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Institute of Medicine (US) Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes; Wunderlich GS, Sloan F, Davis CK, editors. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Washington (DC): National Academies Press (US); 1996.

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Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?

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7Staffing and Work-Related Injuries and Stress


This Institute of Medicine (IOM) committee was charged by Congress to determine whether and to what extent the need exists to increase the number of nursing personnel in hospitals and nursing homes as a means of reducing the incidence of work-related injury and stress among such health care workers. This mandate is both broad and narrow. It is broad because it does not limit the committee to study specific injuries or illnesses. At the same time, it is narrow in the sense that the committee was not asked to comment on the full range of hazards (infectious biologic, chemical, environmental, physical, and psychosocial) to which nursing staff are exposed in the workplace. Specifically the committee charge was to explore possible linkages between staffing levels and skill mix of nursing personnel and the incidence of work-related injuries and stress among nursing personnel.

Nursing personnel work in a wide range of health services settings including hospitals, nursing homes, and ambulatory and community-based environments. In performing their duties, they encounter a remarkable range of work-related hazards. Some evidence suggests that fatigue related to overwork and staffing patterns, including shift work, can contribute to injuries and stress among staff providing nursing services (Gold et al., 1992; Phillips and Brown, 1992). Factors such as the physical work environment, organizational and institutional characteristics and policies, and personal work habits contribute to exposure to the risk of injury and stress. Exposure to occupational hazards—physical, psychological, biological, chemical, and environmental—could have both short-term and long-term effects on the health and safety of the health care giver and, ultimately, on the safety and quality of patient care (Tan, 1991). A sizable proportion of the victims of nonfatal violence are care givers in hospitals and nursing homes. Evidence also exists of abusive and violent behavior of staff toward patients, at times resulting from stress and overwork and at other times from a breakdown of quality controls and appropriate supervision.

This chapter provides a brief overview of the incidence of work-related injuries in hospitals and nursing homes, violence and abuse of nursing staff, and violence and abuse directed toward residents of homes and stress among nursing personnel in hospitals and nursing homes. It then reviews available national statistics and research literature on occupational hazards to examine the risk factors associated with work-related injuries and stress and the linkages with the structural variables of staffing levels and skill mix.

Incidence Of Work-Related Injuries And Illness

The health services industry is one of the largest employers in the United States, employing almost 9 million persons in 1993 (BLS, 1995c). More than half of this workforce is employed in hospitals and nursing homes. Recent statistics and other information suggest that these institutions are becoming increasingly hazardous places of work, exposing workers to a wide range of risks.

In 1993, private industry workplaces reported 6.7 million injuries and illnesses, a rate of 8.5 cases for every 100 full-time workers (BLS, 1994c). Of the 6.7 million cases, nearly 6.3 million were injuries that resulted in time lost from work. As shown in Table 7.1, while the injury and illness rate for private industry as a whole has remained about the same or declined slightly since 1980, the rates for hospitals and for nursing and personal care homes during the same period have increased by about 52 and 62 per 100 full time workers, respectively. During the same period, hospitals reported about 338,000 cases, an incidence rate of nearly 12 per 100 full-time workers, and nursing and personal care facilities reported about 216,000 cases, a rate of 17 percent (see Table 7.1).

TABLE 7.1. Trends in Occupational Injury and Illness Incidence, United States, 1980–1993.


Trends in Occupational Injury and Illness Incidence, United States, 1980–1993.

Nine industries, each with at least 100,000 injuries annually, accounted for nearly 2 million, or 30 percent, of the 6.7 million injuries in 1993 (BLS, 1994a). Hospitals ranked second, and nursing and personal care facilities ranked fourth, among these industries.

Overexertion, being struck by an object, and falls at the same level1 are the leading ways in which workers are hurt on the job. These events account for more than one-half of the 2.3 million nonfatal injuries and illnesses that resulted in days away from work (BLS, 1995a). Workers in nursing and personal care facilities had the highest rate of injuries among all private industries due to overexertion or falling to the same level (BLS, 1995b).

Not surprisingly, most of the injuries and illnesses involving days away from work that are reported by registered nurses (RN), licensed practical nurses (LPN), nurse assistants (NA), orderlies, and attendants occur among women. Most of the workers in these occupations are women. NAs, who are employed predominantly in hospitals and nursing homes, ranked second only to truck drivers and laborers in the incidence of injuries and illness that involved loss of work days (BLS, 1995a). For persons in all occupations who had worked less than a year, NAs were reported as having the most injuries and illness, primarily strains and sprains mostly involving the back. They cited overexertion related to patient care as the primary cause. The major source of injury reported is the patient or the resident whom the aide was trying to lift or help in other ways (see Table 7.2). The association between job category and injury may be confounded by the nature of the work activities; NAs' work involves a great deal of heavy lifting.

TABLE 7.2. Percent Distribution of Nonfatal Occupational Injuries and Illnesses Involving Days Away from Work, for Selected Occupations and Worker Characteristics, United States, 1993.


Percent Distribution of Nonfatal Occupational Injuries and Illnesses Involving Days Away from Work, for Selected Occupations and Worker Characteristics, United States, 1993.

Relationship of Staffing and Injuries and Stress2

Analysis of literature on injuries and stress experienced by nursing personnel provides valuable information on issues involved in work-related injuries and stress. The studies reviewed suggest that the nature of the work, inadequate staffing patterns, clinical issues, equipment, organizational and institutional characteristics, lack of administrative support, lack of decision making authority, lack of resources, training and education, poor body mechanics, physical environment, and pressure to work in at-risk conditions all contribute to the problem of injuries and stress among nursing personnel. Rogers (Part II of this report) observes, however, that the data from these studies are limited because of the lack of replication and because of little evidence of any correlation between staffing and patient outcomes. Sample sizes and sample designs are sometimes questionable in terms of being able to generalize from the findings of individual studies. Many of the studies are descriptive and retrospective in design, and many report only anecdotal findings.

Back Injuries

Back pain is a major problem among the working population of the United States. Most people (about 8 out of 10) experience low back pain at some time in their lives. About 50 percent of the working-age population reports low back pain every year (AHCPR, 1994). Back injuries are among the greatest causes of lost time from work, and they are one of the most expensive workers' compensation problems today (McAbee, 1988). They constitute the greatest number of lost work days and the greatest amount of compensation paid in industry (Owen, 1985; SEIU, 1994).

Nursing staff in hospitals and nursing homes, by the very nature of their work, are particularly vulnerable to the hazards to back injuries and associated pain. These injuries result in time lost from work, disability, reduced productivity, and expense of medical care, and staff turnover. Even so, the extent of low back pain and injury in nursing personnel is thought to be underestimated. Owen (1989) found in a survey of 503 nurses that only 34 percent of respondents with work-related low back pain filed an injury report, and 12 percent contemplated leaving the profession because of back problems. Of all injuries in private industry reported to the Pennsylvania Bureau of Workers' Compensation in 1989, 22 percent were for back injuries. For nursing homes this proportion was 36 percent (SEIU, 1991).

Back injuries are a particularly troubling problem for the staff of nursing homes. They account for a higher percentage of all injuries in nursing homes than in other industries. As stated earlier, the major sources of injuries to nursing home workers are lifting and moving patients and overexertion. Back injuries are the most common injuries among NAs, and their incidence is higher among NAs than among other nursing personnel. Nursing home work is often difficult, stressful, and labor intensive, especially for NAs, who have the most direct contact with residents and do most of the heavy lifting.

Studies also found that recently employed nursing staff are more likely to injure their backs than are more experienced personnel (Greenwood, 1986; Neuberger et al., 1988; Garrett et al., 1992; Feldstein et al., 1993; BLS, 1995a). This fact is noteworthy because high turnover rates of NAs involve frequent additions of new staff who are more prone to injuries than staff with longer tenure or more expertise. The situation clearly suggests the importance of and need for more aggressive training related to the use of lifting devices and lifting teams especially for new employees, including ergonomic training in lifting techniques to prevent back injuries.

Staffing levels in nursing homes have not kept pace with the increased demands for more and better-trained nursing personnel. The case mix of nursing home patients is increasing in complexity as hospitals discharge patients early and transfer them to nursing homes. With sicker and more dependent patients than in the past, nursing homes have become more stressful and hazardous in terms of injuries. This situation is reflected in high turnover among NAs who do most of the heavy lifting. Understaffing (both qualitative and quantitative) leads to injuries, which leads to further understaffing, and the needs of patients go unmet. For instance, if the number of NAs on the floor is low, then it is not possible to have two or more of them available to lift a single person. Often NAs are forced to lift residents alone when assistance is not immediately available.

Garg and colleagues (1992) found that the prevalence of low back pain among NAs is high. On average, in their study, an NA had experienced four episodes of low back pain in the past 3 years, and had not reported three of the four episodes; 51 percent of the NAs had visited a health care provider for work-related low back pain. Assistive devices (e.g., hydraulic lift) were used less than 2 percent of the time. Patient safety and comfort, lack of accessibility, physical stresses associated with the devices, lack of skill, increased transfer time, and lack of staffing were some of the reasons cited for not using such assistive devices. The 2-person walking-belt manual method technique, which is used for transfer of residents from one position or location to another, was perceived to be the most comfortable, secure, and least stressful approach. However, adequate numbers of well-trained personnel are needed to carry out this method. In addition, environmental barriers (such as confined workplaces, uneven floor surfaces, beds that are not adjustable, stationary railings around the toilet, and similar obstacles) made resident care in nursing homes more difficult.

Workers in nursing homes are not alone in experiencing these problems. Several studies indicate that care givers in hospitals have reported work-related back pain and injury, and they implicate lifting techniques, poor staffing, ergonomics, inadequate communication, and physical constitution as contributory factors (Harber et al., 1985; Marchette and Marchette, 1985; Arad and Ryan, 1986; Jensen, 1987; Carney, 1993; Jorgensen et al., 1994). Recommended approaches to reduce the incidence of occupational back injury include better mechanical lifting devices, improved staffing, enhanced training and education, and more attention to worker job capabilities.

Kaiser-Permanente Medical Centers in Portland, Oregon, found back injury rates (based on workers' compensation claims) ranging from 10 to 30 percent on hospital units (Feldstein et al., 1993). Nearly two-thirds of the 53 orthopedic staff nurses in one large hospital reported work-related back pain, and 90 percent indicated patient handling as responsible for their most severe pain episodes (Cato et al., 1989). While assistive devices were considered adequate, levels of staff were cited frequently as inadequate for lifting assistance. Better staffing and staffing availability, improved body mechanics, and assistance with transfers were identified as the most helpful risk reduction strategies.

Several studies and anecdotal reports implicate poor staff-to-patient ratios in the high incidence of back pain and injury in both hospitals and nursing homes (Rodgers, 1985; McAbee, 1988; Larese and Fiorito, 1994). Nursing staff are often forced to lift alone when assistance is not immediately available, which suggests a link between injuries and numbers of staff. Other variables identified are poor working conditions and equipment design, all of which affect the quality of care available or provided. The authors identify a role for management in the prevention of injuries and re-injuries to the back.

The linkage suggested by these studies among staffing patterns and levels, work conditions, and back injuries needs to be validated. Research is necessary to examine the correlation between levels and training of nursing personnel (i.e., RNs, LPNs, and NAs) and patient load, on the one hand, and injury, illness, staff retention, and patient care and satisfaction, on the other. All personnel giving direct care (especially in nursing homes) should have annual training in lifting and transferring patients. Such efforts would improve the quality of life for health care workers and would represent a significant savings to the health care industry.

Needlestick Injuries

Needlestick incidents put nursing personnel at risk of contracting hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) and are the most frequently reported occupational exposure routes to such viruses (Marcus et al., 1991). Nursing staff are the primary victims of needlestick injuries (McEvoy et al., 1987; Wilkinson, 1987; Henderson et al., 1990; Marcus et al., 1991; Doan-Johnson, 1992). Conservative estimates place the incidence of more than 800,000 needlestick injuries each year among health care workers in the United States (Jagger, 1990). Of the 42 health care workers known by the Centers for Disease Control and Prevention (CDC) to have been occupationally infected with HIV through December 31, 1994, 13 (31 percent) were nurses (CDC, 1994). This estimate is generally thought to be an underestimate of the actual number of occupationally-acquired infections.

Most occupational HIV infections are caused by deep needlestick injuries or cuts from sharp objects and the resultant deposition of HIV-contaminated blood beneath the skin. Yet a far more common outcome of a deep needlestick injury or a cut from a sharp object is hepatitis B virus infection (Alter et al., 1976; Grady et al., 1978; Seeff et al., 1978); it occurs in 30 percent of all cases following exposure to hepatitis B core antigen as contrasted with the 0.3-percent risk associated with exposure to HIV (Geberding et al., 1987; Marcus, 1988; Henderson et al., 1990). Notwithstanding these facts, the universal precautions promulgated by the CDC (1988) and enforced by the Occupational Safety and Health Administration (OSHA) are not universally observed by health care workers (Courington et al., 1991). Infractions may occur in up to 60 percent of cases, irrespective of health care workers' participation in programs designed specifically to ensure compliance with universal precautions (Shelley and Howard, 1992). The reasons for such behavior are unclear, but certainly deserve further study.

The question of how to reduce needlestick injuries and the related sequelae remains, therefore, a critical one for both patient and worker safety. However, reliance on needleless systems for medication administration and accessing lines for blood in the hospital and scrupulous adherence to proper technique during invasive procedures, particularly those that are exposure prone, would appear to be the most cost-effective approach available at this time for prevention of work-related deep needlestick injuries and cuts from sharp objects among health care workers. The next step should be to decrease the injuries associated with disposal of needles and other sharp objects.

Some researchers have identified improved staffing and equipment and employee education as contributory factors in reducing the incidence of c injuries (Neuberger et al., 1988). Others include instituting appropriate and effective engineering controls, ensuring compliance with regulatory mandates and work practice policies and guidelines, conducting surveillance programs, and providing useful educational instructions. Further research is critical, however, to measure the outcomes and effectiveness of all such interventions.

In summary then, the committee is struck by the high rates of injuries to nursing personnel in both the hospital and the nursing home setting but it only found conclusive evidence of a strong link between nurse staffing per se and injuries for the category of back injuries. The committee is impressed, however, with three trends that emerge from the information cited above and the further information obtained through its site visits and public testimony—namely, (1) the effect that visible concern and leadership from high management levels can have in reducing injuries; (2) the overriding importance of good training, especially for lesser educated nursing staff; and (3) the utility of existing technologies for patient care (in hospitals) and resident services (in nursing homes) in reducing the probability of certain types of injuries.

RECOMMENDATION 7-1: The committee recommends that hospitals and nursing homes develop effective programs to reduce work-related injuries by providing strong leadership, instituting effective training programs for new and continuing workers, and ensuring appropriate use of existing and emerging technology, including lifting and moving devices and needleless medication delivery systems.

Governance, administration, and management structures of any organization should be committed to workers' safety and health in order for strong programs to be established. Unions and other labor groups and professional associations can exert pressure, and federal or state statutes and regulations can provide pressure and sanction, but effective safety programs depend on absolute support from the highest organizational levels. At the same time, supervisors and workers on the frontlines must be part of the leadership in safety and health. They know the problems and have ideas about solutions. Shared responsibility and shared resources lead to the best results.

Training in safe procedures, group dynamics, and leadership are important elements in this arena. Incentives and rewards for low injury rates must be judiciously used because in some circumstances they could lead to underreporting of incidents and therefore missed opportunities for prevention. Early intervention can help prevent accidents and injuries and ameliorate stress in the workplace that may, if not dealt with, lead to workers' compensation claims and other undesirable consequences.

Violence, Abuse, And Conflict

Violence and Abuse of Health Care Workers and Nursing Staff

In the United States, violent injuries to health care workers in the workplace were reported at least as early as the end of the nineteenth century (Goodman et al., 1994). Violence toward health care workers appears to be on the rise (Lipscomb and Love, 1992). Lack of a standard definition of violence makes it difficult to arrive at accurate estimates of the scope of the problem. Increased violence in the general population as a means of solving problems, greater use of mind-altering drugs, alcohol abuse, and the increased availability of weapons may all contribute to the problem of violence in health care settings (Lipscomb and Love, 1992). Patients carrying hidden weapons are a concern in psychiatric and general emergency departments across the country.


Workplace-related violence has been increasingly recognized as a particular problem for nursing personnel, especially in settings located in inner cities, and particularly in emergency departments and psychiatric facilities. The committee heard many reports during site visits and in testimony about assaults in hospitals, especially those located in inner cities, and particularly in emergency departments. Witnesses who testified before the committee emphasized the crowded nature of emergency rooms, the characteristics of the patients coming in, and the lack of sufficient staff as contributory factors to the risk of violence directed at health care personnel.

The increase in violence in the health care setting reflects to a large extent the increase in violence in the community. In 1992, private industry reported about 22,400 incidents of nonfatal assaults and acts of violence requiring an average of 5 days away from work (BLS, 1994b). Most of the violent acts involved threats, hitting, kicking, beating, biting, stabbing, squeezing, pinching, scratching, twisting, rape, and shooting. Thirty-eight percent of workers subjected to nonfatal violence were health care givers in nursing homes and hospitals (BLS, 1995d). Most of these care givers were female NAs and licensed nurses. Typically they required 3 to 5 days away from work to recuperate from their injuries. Ironically, some of these workers were injured by patients who resisted their assistance or were assaulted by patients who were prone to violence (BLS, 1994b).

Until recently, studies of violence in health care settings have focused mainly on assaults on staff by patients in psychiatric care settings such as mental health hospitals, psychiatric hospitals, or psychiatric units of hospital. Around 70 to 80 percent of staff in mental facilities reported assaults on them by patients (Lanza, 1983; Poster and Ryan, 1989).

In response to its members' concerns, the Emergency Nurses Association conducted a national survey in 1994 of emergency department nurse managers (Emergency Nurse Association, 1994). In this survey, violence was defined to include verbal and physical assaults with or without weapons. Factors contributing to violence toward staff were alcohol abuse, drug abuse, anger and high stress, overcrowding of the department, open access to the emergency department, and psychiatric patients. Other relevant factors included prolonged waiting times, gang-related activities, increasing numbers of patients needing care for injuries resulting from violence, trauma, and staff-to-staff conflicts. Other studies of emergency and psychiatric departments of hospitals also found incidences of physical attacks on medical and nursing staff and carrying hidden weapons to the hospital (McCulloch et al., 1986; Lavoie et al., 1988; Goetz et al., 1991).

Unfortunately, these and other studies revealed that staff are often unable to predict who the weapon carriers are.

Several administrative, organizational, and environmental factors have been associated with violent injuries in the workplace. These include limited training in the management of violent behavior (e.g., containing or restraining an assailant); staffing levels and patterns, including the use of agency nursing staff; and the day shift tour of duty. Hospital administrators and nurse managers must facilitate staff awareness of the potential for violent situations and enhance the capability to deal with them effectively.

Nursing Homes

Nursing staff, particularly NAs in nursing homes, are also subject to abuse by residents. Studies about the incidence of aggressive resident behavior in nursing homes are sparse, but the few studies available suggest that the presence of behavioral problems is a matter of concern (Zimmer et al., 1984; Beck et al., 1991).

Management of aggressive resident behaviors presents difficult care problems for nursing staff. Researchers have documented frequent incidence of aggressive behavior displayed by residents including physical and verbal abuse (Everitt et al., 1991). Sometimes aggressive resident behaviors are violent. In a study of 101 nursing homes and intermediate care facilities, Winger and colleagues (1987) found 84 percent of residents in nursing home and 54 percent of residents in intermediate care facilities displayed behavior that endangered self and others. Meddaugh (1987) reviewed charts and incidence reports on 72 residents in a skilled nursing facility and found that 26 (27 percent) residents abused staff 1 to 2 times in a 3-month period. Lusk (1992), in an exploratory study, found a variety of injuries such as black eye or torn shoulder cuff requiring surgical repair from residents' aggressive behaviors as reported by nurse aides. Rudman and colleagues (1993) in their study of two Department of Veterans Affairs nursing facilities found a higher incidence of physically aggressive behavior in facilities with a greater percentage of neurologic and psychiatric patients. In a study of 124 residents in 4 nursing homes, Ryden and colleagues (1991) found that 51 percent of aggressive behavior was physical, 48 percent verbal, and 4 percent sexual.

The committee notes that one feature of Alzheimer's disease and other cognitive and emotional impairments found among older patients is lack of cooperation with efforts to provide personal care. For instance, the behavior could include for some patients violent resistance to undressing and bathing. The issue is that the patients are not so much engaging in unprovoked violence against nursing staff, rather residents may believe they are defending themselves against what they perceive to be unwanted touching and personal assault. The regimentation of institutional life makes many patients uncooperative and some of them manifest their feelings in particularly hostile mannerisms and verbal abuse (Everitt et al., 1991).

Violence toward staff may be to some extent an indicator of poor quality of care. Patients in some instances may be reduced to violence as the only way to gain control over their environment. The problem here may be the lack of recognition of good nursing practice in (1) designing nursing home environments that stimulate residents to take responsibility for their own behavior, and (2) rewarding individual staff initiative as opposed to rewarding conformity to make life easier for staff.

In summary, the evidence to date suggests that violence directed at health care workers in hospitals and nursing homes is a significant and growing issue for worker safety, peace of mind, and ultimately good patient care. The committee concludes that it is critical that health care institutions implement strategies to prevent such assaults on workers and that they provide adequate security especially in the high-risk departments (such as emergency room areas or psychiatric units). It also concludes that staff training in effective ways to control violent patients is essential as part of a long-term strategy by which health facilities and institutions can prevent or minimize the harms that may stem from violence and abuse directed at health care workers.

Violence and Abuse Against Patients and Residents

Physical, verbal, and psychological abuse can and does occur in all settings, from hospitals and nursing homes to personal residences, and it can be inflicted by family members as well as health care personnel (including nursing staff). Relatively little has been written about abuse of the elderly in the peer-reviewed medical and health policy literature, although some discussion of this issue of abuse has appeared (Lachs and Pillemer, 1995).

Nursing Homes

What attention has been given to this problem over the years has tended to focus on abuse by NAs working in nursing facilities, and the issue, particularly in nursing homes, is receiving increasing amounts of attention in local and national media. The Gannett News Service, for instance, prepared a series of articles on the topic in February 1994, that were picked up by various newspapers around the country. Requests for further information on the series led Gannett to compile all the articles in an 8-page special investigative report (Eisler, 1994).

Reports of abuse in the press range from neglect, humiliation, and theft to battery and even rape (e.g., Allen, 1994; Bernardi, 1994; Eisler, 1994). Similarly, in the first half of 1995, the 20/20 television news magazine, using hidden cameras, produced a segment documenting abuse. Other investigators have characterized the behavior of NAs as rude, neglectful, uncaring, insulting, and sometimes verbally and physically abusive (Kayser-Jones, 1990). Physical abuse resulting from poor care, such as skin breakdown, rough handling, or inattention to bowel and urinary elimination needs, is another serious problem that occurs in institutions and can be inflicted by health care personnel (Baker, 1977).

Clearly, many NAs in nursing homes are not abusive. A certain proportion, however, do verbally or physically abuse, steal from, or otherwise take advantage of nursing home residents. Unfortunately, even a small proportion of abusive staff can affect the health, quality of care, and peace of mind of thousands of nursing home residents. Pillemer (1988) has developed a theoretical model of maltreatment as an outcome of staff and residents that are influenced by aspects of the nursing home environment and by certain factors exogenous to the facility. According to his model, which is supported by a review of literature, the characteristics of staff who are more likely to be abusive are young age (Penner et al., 1984), lower levels of education (Baltz and Turner, 1977; White, 1977), male (U.S. Department of Justice, 1985; Straus, 1986), least experienced (Penner et al., 1984), and more stressed (Heine, 1986).

Nursing home residents are very vulnerable, given that their average age is around 80 years, that many may be quite frail, and that many may be relatively isolated from family and friends. In the committee's view, therefore, nursing facilities should be required to ensure a safe and protective environment for residents by employing and retaining employees who protect and care for them and do not abuse and steal from them. Some observers suggest that the stressful work role of NAs in these facilities leads to exhaustion and burnout that may in turn precipitate abuse, and they argue that mechanisms are needed to help nonprofessional staff deal with their work-related stress (Foner, 1994).

Moreover, personnel with questionable backgrounds should be barred from employment as care givers to the old and frail. Because of the large numbers of NAs and their mobility resulting from high turnover rates, however, tracking those with histories of abusive or criminal behavior is difficult. Movement from one facility to another, from one state to another, or even from one facility of a chain of facilities to another can be sufficient to hide an abusive staff person.

At present, employers may be reluctant to conduct extensive checks on new employees for fear of litigation. Standard requirements for such background checks, however, would give facilities the authority to refuse employment to those with questionable and criminal backgrounds. Although theft and resident abuse are considered common occurrences in some nursing facilities, some of them may be reluctant to terminate employees with problem behaviors because of legal liabilities. On the other hand, facilities that fail to take action against abusive or problematic employees clearly are subject to receiving deficiencies and open themselves to legal liability.

The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) requires each state to maintain a registry of NAs who have satisfactorily completed NA training and/or a competency program. In addition, OBRA 87 (sec. 1819(e)(2)) mandates that states include in these registries documented findings of a state regarding resident abuse, neglect, or misappropriation of resident property by any individual on the registry as well as any statement by the individual disputing the findings.

To date, however, these registries have had limited effect, in part because of difficulties in verifying the accusations of abuse and delays in posting the information. A major limitation of the registries is that at best they only make it possible to prevent abuse from happening again. Registries cannot prevent abuse from happening initially, nor do they prevent abusive individuals from moving to a less regulated state or work environment. Fear of litigation also prevents prior employers from saying anything about past abusive behavior during a reference check. At the present time a person does not get on the state registry unless convicted or ''documented."

The committee is not satisfied with this state of affairs insofar as protection of vulnerable patient and resident populations is concerned. Although it recognizes that the main difficulties probably lie in the nursing home arena, it also takes note of the fact that employment of NAs and other types of ancillary nursing personnel in hospitals is increasing. In the end, the committee came to consensus on a broad recommendation concerning the responsibilities of health facilities in not employing problematic staff.

RECOMMENDATION 7-2: The committee recommends that all hospitals and nursing homes screen applicants for patient care positions filled by nurse assistants for past history of abuse of patients and residents, and criminal records.

Issues for review in the screening process should include arrest record, behavioral problems, substance abuse, and unsatisfactory work habits. Some states currently require reporting and background checking for new employees. When state licensure departments maintain records on individuals who have disciplinary and behavioral problems, this recommendation would apply only if the information did not include all the areas of inquiry mentioned by this committee. Hospitals and nursing homes should consider engaging the services of consulting firms to assist them in the screening process for potential new hires. To mitigate the issue of invasion of privacy, facility personnel offices should post appropriate notices announcing that all applicants must pass a complete and satisfactory background check before an employment decision is final.

Responsibility for neglect and abuse is by no means confined to NAs or similar ancillary personnel. Failure of the system because of poor management practices of facilities can also lead to an NA ending up on the registry. Thus, the abuse prevention system should ultimately be applicable to all who work in nursing facilities and, for that matter, all health care institutions.

The vulnerability of patients and residents, as well as health care personnel, to abuse, violence, and injury is becoming better documented. To protect these groups, basic and continuing education programs need to be developed that prepare nursing personnel to intervene in situations involving conflict and violence. Necessary skills include early recognition, assessment, conflict resolution, and emergency management.

Conflict Resolution

Although most health care facilities are diligent in observing residents' rights, none can guarantee that every right of every individual will be respected. Problems and conflicts are bound to occur, and complaints often can be equitably and amicably resolved within the facility or institution. In nursing homes, when a problem cannot be resolved internally, however, a resident or family member may contact the local office of the state long-term care (LTC) ombudsman program. Examples of problems and conflict between a resident or his or her family member(s) and staff that may be settled through various conflict resolution mechanisms include feelings of being deprecated or belittled; perceptions that a loved one is not receiving all available services or treatments; concerns about financial matters that are not fully explained or accounted for; feelings of discrimination; and concerns that the facility staff does not adequately discuss treatment, transfer, or discharge options.

Citing the dearth of research regarding maltreatment of residents of nursing homes, Pillemer (1988) suggests that staff behaviors are influenced by aspects of the nursing home environment and by certain factors exogenous to the facility. More recently, Pillemer and Hudson (1993) reported on an evaluation of a model abuse prevention curriculum for nursing assistants. According to the authors, those involved showed high satisfaction with the program, which reduced conflict and abuse of residents. The committee expresses strong support of all these efforts to develop innovative conflict resolution and similar programs and curricula.

Work-Related Stress

Extensive information documents that nursing work is stressful and that it can lead to a variety of work-related problems such as absenteeism, staff conflict, staff turnover, morale problems, and decreased worker effectiveness (Doering, 1990; Hiscott and Connop, 1990; Rees and Cooper, 1992; Fielding and Weaver, 1994). Exacerbated stress can lead to burnout and turnover of nursing personnel. Both the causes and correlates of work-related stress, and the outcomes and sequelae for nurses as well as patients or residents, are of concern to this committee.

Sources and Consequences of Stress

Several research studies focusing on nursing staff in acute care settings have attempted to identify a wide range of factors associated with stress. They include overwhelming workload, limited facilities and space, inadequate help, too much responsibility, too little continuing education, poor organization, excessive paperwork, inadequate communication with physicians, intrastaff tensions, and many other variables. Lack of recognition and lack of administrative support and leadership also can lead to stress. Although RNs frequently reported in testimony and during the committee's site visits that low staffing levels cause stress, empirical evidence does not corroborate their perception, although it clearly can exacerbate other stressful circumstances, as discussed below.

Some early studies of stress found that critical care nurses and intensive care nurses experience more stress than do staff in other units, but research has not consistently validated this finding (MacNeil and Weisz, 1987; Yu et al., 1989; Foxall et al., 1990). A survey of emergency room RNs, identified inadequate staffing and other resources, too many nonnursing tasks, changing trends in emergency department use, and patient transfer problems as causes of stress. They also described shortages of nursing staff during busy periods and at night, and the use of untrained relief staff, as other important factors in stress (Hawley, 1992).

One specific source of stress among health care workers is shift work. According to a 1991 review of 16 studies conducted by the Office of Technology Assessment (OTA, 1991), rotating nurses reported higher levels of stress, had more sleep disturbances, had significantly higher personal health problems, and suffered more injuries and accidents related to lack of sleep than fixed-shift nurses. Other research studies on shift work also reported adverse effects on performance, workers' health, performance, and mental and physical fitness (Gold et al., 1992).

Nursing personnel who work with the elderly confront many complex and potentially stressful situations in nursing homes where the work is highly demanding and labor intensive. Nursing personnel who work with patients with Alzheimer's disease are especially vulnerable to the effects of stress and burnout. These patients present many difficult care and management problems because of their progressive cognitive, functional, and psychosocial deterioration, which can result in bizarre and combative behaviors, emotional outbursts, and wandering. Moreover, nursing home staff are often poorly trained to cope with the disruptive behaviors of residents and are, therefore, repeatedly frustrated by their inability to manage recurrent problems (Stolley et al., 1991). Many nursing homes are also not equipped with environmental structures or the support and service systems required to care appropriately for the person with Alzheimer's disease (Peppard, 1984).

One recent study, using a quasi-experimental design with repeated measures, examined whether staff who cared for patients with Alzheimer's disease on a special care unit (SCU) experienced less stress and burnout than staff who cared for such patients on traditional (integrated) units (Mobily et al., 1992). The principal area of stress reduction for nursing personnel working on the SCU involved staff knowledge, abilities, and resources. Similarly, subscale analysis indicated significantly less stress for staff who worked in the SCU with respect to residents' verbal and physical behavior. The SCU was designed specifically to provide the special environmental structures and support and service systems that are required to enhance functioning and decrease associated behavioral problems of patients. These may be important factors in reducing stress and burnout for staff caring for residents suffering from Alzheimer's disease (Mobily et al., 1992). The investigators also recommended that, whenever possible, staff who work with such residents be screened carefully and selected for their ability to be sensitive to their needs, their flexibility, their imagination, and their ability to respond to persons with impaired communication and ever-changing moods (Coons, 1991). Specialized training in the care of residents with Alzheimer's disease is also a critical factor.

High stress at work can create morale problems that ultimately detract from the staff member's job performance (Sheridan et al., 1990). The causal model developed from research on work-related stress and morale among nursing home employees highlights both antecedents and outcomes of work-related stress (Weiler et al., 1990). The outcomes of work-related stress are linked to adverse physical and psychological consequences (LaRocco et al., 1980). According to Weiler and colleagues (1990), these outcomes can include: (1) burnout, defined as a syndrome of emotional exhaustion, depersonalization, and lack of personal accomplishment; (2) depression, which is the degree of negative affect experienced by nursing personnel; (3) poor or low job satisfaction, which involves effective orientation of nursing personnel toward the work situation; and (4) work involvement, defined as the degree to which nursing personnel identify with their job.

Although burnout has been the focus of many studies (see, e.g., Pines and Maslach, 1978; Dolan, 1987; Husted et al., 1989; Berland, 1990; Oehler et al., 1991; Johnson, 1992; Kandolin, 1993; Duquette et al., 1994), a uniform definition of burnout has not been established. Proposed definitions range from a simple equation of burnout with staff turnover to effectively including all four of the outcomes identified above by Weiler and colleagues. Nevertheless, most definitions found by the committee tend to describe burnout as having psychological, physical, and behavioral components. Pines and Maslach (1978, p. 236) define burnout as "a syndrome of physical and emotional exhaustion involving the development of a negative self-concept, negative job attitude and loss of concern and feeling for clients." In the long-term care setting, Heine (1986) characterizes burnout as a loss of concern for residents and physical, emotional and spiritual exhaustion that may lead to indifference or negative feelings toward elderly residents, overuse of chemical or physical restraints, and heightened potential for abuse. Because of the variety of definitions of burnout, the committee chooses simply to use the term for a state in which stress has resulted in persistent lower job satisfaction and potentially reduced work performance and effectiveness. At extreme levels of burnout, measurable problems such as increased staff turnover may occur. Goldin (1985), for instance, found that burnout results in such administrative difficulties as high rates of tardiness, absenteeism, and attrition.

Dolan and colleagues (1992) discuss issues surrounding the propensity of nursing staff to quit, which has been acknowledged as the best predictor of turnover. Behaviors related to stress, burnout, and depression are notable and can have a subsequent impact on quality of care and turnover. The investigators surveyed 1,237 staff who worked in 30 Quebec hospital emergency rooms and intensive care units about 14 job demands (the response rate was 84 percent). Results indicated that lack of professional latitude (which included restricted autonomy, skill underutilization, and lack of participation in clinical decision making), clinical demands, role difficulties, and workload problems all contributed to the propensity to quit. The authors suggested that interventions aimed at improving the quality of work and the general work-related quality of life should be implemented to enhance employee mental health, reduce rates of turnover, and curb costs.

The work conditions of RNs are repeatedly cited as being a source of stress. Some authors indicate that the quality of nursing care is seriously jeopardized and that RNs often leave nursing as a result of stress or burnout (Anonymous, 1986; Masterson-Allen et al., 1987; Lucas et al., 1993).

Many organizational factors have been cited that influence nursing stress, burnout, and productivity in nursing care, and that may result in short-term or long-term absenteeism. Research by Hare and Pratt (1988) has shown that higher levels of nursing burnout in both acute and LTC settings may be related to the nature of the physically and emotionally strenuous work tasks, low status in comparison to other positions in the health care system, limited training, low wages and benefits, and, of interest to this report, poor staff-to-patient ratios. Duquette and colleagues (1994) indicate that organizational stressors influence the development of burnout, particularly role ambiguity, staffing, and workload; age, with younger RNs being more susceptible to seeing their role as more ambiguous and their workload heavier; and buffering factors including hardiness, social support, and coping. Weiler and colleagues' (1990) causal model, developed from research on work-related stress and morale among nursing home employees, highlights both the antecedents and consequences of stress. The investigators suggest a variety of interventions to address organizational responses to stress. They include improved in-service training, increased variety in job tasks, improved supervision, clear and realistic objectives for resident care, higher wages and better benefits for staff, and adequate staffing levels. They note that higher compensation and richer staffing levels may be considered nonnegotiable by some administrators because of the cost implications associated with their implementation, but that the costs related to staff burnout, absenteeism, and turnover, can far outweigh the costs associated with adequate staffing and compensation. Health care administrators must address the issues of the impact of organizational stressors on nurses if there is to be any hope of resolving the problem (Whitley and Putzier, 1994). New approaches to staff selection and recruitment, flexibility in staffing, increased resources, and increased decision making by nurses is essential.

Changes in the physical environment and structural factors may also be critical elements in preventing or alleviating stress and work-related tension and pressures. Lyman (1987) suggests that physical and architectural features, such as adequate space, separate activity rooms, staff offices and toilet facilities, resident care facilities, barrier-free hallways, visible exits with amenities such as wide entry doors and ramps, and emergency exits, may decrease care giver burden and stress.

Enhancing social support networks is another important strategy that can serve as a buffer against the stresses inherent in working with the elderly. Problems with support in the work environment, especially from peers and supervisors, have repeatedly been shown to be a primary source of stress among nurses (Cronin-Stubbs and Rooks, 1985). Further, compelling evidence exists that social support serves to mitigate the adverse effects of stress and to reduce burnout among nursing staff (Constable and Russell, 1986).


The committee has reviewed the literature on work-related injuries, violence and abuse, and stress afflicting nursing personnel in hospitals and nursing homes. Nursing is a hazardous occupation, and nursing personnel are exposed to a wide variety of health and safety hazards—biologic, chemical, environmental, mechanical, physical, and psychosocial. The committee has also reviewed available research to assess the factors that contribute to work-related injuries and to stress and burnout. Except for back injuries, the committee is unable to substantiate conclusively the linkages among staffing numbers, skill mix, and work-related problems.

In examining available information on violence and abuse, the committee became aware of the intricate problems of pressure-filled work situations and of violence and abuse directed at patients, especially the residents of nursing homes. It concludes that considerable problems may exist at the level of NAs and other ancillary nursing personnel especially in nursing facilities, who may be subject to great stress and probability of injury (especially back injury) and who may be newly employed and comparatively thinly trained.

The committee believes that many injuries and much of the violence toward staff in hospitals and nursing homes are preventable and that prevention is a shared responsibility of employers and employees. The committee urges hospitals and nursing homes to assess the effectiveness of prevention training and other models of organizational and nurse leadership described in contemporary research studies on the subject. It also urges hospitals and nursing homes to develop and implement strategies to prevent or reduce the incidence of injuries, violence and abuse, and stress and burnout in these health care workplaces.



Falls "at the same level," as contrasted with "falls to a lower level" (such as those incurred by construction laborers and roofing or sheet metal workers who fall from a height), is a category of disabling event used to measure varying degrees of disabling work-related injuries. These injuries are reported by employers to the Bureau of Labor Statistics as part of the Annual Survey of Occupational Injuries and Illnesses.


Much of the information in this section was taken from papers commissioned by the IOM committee from Bonnie Rogers and Maas and colleagues. The committee appreciates their contributions. The full text of the papers can be found in Part II of this report.

Copyright 1996 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK232675


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