

Ratios for breast cancer were somewhat higher than expected for nurses compared with all workers and lower than expected compared with other white-collar workers. Delayed childbearing, often a characteristic of white-collar workers, has been associated with breast cancer, Peipins explains. The cause also could be related to lifestyle or nutrition factors.

Deaths due to chronic lymphoid leukemia were higher than expected for working-age nurses in both comparison groups. Chronic myeloid leukemia was higher for older nurses in both comparison groups, as well.

The study points out that nurses are known to be at risk for leukemia from exposures to chemotherapeutic agents, anesthetic gases, and ethylene oxide.

Malignant neoplasms of the nasal cavities among working-age nurses caused more deaths than expected. Although exposure to formaldehyde could be implicated, Peipins says the excess deaths could be related to other exposures to chemicals more common in the health care setting that have not been associated with nasal cavity cancer.

Excess mortality from diabetes was seen only in comparison with other white-collar workers. Fewer than expected deaths due to heart disease were seen compared with all workers.

The study also acknowledges the role of stress and burnout as significant health risks for nurses. Excess mortality among nurses due to suicide has been previously reported, it notes. The finding of elevated PMRs for accidental poisonings due to drugs and medications — "interesting to have that among people who are quite familiar with drug dosages," Peipins says — could be a misclassification of that category on death certificates and might actually represent suicides.

Another puzzling finding concerned mortality due to accidental falls, which was higher than expected among working-age nurses in both occupational comparison groups. Death certificates did not state whether those falls occurred in the workplace. If they did not, could suicide again be suspected, or is it another misclassification of data?

While risks are associated with patient handling or spills on floors, "most falls in the hospital setting are not likely to be fatal," Peipins says, "but perhaps [the finding] warrants examination from an industrial hygiene perspective. Are nurses falling? What seems to be the story here?"


1. Peipins LA, Burnett C, Alterman T, et al. Mortality patterns among female nurses: A 27-state study, 1984 through 1990. Am J Public Health 1997; 87:1539-1543.