On the job safety for home care workers: Caution goes a long way

Here’s where to find it and how to get it

A 1992 study by the Department of Labor and Industries found that more nursing aides, health aides, health technicians, social workers, and nurses were attacked on the job than were police officers or prison guards. A year later, the Bureau of Labor Statistics data found that health care workers have the highest incidence of assault injuries.

On a daily basis, home care staff are going into some of the worst neighborhoods and into homes where violence is no stranger. Given the daily requirements of the job, what can home care workers do to protect themselves from violence in high-risk neighborhoods? Hospital Home Health takes a look in this two-part series at staying safe on the home care beat.

Uniforms: Friend or foe?

Depending on whom you ask about how to handle a threatening situation, you’ll get a different answer. But the one constant is that home care professionals need to be alert to the many dangers they face. More than being alert, though, home care professionals need to be prepared to deal with a host of potentially dangerous situations and have a sound course of action in mind.

For example, if assaulted on the street, your best defense is to feign illness, drop to the ground, and scream that you are having a heart attack; people are more likely to help in medical emergencies than in cases of a perceived attack or threat of violence.

In some cases, professionals also recommend faking a sudden bout of insanity and tell of incidences where the intended victim dropped to the ground shrieking and began eating grass and dirt. Not a pleasant thought, but an effective one as the would-be attacker fled.

Just as the idea of calling attention to yourself upon the threat of an attack seems natural, it seems just as natural that you would want to avoid calling any undue attention to yourself when making home visits in high-risk neighborhoods. There is a debate within the home care community whether it is better to be identified as a health care professional and looked upon favorably by the area’s residents or whether it’s just advertising your access to prescription medications.

Paul Dewhitt, RN, a home care nurse with Cuidado Casero Home Health in Dallas, says he frequently goes into inner-city slums to visit patients where drugs are being sold on the corner. "I am even hit up to buy. I have actually had to get down on the floor with family members on more than one occasion when gunshots were heard in some high-risk communities. It’s a jungle out there."

Stand out or blend in?

It’s no wonder then that Dewhitt says, "Inner-city nurses need to think twice about uniforms as they can make you an easy target for attack by desperate and dangerous types who are looking for an easy source of drugs or medical supplies. Uniforms are important to lend authority to the home nurse and enhance the reception of teaching and education as well as give a reassurance of competence.

"The policy at my agency is to wear scrubs or a lab coat, but in a dangerous situation, I fold up my light lab coat and put it in my bag, and then I put it on once inside the patient’s home," he adds. "We all carry bags, and if we look like the doctor or nurse with syringes and drugs, we are asking for problems."

Dewhitt further attempts to blend in by wearing street clothes that are "tasteful and conservative and plain."

When it comes to going incognito, Denise McCarraher, RN, audit nurse/case manager, with the IVNA of Richmond, VA, is all for donning a lab coat once she is inside.

"Considering I work in some of our city’s worst drug and shooting areas, I couldn’t agree more," she says. "It is not difficult to figure out that we are nurses to start with if anyone asks their neighbors who the woman with the bag is that goes to the house in the middle of the block each morning. I certainly don’t need a uniform to attract any more attention than my repeated presence causes."

It’s an interesting parallel then that other home care nurses, such as Alice Fritz-Warren, RN, BSN, MSN, the regional performance improvement director for Sun Plus Home Health in San Leandro, CA, have found that their uniforms afford them a bit of protection in an otherwise less-than-safe neighborhood.

As she explains it, she has "worked in the inner city on and off for the last 10 years. I have been approached numerous times by drug dealers and groups of kids wearing gang colors. When they saw my scrubs or lab coat and realized that I was there to help, they backed off. I have even come back to my car to find some rather forbidding-looking men guarding it."

One home care nurse in Cleveland says that she has found more cooperation and respect when dressing in scrubs or at least a lab coat that clearly identified her as a nurse. Barb Johnson, administrator for Progressive Home Care in Cleveland, says that one of the biggest mistakes a home care professional can make is to carry a bag, or a purse, for that matter as that is "definitely asking for trouble." She advocates keeping it simple: a lab coat, stethoscope around the neck, and necessary supplies in the pocket, period.

"Somehow, even gang members who have grandmas appreciate the help you’re giving and will often escort you to and from the door," she says. "I wouldn’t drive a new car or go down there after dark though. My mama didn’t raise a total fool."

Whereas Dewhitt would like to be able to keep his scrubs on while on the street, he says he doesn’t "feel that the male nurse would be afforded the protective response that some female nurses have experienced. I wish I could wear [scrubs], but I think of the reports of just these types of attacks and an inservice done by a police detective who discouraged just this practice. . . . When I’m on the street, it’s street clothes for me."

Situations beyond your control

While the decision to don scrubs outside the home is something home care nurses can control, the atmosphere of violence both in and out of the home is not. One such case is that of a Maryland home care nurse who fell victim to a hit man who was hired to kill the patient and his mother.

"The case involved the estranged husband who hired a hit man who went into the home of a patient, shot and killed the mother and the home care nurse, and then disconnected the child’s respirator, says Elizabeth Hogue, a home care attorney from Burtonsville, MD. Perhaps the case is a bit extreme, but it well illustrates the dangers that home care nurses and aides face on a daily basis.

Hogue has received all types of calls. One she remembers in particular was from a home care agency that called about its nurse. The woman had locked herself in a closet with her cell phone and was calling for help because on the other side of the door stood the patient’s father, brandishing a knife and threatening to kill her. It’s hard to imagine that the very person there to help could become the victim of violence, but it’s not so hard when one considers the pressures family caregivers face.

"One thing I’ve noticed," she says, "is that a lot of anger that patients have is displaced on home care workers especially because they are on the patient’s turf where they feel they have authority. The family doesn’t put the home care worker’s role into perspective. They’re exhausted, worried, and afraid, and the home care workers catch it."

So what choices do home care staff have in instances where they are afraid, whether it be because of gang violence in the neighborhood or patients who keep guns under their pillows?

Providing a safe workplace

"If you’re talking about independent contractors," says Hogue, "they can refuse to go into a situation. But if you’re looking at employees and the boss insists, then they must go."

"Any boss who insists on an employee going to a dangerous situation would be very foolish indeed," she adds.

"If home care workers are afraid, you must take that very seriously. Help them articulate why they feel that way, but knowing [home care workers] and their propensity to deny threats of danger, you really have to pay a lot of attention, otherwise you are open to a lot of liability," Hogue says.

"I’m not only referring to straightforward negligence but OSHA [Occupational Safety and Health Administration] issues as well. The general clause under the OSHA statute requires employers to provide a safe working environment for employees.

"There’s an old legal adage that says, Every dog is entitled to one bite.’ Once workers say they are afraid, the dog has had its bite. If you make them go back, you’re asking for it. The highest obligation of providers is to protect their staff. The highest obligation — there isn’t anything that is more important than that," she points out.

Greg Solecki, vice president of Henry Ford Home Health Care in Detroit, agrees. Solecki’s agency, he says, has a standing policy whereby "because of our mission and the area we serve, personal safety is high on our list of priorities. First and foremost, we always stress to staff that they are never to make a home visit in a situation where they feel unsafe. We value their intuition, and our policy is to support their decision when they feel unsafe. Interestingly enough, I think this empowerment has resulted in very few staff refusing to go anywhere."

Certainly the agency has responsibility for the safety of its employees, but as Hogue notes, a large degree of responsibility also lies with the employees themselves. "One of my overriding concerns is that home care providers ignore their own fear because they so badly want to take care of patients and help them that they ignore symptoms they should not.

Report criminal activities to police

"So many agencies and staff are afraid to notify police when patients and family members engage in criminal conduct. Not so much because of fear of reprisals, but the attitude that, Oh well, the patient didn’t mean it,’ and they downplay the seriousness so much that they convince themselves there’s no need to report. I would encourage them to always go to the police," she stresses.

As Hogue sees it, one reason behind this hesitancy to report situations to the police and the tendency to downplay what are often serious situations lies in the fact that "if they didn’t cope with their vulnerability through denial, they might not be able to do what they do. If they would just pay attention to that much, it would help them. They don’t want to alienate the patient and their family, so they end up asking themselves, How can I have the kind of relationship with patients if I say and do these kinds of things?’"

While there are no easy answers, there is a steadfast rule, which every home care employee would be well-advised to heed, says Fritz-Warren. "The bottom line is to do what helps you feel comfortable in dangerous areas. Always pay attention to those hairs on the back of your neck or the butterflies in the pit of your stomach. If they tell you not to go there — don’t."

[For more information, contact:

  • Paul Dewhitt, RN, Cuidado Casero Home Health, 600 Six Flags Drive, Suite 624, Dallas, TX 76011. Telephone: (817) 640-0646.

  • Alice Fritz-Warren RN, BSN, MS, Regional Performance Improvement Director, Sun Plus Home Health, 303 W. Joaquin, Suite 110, San Leandro, CA 94577. Telephone: (510) 895-1604.

  • Elizabeth Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. Telephone: (301) 421-0143.

  • Barb Johnson, Administrator, Progressive Home Care, 14090 Ridge Road, Cleveland, OH 44133-4968. Telephone: (440) 230-1200.

  • Dee McCarraher, RN, Audit Nurse/Case Manager, IVNA, 1004 N. Thompson St., No. 300, Richmond, VA 23230-4927. Telephone: (804) 358-0200.

  • Gregory Solecki, Vice President, Henry Ford Home Health Care, One Ford Place, 4C, Detroit, MI 48202. Telephone: (313) 874-6500.]

Personal Safety on the Job

  • Every employee should understand the concept of "universal precautions for violence," i.e., that violence should be expected but can be avoided or mitigated through preparation.

  • Employees should be discouraged from wearing jewelry to help prevent possible strangulation in confrontational situations. Moreover, employees such as home care workers should carry only required identification and money.

  • Trust your instincts when it comes to avoiding threatening situations, and exercise extra care in elevators, stairwells, and unfamiliar residences. If there is a hazardous situation, leave the premises immediately, and if necessary, request police assistance.

  • Be familiar with your employee contract and your agency’s workplace safety program (if applicable) so that you are clear on how visits will be conducted, the rules involving the presence of others in the home during the visits, and the refusal to provide services in a clearly hazardous situation.

  • If possible, carry a cell phone. At the very least, use a call-in system to verify your time of arrival at a home and your time of departure.

  • Keep a daily work program and keep a designated contact person informed about your whereabouts throughout the workday. In the event you fail to report in, the contact person should follow-up.

Source: Occupational Safety and Health Administration, Washington, DC. Web site: www.OSHA.gov.