Environmental Hazards for the Nurse as a Worker*
Nursing is a uniquely hazardous occupation. This appendix summarizes some of the major hazards nurses may face on-the-job, and provides statistics for illnesses and injuries among nurses associated with working conditions. This discussion will illustrate the pervasive nature of environmental and occupational hazards in a setting familiar to the reader.
The Bureau of Labor Statistics reports that there are 1,859,000 RNs (1993) and 659,000 LPNs (1992) employed in the United States. Of the 2,518,000 nurses, 882,647 35% are employed in hospitals, and the rest in other health care settings including but not limited to nursing homes, health maintenance organizations, physicians' offices, community health agencies, schools, and corporations.
In 1992, the rate of occupational injury and illness for nurses in health care settings was 18.6% per 100 full-time workers (18.2% accounted for injuries). This is higher than for hazardous occupations such as heavy construction where the rate of occupational injury and illness is 13.8% per 100 full-time workers or mining where the total is 7.5% per 100 full-time workers (DiBenedetto, 1995).
Appendix B, Environmental Hazards for the Nurse as a Worker, was written by committee member Gail F. Buckler. Ms. Buckler is a clinical instructor in the Environmental and Occupational Health Sciences Institute, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School and Rutgers, the State University of New Jersey, and assistant professor of clinical nursing, School of Nursing, UMDNJ.
Nurses confront potential exposure to infectious diseases, toxic substances, back injuries, and radiation. They also are subject to hazards such as stress, shift work, and violence in the w workplace. These typically fall under the broad categories of chemical, biological, physical, and psychosocial hazards.
The risk of infections is present not only in hospitals but in other settings where nurses are employed such as nursing homes, institutions for the retarded, prisons, and outpatient facilities, i.e.: dialysis centers, workplace health centers, or community health clinics. In hospitals high risk areas include pediatric areas, infectious disease wards, emergency rooms, and ambulatory care facilities.
Hepatitis B (HBV) is the most prevalent work-related infectious disease in the United States. Although blood is the major source of the virus, it may also be present in saliva, semen, and feces. Transmission may occur from a percutaneous stick from a contaminated needle or other sharp instrument (the risk of contracting HBV after a stick with a known contaminated needle is 6–30 percent) (Udasin and Gochfeld, 1994), after contaminated blood enters a break in the skin or splatters onto mucous membranes, or upon ingestion. The OSHA Bloodborne Pathogens Standard has provisions for preventing Hepatitis B in healthcare workers including Hepatitis B vaccine, education, procedures for sterilization and disinfection, and use of personal protective clothing. In addition, the CDC has recommendations for work practices during invasive procedures.
Hepatitis A poses a risk for workers in settings such as institutions for the retarded where personal hygiene may be poor (Levy and Wegman, 1995). The use of good handwashing techniques is most effective preventive measure for this virus.
Delta hepatitis occurs only in patients who are infected with Hepatitis B (Levy and Wegman, 1995). This occurs mainly in IV drug abusers, and hemophiliacs and may be transmitted to patients who undergo hemodialysis. The preventive measures utilized to minimize the spread of Hepatitis B should be instituted to limit the transmission of Delta hepatitis.
The majority of cases of Hepatitis C are associated with IV drug use or are idiopathic in origin. The disease has rarely been transmitted to health care personnel via percutaneous exposure. Additional research is needed to determine the extent of this disease as an occupational hazard.
The United States experienced a resurgence of tuberculosis in the 1990s. This is attributed to the HIV epidemic, an increase in immigration
from Asia, homelessness, and the emergence of drug-resistant strains of tuberculosis. Nurses employed in hospitals (particularly in emergency departments, pulmonary departments, and HIV units), long term care facilities, outpatient clinics and prisons are at risk for contracting tuberculosis (Hellman and Gram, 1993; Levy and Wegman, 1995). Often the patients who they come in contact with are undiagnosed (Hellman and Gram, 1993). The CDC has recommendations for tuberculosis infection control and OSHA will be issuing its proposed tuberculosis standard in the near future.
Nurses in many settings may be exposed to infectious diseases such as measles, mumps, rubella, and influenza. Immune status should be determined when feasible for employees with direct patient care responsibilities and appropriate immunizations should be offered.
Human immunodeficiency virus may be acquired by exposure to infected blood or body fluids. The risk of contracting HIV after percutaneous exposure with a contaminated needle is 0.3–0.4 percent (Udasin) and Gochfeld, 1994). Of the 42 documented seronconversions in health care workers, 13 were nurses (HIV/AIDS Surveillance Report—CDC). The OSHA Bloodborne Pathogens Standard's published guidelines are designed to prevent occupational exposure to HIV. The CDC recommends that blood and body fluids of all patients be considered potentially infectious and, consequently, universal precautions should be adhered to with each patient contact.
Antineoplastic agents may be prepared and administered in a variety of clinical settings. A number of studies have documented the hazards of cytotoxic drugs to nurses who work with them. These agents have been associated with mutagenic, teratogenic, and carcinogenic effects as well as adverse effects such as irritation of the skin, eyes, and mucous membranes or acute allergic reactions (Rogers, 1987). Improper handling, i.e., mixing of these agents contribute to exposure in workers. OSHA guidelines and recommendations by several professional associations exist for safe handling of antineoplastic agents.
Ethylene oxide is commonly used in hospitals to sterilize medical instruments and heat-sensitive substances and may be encountered in central supply, surgical services, and patient care areas. It is documented that this agent possesses carcinogenic, mutagenic, and teratogenic properties. It is also associated with respiratory tract irritation, central nervous system effects, and chemical burns (U.S. Department of Health and Human Services, 1988). OSHA has a standard designed to protect workers from exposure to ethylene oxide.
Exposure to waste anesthetic gases may occur in operating rooms, labor and delivery, and recovery rooms. Long-term exposure to these agents have been associated with an increased risk of renal (methoxyflurane) and hepatic (halothane) disorders and have also been correlated with an increased risk of spontaneous abortions and congenital abnormalities (nitrous oxide) in exposed workers. There are no standards published by OSHA for waste anesthetic gases, however, the National Institute for Occupational Safety and Health (NIOSH) has recommended exposure limits for nitrous oxide and the halogenated compounds.
Nurses have potential exposure to formaldehyde when they work in renal dialysis units, during the transfer of tissue to formalin in preparation for pathology, and as a residue when it is used for the disinfection of operating rooms. Formaldehyde is associated with irritant and allergic dermatitis, eye irritation, and occupational asthma. It is considered a possible human carcinogen. OSHA has a standard which limits worker exposure to formaldehyde.
Glutaraldehye is a germicide used in the cold sterilization of instruments. Nurses who perform cold sterilization in dialysis, endoscopy, and intensive care units are subject to exposure. Exposure has been linked to the practice of soaking instruments in open containers without benefit of local exhaust ventilation as well as during manual cleaning of instruments. It is a skin and mucous membrane irritant. It may also cause skin sensitization, asthma-like symptoms, headache, and flu-like symptoms. At high levels of exposure, it has been associated with liver toxicity. OSHA has determined that symptoms may be induced by airborne concentrations of 0.3 ppm or greater. A NIOSH study showed that routine use of glutaraldehyde in hospitals produced personal breathing zone and ambient air levels of 0.4 ppm (Wiggins et al., 1989). A ceiling limit (maximum allowable level at any time) of 0.2 ppm has been set by OSHA for exposure to glutaraldehyde. Reduction of exposure should take place by the use of engineering controls and good work practices.
Elemental mercury is used in various instruments found in healthcare settings. The greatest opportunity for exposure exists when there is breakage of the glass part of a thermometer of sphygmomanometer and the mercury spills onto the floor or countertop. Exposure to high levels can cause acute poisoning and death. Short term high exposures can cause pulmonary and central nervous system damage. Workers can bring mercury home on their shoes and clothing and, as a result, expose family members (Hudson et al., 1987). Prevention of toxicity can be accomplished by employee education, environmental controls, and proper handling of spills.
Back injury ranks second among all causes of occupational injuries for all occupations. It is reported that 40,000 nurses report back related injuries annually (Garrett et al., 1992). Nursing activities such as lifting patients in bed, helping patients out of bed, transferring patients from the bed, and carrying equipment weighing 30 pounds or greater are the most frequent causes of back pain.
Back injuries in hospital nursing personnel account for greater than half the total compensation payments for back injury and it is estimated that greater than 764,000 lost work days are incurred each year (Garrett et al., 1992). The activities performed by nursing personnel at extended care facilities place them at greater risk for back injuries. Frequent lifts and assists for patients who tend to be weak, debilitated, and elderly increase the risk of back injuries in those who provide their care. Registered nurses, licensed practical nurses, and nurse's aides are among the health care workers most frequently affected by this type of injury.
A study of workers' compensation data indicated that nurse's aides ranked fifth and LPNs ninth among all occupations in filing for work-related back injury (Fuortes et al., 1994). The incidence of low back injuries in nurse's aides was found to be at least three times greater than for nurses. Studies have revealed that newly qualified nurses or trainees are at greater risk for back injury than more experienced personnel. Additional risk factors for back injury are gender (females have higher incidence), shift (evening shift is highest risk), and weight of the nurse (excess weight and poor muscle tone influence development of lumbar lordosis and elevated intra-vertebral disc pressure).
The ergonomics of various nursing functions should be taken into consideration when developing a back injury prevention program. Protocols should be developed which take into account assessment and adjustment of specific tasks, as well as for identifying the need for assistance and type required. Training and orientation regarding lifting techniques upon initial hire and upon reassignment would be a useful preventive measure.
Exposure to ionizing radiation is associated with mutagenic and teratogenic properties leading to an increased risk of miscarriage, stillbirth, and other adverse reproductive outcomes, as well as cancers such as myelogenous leukemia, bone, and skin cancer.
Nurses have potential exposure to ionizing radiation while holding patients who are undergoing radiographs, and during direct care of patients
undergoing nuclear medicine tests and implants (McAbee et al., 1993). Personnel in departments where portable x-rays are performed (i.e., emergency room, surgical areas, intensive care units) are often inadvertently exposed to radiation. Although researchers differ over quantifying the amount of radiation that is hazardous, there is evidence that low levels can cause biological damage.
OSHA's standard for ionizing radiation is designed to protect workers who are not covered under the Nuclear Regulatory Commission and the exposure limit is set at three rem per quarter (of a year). The Joint Commission on Accreditation of Health Care Organizations mandates that hospitals with radiology equipment have a health physicist on staff (U.S. Department of Health and Human Services, 1988).
Nurses who work with terminally and chronically ill patients, and nurses who work in the intensive care units, emergency room, burn unit, or operating room are at particular risk for stress related symptoms. The early signs of stress include irritibility, loss of appetite, ulcers, migraine headaches, emotional instability, and sleep disturbances (Lewy, 1991).
Workplace factors that may contribute to stress include dealing with life-threatening illnesses and injuries, demanding patients, overwork, understaffing, difficult schedules (i.e., rotating shifts or working multiple shifts), specialized equipment, the hierarchy of authority, lack of control and participation in planning and decision making, and patient deaths. In many hospitals, the nurse may feel isolated, fatigued, angry, and powerless due to a sense of depersonalization created by a large bureaucratic system.
When the signs of stress are not recognized and treated, burnout may result. Stress-related symptoms can lead to an increase in the use of cigarettes, alcohol, and drugs. The worker's attitude and behavior may be adversely affected, leading to decreased job performance, and increased absenteeism.
Methods for coping with stress include regularly scheduled staff meetings; development of a stress management program and adequate coping mechanisms; availability of an employee assistance program; flexibility and worker participation in development of work schedules; appropriate training and educational sessions; creation of an organized and efficient work environment (to the extent that this can be accomplished); recognition and proper action on legitimate complaints; and group therapy/support groups for staff who deal with difficult professional problems.
Nurses in mental health facilities have, for a long time, been the subjects of patient violence. Other high risk settings include emergency departments, pediatric units, medical-surgical units, and long term care facilities (Lipscomb and Love, 1992). Weapon carrying is not uncommon in psychiatric and general medical emergency rooms.
The environmental risk factors associated with assault of health care workers are inadequate training, staffing patterns, time of day, and containment practices. Studies show that inexperienced workers and nursing students are at increased risk of assault. The majority of the injuries are sustained in the process of containing patient violence and the rest are battery injuries.
Preventive measures include adequate security in high risk areas, staff training upon hire and annually, written procedures for controlling violent patients, worker participation on the hospital health and safety committee, and use of legal action against the assaultive party and the institution.
In summary, nurses are subject to exposure to environmental hazards through their contact with patients, physical and psychological job demands, and as a result of the drugs and technology with which they work. Consequently, they have intrinsic knowledge about a variety of environmental factors that can be encountered professionally. Their enhanced understanding of these problems can be useful in accessing the environmental issues that may be faced by their patients.
Bureau of Labor Statistics, Personal Communication. Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, 6:1, p 11.
DiBenedetto, D., Occupational Hazards of the Health Care Industry: Protecting Health Care Workers. AAOHN Journal, 1995, 43:3, pp 131–137.
Fuortes, L.J., Shi, Y., Zhang, M., et al., Epidemiology of back injury in university hospital nurses from review of workers' compensation records and a case-control survey. Journal of Occupational Medicine, 1994, 36:9, pp 1022–1031.
Garrett, B., Singiser, D., Banks, S., Back injuries among nursing personnel: the relationship of personal characteristics, risk factors, and nursing practices. AAOHN Journal, 1992, 40:11, pp 510–516.
Hellman, S.L., Gram, M.C., The resurgence of tuberculosis: risk in health care settings. AAOHN Journal, 1993, 4:12, pp 66–72.
Hudson, P., Vogt, R., et al. Elemental mercury exposure among children of thermometer plant workers. Pediatrics, 1987, 79:6, pp 935–938
Levy, B.S., Wegman, D.H., eds., Occupational Health: Recognizing and Preventing Work-Related Disease. Third Edition, 1995, Little, Brown and Company, pp 355–379.
Lewy, R.M., Employees at Risk: Protecting the Health of the Health Care Worker. 1991, Van Nostrand Reinhold, pp 112–126.
Lipscomb, J.A., Love, C.C., Violence toward health care workers: an emerging occupational hazard. AAOHN Journal, 1992, 40:5, pp 219–228.
McAbee, R.R., Galluci, B.J., Checkoway, H., Adverse reproductive outcomes and occupational exposures among nurses: an investigation of multiple hazardous exposures. AAOHN Journal, 1993, 41:3, pp 110–119.
Rogers, B., Health hazards to personnel handling antineoplastic agents. In State of the Art Reviews: Occupational Medicine, Health Problems of Health Care Workers, Emmett, E., editor, 1987, 2:3, pp 513–524.
Udasin, I., Gochfeld, M. Implications of the occupational safety and health administration's bloodborne pathogen standard for the occupational health professional, JOM, 1994, 6:5, p 549.
U.S. Department of Health and Human Services, PHS, CDC, NIOSH, Guidelines for Protecting the Safety and Health of Health Care Workers. 1988.
Wiggins, P., McCurdy, S., Zeidenberg, W., Epistaxis due to glutaraldehyde exposure. JOM, 1989; 31:10, pp 854–856.