budgets, and complexity of care in nursing facilities today, strong leadership from DONs is required if high quality, cost-effective care is to be provided. The committee concludes that nursing facilities should place greater weight on educational preparation when employing new DONs.

In the area of reimbursement policies, the committee notes the existence of several experiments designed to look at outcome-based incentives for improved quality of care. The committee concludes that additional research and demonstration projects on the use of financial and other incentives are needed to improve the quality of care and outcomes in nursing homes.

Staffing and Work-Related Injuries and Stress

Nursing is a hazardous occupation. Whereas the injury and illness rate in private industry as a whole has been stable or declining slightly since 1980, the rates for hospitals and nursing homes during the same period have increased by about 52 percent and 62 percent, respectively. Recent statistics and other information suggest that these institutions are becoming increasingly hazardous places to work, exposing workers to a wide range of risks.

The committee reviewed the literature on work-related injuries, in particular back injuries and needlestick puncture wounds, that affect nursing personnel in hospitals and nursing homes. It also reviewed available research to assess the factors that contribute to work-related stress. The committee was struck by the high rate of injuries to nursing personnel in both hospitals and nursing homes, but except for back injuries the committee is unable to substantiate conclusively any linkages among staffing numbers, skill mix, and work-related problems. The committee is impressed, however, with the apparent effects of leadership from management, good employee training, and existing technologies on reducing the probabilities of injuries among nursing personnel.

The committee concludes that considerable levels of injuries and risk of injury may exist at the level of NAs and other ancillary personnel, especially in long-term-care 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 thus found an important need, especially among new employees, for more aggressive training related to the use of lifting devices, lifting teams, and ergonomic training in lifting techniques to prevent back injuries. The committee concludes that all personnel giving direct care (especially in nursing homes) should receive annual training in lifting and transferring patients. Such efforts would improve the quality of life for health care workers and could represent a significant savings to the health care industry. The committee also concludes that hospitals and nursing homes should develop effective programs to reduce work-related injuries.

Violence toward health care workers appears to be on the rise. Increased violence in the general population, greater use of mind-altering drugs and alcohol

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