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).

Summary

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



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