Exploring the hazards nurses face and the challenges on the horizon, Kim Sunley concludes that a focus on the health and well-being of health-care staff will reap benefits for patients.
Hardly a week goes by without media coverage of patient safety issues – from medical errors to rates of health-care-associated infections – but little is heard about the safety and health of those who care for patients: the 300,000-plus nurses and many more nursing health-care assistants across the UK. And where there is media interest, it usually concentrates on the high levels of sickness absence within the NHS, or reports of unhealthy lifestyles led by health-care workers.
However, there is now a growing body of evidence that patient safety and the patient experience are directly linked to the health, safety and well-being of health-care staff, so it’s in everyone’s interest that nurses are kept safe and healthy in their working environment. In the words of former health minister, Ann Keen, in response to the Boorman review1 of the health and well-being of the NHS workforce: “What’s good for staff is good for patients”; in other words, a culture that cares for both.
Stress and suffering standards
The occupational hazards faced by nurses are as diverse as the jobs they carry out, from the nurse on the ward being exposed to skin irritants to the nurse working in the community and the associated risks of being a lone worker.
However, one hazard appears to cut across all roles: workplace stress. In the 2009 Royal College of Nursing (RCN) survey of 9000 nurses in the UK,2 55 per cent said they were under too much pressure at work, with 54 per cent saying they were too busy to provide the standard of care they would like. Work-related stress was also reported as a major motivator for changing employment.
While the Boorman review revealed high levels of sickness absence compared with other sectors, it also highlighted significant levels of presenteeism.1 In the review, the latter is defined as presence at work, despite feeling ill enough to justify being at home. Presenteeism was a particular problem among nurses, with 71 per cent of qualified nurses in the 21-30 age group saying they had come into work when too sick, compared with 45 per cent of staff in the same age group working in corporate services. Pressure from managers, or fear of letting their colleagues down, were identified as key factors related to presenteeism. But health-care workers attending work when infectious can carry more than the obvious risks to patients, in the form of worker fatigue, stress and impaired judgement.
Causes of absence
In common with other sectors, musculoskeletal disorders and mental ill health are the most prevalent causes of absence in the NHS. However, skin problems are the third cause of absence, many of which are likely to be dermatitis. A recent HSE report into the management of occupational dermatitis in 44 NHS organisations in England, Wales and Scotland found that 46 per cent of health-care staff questioned during visits were suffering skin problems, ranging from dry skin to dermatitis.3 The report found deficiencies in the way occupational-health services are integrated into health and safety management systems to prevent or manage work-related contact dermatitis.
While not all cases of musculoskeletal or mental-health disorders are work-related, the Boorman review highlighted the probability of an NHS worker incurring an illness to be 1.49 times greater than that of a non-health worker, and the probability of the former having an accident as 1.73 times greater.1 There is no denying that nursing can be a physically and psychologically demanding occupation, with manual handling and stress being significant hazards. Slips and trips are also common in the sector, which has been targeted by the HSE as part of its ‘Shattered Lives’ campaign, including a graphic example of a nurse whose slip injuries resulted in the loss of a limb and ended her career.4
Ill-health retirement figures are also a cause for concern. There are approximately 2500 NHS workers retired on the grounds of ill health each year – more than half as a result of musculoskeletal disorders and mental-health problems. A review into ill-health retirement in the NHS considered that proactive management and preventative measures could have averted about 25 per cent of ill-health retirements.5
Sharps success
Injuries attributed to medical sharps, such as needles or scalpels, previously used on patients are also common occurrences in the health-care environment. Injuries are estimated to be as high as 100,000 a year and expose nursing staff to more than 20 different blood-borne diseases. Since the late 1990s, 11 health-care staff have contracted hepatitis C from injuries with infected sharps and five HIV transmissions have also been confirmed in the UK.6,7
While the risk of transmission of infectious diseases is low, the anxiety and stress of waiting for blood results to come through and the unpleasant side-effects of medication taken following exposure cannot be underestimated. Following an injury of this nature, nurses can sometimes face up to six months of uncertainty, which can impact on their personal lives.
Sharps injuries can be prevented but, to date, the approach to the prevention of sharps injuries has focused on individual behaviours, including failure to recap a used needle, safe disposal in a sharps bin, and use of personal protective clothing.
However, there is an engineered solution in the form of sharps safety devices, such as needles that retract into the barrel of a syringe immediately after use, or even needle-less devices. In the US, legislation, by way of the Needlestick Safety and Prevention Act, has been in place since 2000. The Act requires employers to provide safety-engineered medical devices and related equipment to protect their staff from needlestick and sharp injuries, as well as training and safe systems of work.
Working closely with other employee and employer representatives at a European level, the RCN has successfully negotiated a European Framework Agreement on the Prevention of Sharps Injuries in the hospital and health-care sectors, which is being taken forward by the European Commission as a health and safety Directive.8 The Directive, which applies to health-care organisations and services in both the public and private sectors, reinforces the principles of protection within Article 6(2) of the Council Directive 89/391, including avoiding the risks, adapting to technical progress, and giving collective measures priority over individual measures.
The HSE is currently exploring the options for transposing the Directive into British law by 2013 and, while there is a requirement within COSHH to assess the risks from biological agents, it is evident from the number of injuries that current approaches to the prevention of sharps injuries are not as effective as they could be.
Working in partnership
The Framework Agreement and subsequent Directive emphasise the importance of partnership working between employers.
Through the Partnership for Occupational Safety and Health in Healthcare – a group involving the NHS Employers organisation, representatives from both the health and safety and occupational-health professions, and other trade unions – new occupational health and safety standards have been developed for the sector on a range of issues, from violence to manual handling. The organisation has also developed a supplementary ‘Back Pack’, outlining the role and expectations of line managers, staff and safety representatives in addressing musculoskeletal injuries in the NHS.
Work-related stress has been a continued work stream for the group. A number of partnership workshops involving the NHS Litigation Authority and HSE have been run, one of the findings from which was a lack of information on ‘what works’. As a result of the feedback, the group has commissioned a study to evaluate the effectiveness of stress interventions in the sector, with preliminary results expected later this year.
Much of the national work of the RCN is delivered locally in NHS and other health-care organisations by safety reps, who are encouraged to work in partnership at a local level through health and safety committees. A host of tools is available to support them in their role, including the violence risk-assessment tool and online learning resources.
Future challenges
RCN safety reps have reported increasing difficulties in obtaining time off to carry out their role, particularly if they work on the front line. To tackle this problem, a national time-off and facilities agreement for trade-union reps has been negotiated for the NHS, which reinforces the requirements of the Safety Representatives and Safety Committee Regulations. Nevertheless, increased difficulties in obtaining time off to carry out the safety rep’s role is, arguably, a sign of the times and pressure on front-line staff has also resulted in difficulties in staff obtaining mandatory training, which includes health and safety training.
Another challenge to the UK economy – especially in the health-care sector – is the ageing workforce. The 2009 RCN survey found that 27 per cent of nurses working in the community and 19 per cent in NHS hospitals were more than 50 years old.
While the effect of ageing on workers varies considerably between individuals, the European Agency for Occupational Safety and Health recognises that older workers are more at risk from musculoskeletal disorders, owing to physiological changes in muscle strength and joint movement. The Agency also points out that older workers may not find it so easy to carry out demanding shift work and may need more time to recover between shifts.9
Lone working is also likely to increase as care continues to move from the hospital to the home setting – a trend that will present a whole set of unique health and safety challenges to protect those who undertake such activities.
We also await the results of HSE research into the health impact of night-shift work, due to be published next year. The recent decision of the International Agency for Cancer Research to classify shift work as a probable cause of breast cancer understandably caused much alarm among the many nurses who work nights.10 In response to the report, the RCN reinforced the requirement for health-care employers to follow the Working Time Regulations in relation to rest breaks, compensatory rest and health checks for night-shift workers, and for members to be ‘breast aware’.
Clearly, nursing care has to be delivered around the clock, but we need to know whether these interventions are enough to lower the risk, and whether other measures need to be taken.
Conclusion
There is much rhetoric about the NHS being an exemplar employer and looking after the health, safety and well-being of its staff, but the results of the Boorman review and reports from RCN members show that there is clearly more to do to address the burden of occupational disease and injuries, and subsequent absence and ill-health retirements.
A full and comprehensive approach to workplace health, safety and well-being is needed: one which, firstly, addresses the organisational factors that lead to ill health and injury, and which also supports individual workers to make choices on healthy lifestyles, particularly those who work shifts. Presenteeism, too, needs to be further up the agenda of human resources and occupational safety and health professionals.
Much can be achieved through partnership working and there is a key role for health and safety professionals to work together with local RCN safety representatives, and nationally through respective partnership groups to ensure that occupational health and safety stays high on the agenda. While there is an economic case for investing in staff health and safety, there is also a patient-safety case – and this may be the more persuasive argument to focus on as budgets come in for greater scrutiny and spending gets cut.
References
1 Boorman, S (2009): ‘The Boorman Review: NHS Health and Wellbeing – Final Report’, Department of Health, www.nhs.healthandwellbeing.org
2 Royal College of Nursing (2009): The RCN Survey: Past Imperfect, Future Tense. Nurses’ employment and morale in 2009, RCN, www.rcn.org.uk
3 HSE (2009): Report of an Inspection Project 2008-2009, Prevention and management of work-related contact dermatitis in the NHS acute sector, HSE FOD
4 HSE Shattered Lives STEP Tool – Health-care sector, introductory course, accessed on 9 June 2010 at www.hse.gov.uk/slips/step/ChooseRole-Health.htm
5 Cited in the Boorman Review (see above), p46 – www.nhs.healthandwellbeing.org
6 Health Protection Agency (2008): ‘Eye of the Needle’
7 Godfrey, K (2001) ‘Sharp practice’ in Nursing Times, 2001, 97, pp22–24
8 Council Directive 2010/32/EU: Implementing the Framework Agreement on prevention of sharp injuries in the hospital and health-care sector
9 European Agency for Safety and Health at Work, information on the hazards and risks associated with older workers, accessed on 9 June 2010 at http://osha.europa.eu/en/priority_groups/ageingworkers
10 Straif K et al (2007): International Agency for Research on Cancer Monograph Working Group, ‘Carcinogenicity of shift-work, painting and fire-fighting’ in Lancet Oncol, 2007; 12, pp1065-1066
Kim Sunley is senior employment relations advisor at the Royal College of Nursing.
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