Ann Smith starting working as a bedside nurse on an Edmonton general medical unit in 2012, three years after graduating with her nursing degree. She was working a night shift when she entered the room of an elderly patient who had called for help to get to the washroom.
The patient had very limited use of her lower limbs and felt like a deadweight in Smith’s’ arms. “The unit was busy, as always, and unfortunately there wasn’t anyone immediately present to help me.”
Smith felt a twist in her back from the awkward lifting and moving of this patient, but continued her shift that night. She continued work on the unit, and while she tried to be more careful and use assists in moving or transferring patients, her back continued to ache. After about six months the pain had not subsided, and was actually getting worse.
Smith had always been passionate about pursuing a career in front line patient care, but found that she was unable to meet the physical demands of the job. Shifts at work were challenging – even just walking between patient rooms and time spent on her feet for extended periods of time were becoming difficult. She says “I’m still young – I practiced bedside nursing for just three years – and my entire career, and dream career, are gone for now. I just can’t do it because of the physical demands.”
Ann Smith is a pseudonym and many details of her story have been changed to protect her anonymity. However, her quotes have not been altered. She is pursuing further graduate training in nursing research and teaching, and while she hopes that her back injury will recover, in the meantime she is looking for other ways to salvage a career cut short by injury. When asked if she would have done something different that night, Smith said she would not, or at least could not have under the circumstances of a busy unit with many patient care demands.
She reflects on her brief career as a front line nurse “you know there are hazards in the workplace, but I never thought that this would happen to me.”
The hazards of health care work
Smith’s story is not uncommon. The health care workplace has a number of hazards which have the potential to injure and harm. Every day, health care workers encounter physical risks from repetitive lifting and moving, chemical risks, risks of infection and the threat of violence.
In Ontario, the hazards of health care work were dramatically highlighted during the SARS crisis. Overall, 375 people contracted SARS in the spring of 2003. Over three quarters were infected in a health care setting, of whom 45% were health care workers.
Justice Archie Campbell led a commission to learn from SARS, and highlighted the danger for staff working in health care settings – and in this case, hospitals. The report opens by stating “hospitals are dangerous workplaces, like mines and factories, yet they lack the basic safety culture and workplace safety systems that have become expected and accepted for many years in Ontario mines and factories.”
Cameron Mustard, president of The Institute for Work & Health notes that while other sectors – like mining and manufacturing – have been able to reduce the number of injuries in their workplaces, similar reductions haven’t been seen in health care.
“There is a relatively high incidence of injury and illness for health care workers and while some improvements have been made for safety – it has not been as fast or as dramatic as in other sectors” he says.
Mary Ferguson-Paré, past Chief Nursing Executive at University Health Network also highlights how health care work is different than other industries. “It is expected in health care that front line workers put themselves forward to care for patients at all costs – they step up and do what they can, often at their own peril.”
Differences between health care and other industries
Workplace injuries have been steadily declining over the past two decades. In 1987, 48.9 of 1,000 working Canadians received some form of workers’ compensation for injury on the job, and this has declined continuously to 14.7 per 1,000 in 2010. While injury rates for health care workers have declined slightly over that same time period, they remain stubbornly difficult to change.
A study of health care worker injuries in three British Columbia health regions from 2004 to 2005 found that injury rates are particularly high for those providing direct patient care – and highest among nursing or care aides (known as health care aides in Alberta, and personal support workers in Ontario).
Recent data from Alberta shows that about 3% of health care workers are at risk of a disabling injury in 2012, compared with 1.45% of workers in the mining and petroleum industry.
One challenge in understanding the extent to which people in health care are injured at work is that injuries tend to be underreported. Generally the data used to measure health care worker injury is through workers’ compensation claims. A study of Canadian health care workers found that of 2,500 health care workers who experienced an injury, less than half filed a workers’ compensation claim.
Research on why health care workers do not file compensation claims suggested that they have doubts about their eligibility to claim injuries, and are concerned about the implications of reporting an injury to their careers, reputation and income.
Why are health care workers getting injured?
Experts in workplace injury and safety point to the unpredictable nature of health care as contributing to worker injury.
“There is unpredictability about the hour to hour, moment to moment work you’re doing in a health care environment. You are in constant motion,” Mustard says. He points out that many other industries have “environments where work tasks are more standardized and it is feasible to think about reducing hazards inherent in that environment.”
Nancy Johnson, a Health and Safety Specialist at the Ontario Nurses’ Association says “occupational health and safety cannot be mechanized – it’s impossible to do everything with machines – in industry loads are static, but in health care loads are unpredictable and dynamic.”
However, there have been efforts to mechanize some of the dangerous aspects of health care. Musculoskeletal injuries are the leading category of occupational injury for health care workers. A study of workers in British Columbia published in 2010 found that about 83% of health care worker injuries were musculoskeletal in nature. The study notes that most of these injuries were sustained during patient handling – which could include repositioning, transferring and assisting patients during a procedure. These injuries to muscles, tendons or nerves are often the result of continuous repetition and strain.
Mechanical lifts to help health care workers lift and reposition patients have been suggested as one way in which the physical work of caregiving can be mechanized. In 2004, the Ontario Ministry of Health and Long-Term Care spent $80 million dollars to purchase and install mechanical lifts, and train staff over a three year period.
However, research has found that such lifts only have a moderate impact in practice. A systematic review on lifts suggests that in order to be successful, lifts need to be installed along with policies preventing staff from manually lifting patients, and dedicating staff time to train on how to use this new equipment.
Ferguson-Paré says that while lifts have been installed, workers often don’t have the time or back up to use them effectively. She notes that “at the same time that lifts were installed [in Ontario] nurse staffing levels have been cut. When you boil down staffing to a bare minimum, often people will take shortcuts and are in a rush so they don’t take extra time to use a ceiling lift, or call a second person to assist.”
Who is doing the heavy lifting in health care?
Another challenge associated with workplace injuries is the composition of the health care workforce itself.
The November 2013 report from The Institute for Work & Health notes that 72% of the health and personal care workforce is female. This is even more pronounced in the nursing workforce, with a 2011 Canadian Institute for Health Information report noting that over 90% of registered nurses are women.
Mustard says that while sensitivities exist around reinforcing gender stereotypes, it is worthwhile asking whether “an older woman is more vulnerable to the challenges of the physical work in health care.”
Evidence suggests that this is the case – a 2009 British study of over 40,000 workplace injury claims found that 89% were made by women, and 11% by men.
Gert Erasmus, senior provincial director of workplace health and safety for Alberta Health Services says that “health care is a people intensive business – combine that with physically demanding jobs and an aging workforce.”
One approach taken in Ontario to addres this problem is the Late Career Nurse Initiative – where organizations apply to receive funds to place nurses who are 55 or older in less physically demanding roles. Debra Bournes, Provincial Chief Nursing Officer, highlights that “nursing is a very labour intensive, physically demanding role and this initiative was designed to keep them in the workforce for longer.”
The Canadian Federation of Nurses’ Unions notes nurses retire around the age of 56 – compared to the average Canadian worker at 62.
Bournes was unable to share evaluations of this initiative but notes that there are data being collected around its impact on retention of nurses.
New frontiers & challenges in health care worker safety
While there have been a number of policy changes and investments made across Canada to improve worker safety, research suggests more needs to be done to bring about effective change.
Experts also point to the changing work environments for many health care workers. There is a worldwide trend towards moving health care services out of hospitals into patients’ homes. Thease are uncharted waters for workplace safety and prevention of injury. Little is known about how often workers in peoples’ homes are injured and the kinds of injuries they are sustaining.
Gert Erasmus notes the tremendous insecurity of providing health care inside patients’ homes. “They [health care workers in homes] work in an environment that is not controlled at all, which is fundamentally different than most industries and workplaces.” In this environment, workers are more likely to be alone, lacking back up from colleagues, and the help of aids such as mechanical lifts.
Miranda Ferrier, President of the Ontario Personal Support Worker Association says that each time a personal support worker enters a new patient’s home – they enter into the unknown. “You are lucky if you know anything about a client when you go into the home” she says.
Ferrier raises concerns about the hazards of this environment, which is not designed for health care – “you are often moving or lifting adults, and don’t have the space, or back up, to do things correctly.”
Prior to joining Alberta Health Services, Erasmus led health and safety portfolios for various industries including oil and gas, petrochemicals and aluminum. He says “the biggest difference between health care and private industry is around culture. In health care the message is take care of your patient at all costs – including that of your own health and safety.”
There is a growing recognition among experts and policy-makers that the culture of health care needs to change to focus on worker safety as a priority.
Mary Ferguson-Paré says “while there are many programs in place to prevent injury through installing lifts, or educating workers, unfortunately the protection of health care workers from harmful situations isn’t systemic – what is systemic is the duty of care to patients.”