Skilled nursing care centers have at their core the mission to keep patients and residents safe. But in doing so, health care workers often face the risk of injury in their daily efforts to feed, clothe, bathe, and transport residents.
Opportunities abound for nursing centers and assisted living communities to supply employees with equipment designed to ease this burden. It may also be a catalyst to recruit and retain younger workers to aid the now-aging workforce, as workers are becoming less able to take on extra physical demands.
While patient safety is a crucial part of any center’s regime, “it’s just as important to see how employees are being handled in that organization as well,” says Brian Downs, vice president of quality and provider relations with the Workers’ Compensation Trust (the Trust) in Wallingford, Conn.
The Risks Involved
When the core part of one’s job involves caring for people, injuries and other safety concerns are bound to happen, says Lyn Bentley, vice president of quality and regulatory affairs at the American Health Care Association. Health care workers often face the risk of injury in order to keep patients safe. “Many of the residents we care for can’t provide assistance in their movements. They have no strength in their muscles, and when you’re providing care, sometimes unexpected things can happen,” Bentley says.
Especially in skilled nursing centers, workers face musculoskeletal injuries and other ergonomic hazards. In an ongoing survey of its members that covers all work environments, the American Nurses Association (ANA) determined that 62 percent had concerns about suffering from a disabling musculoskeletal injury on the job. In an ANA health risk appraisal conducted in 2013-2014, 42 percent of its members cited manual lifting as a high-risk task.
Workers also risk contracting bloodborne pathogens when coming into contact with a patient’s bodily fluids, or get irritated eyes from exposure to household cleaners and other chemicals. If nurses or certified nurse assistants (CNAs) don’t adequately protect themselves, that’s a problem, Bentley says.
At times, they may encounter aggressive behavior
on the job from patients who have dementia and aren’t in control of their faculties, or sometimes from other individuals who are struggling with fear and anxiety about their situation.
Federal regulators say that some of these hazards can be addressed through available measures, such as personal protective equipment like goggles, protective garments, and other similar equipment designed to protect the wearer’s body from infection. But as health care experts claim, getting a facility to change its ways and embrace equipment that could reduce worker injuries isn’t always that easy.
According to experts at the Trust, one way to relieve worker fatigue and prevent injuries is to more efficiently address workflow. This may involve reengineering some jobs to reduce one-on-one handling to a minimum, or redesigning some positions so that one particular individual is not on the frontline every single day and every hour.
Carol Fronczek, ARM, vice president for loss control services with the Trust, emphasizes the importance of having a strong and effective accident investigation program in place that identifies the true causes of injuries.
People will say that they hurt themselves because they didn’t use a piece of equipment. But if you get down to the root cause, it could be because the piece of equipment was not readily available, the CNA was not trained or was unfamiliar with the specific piece of equipment, or the equipment had not been properly maintained.
Ultimately, this is about the culture of the facility, Fronczek says. “If there’s a strong safe patient-handling program to prevent injuries, it has to be ingrained in everything the facility does. It’s not about whether they have the equipment—but how are they using it, how they’re being trained, and the enforcement and culture behind it.”
At Baltimore-based Erickson Living communities, the philosophy is to promote both healthy lifestyles and safety-consciousness efforts. A developer and manager of senior living communities and health services, Erickson’s network spans 19 campuses in 11 states, serving more than 24,000 residents.
“We recognized pretty early that by aligning health and safety strategies, we can really provide measurable benefits to our staff,” says Marcia Price, Erickson Living’s vice president of health and operations. This is not just about keeping employees safe, but addressing their personal health and wellness, work-related services and safety programs, managing their workers’ compensation, and having a health advocacy approach.
Most of Erickson Living’s communities have onsite employee health and wellness clinics staffed by a nurse practitioner, who can address health issues as well as workplace injuries.
In Price’s view, it doesn’t matter whether a state has a safe patient-handling law or not, or how strict it is (see sidebar
“We need to do the right thing for residents and staff, regardless. Our policy is to meet the higher standard—we want every employee to return home in the same condition that they came to work.”
Role of Strong Leadership
This is also about good communication skills, says Karen Cody, CPCU ARM, director of risk management with Preferred Care Partners Management Group (PCPMG) in Plano, Texas. PCPMG manages 111 facilities in 12 states that represent skilled nursing, assisted living, and intermediate care facilities for people with developmental disabilities.
“I see employee injuries skyrocket when our staff and management aren’t working together. When a leader comes in and cares for the staff, is concerned about their health and safety, and communicates their concern with that employee, injuries reduce. We can put in all the safety devices and every piece of protective equipment, but if an employee doesn’t get a sense of belonging or that they’re cared for, they’re not going to use it.”
Cody has put in a number of checks and balances at her centers to reduce injuries, including a patient-handling and -movement policy that’s based on Occupational Safety and Health Administration guidelines and Texas law.
One thing the policy stresses is the use of lifting aids and assessing the patient in advance of a lift to determine the safest means of accomplishing the
“Mechanical lifting equipment and/or other handling aids should be used to prevent the manual lifting and handling of patients except when absolutely necessary,” the policy says. It also says that staff members can refuse, without being subjected to any personnel actions, to lift or move a patient if they believe it may
result in an injury to the resident or to themselves.
Each facility managed by PCPMG conducts staff observations of resident handling twice a month and records any lifts and transfers on a form, which they submit to the management company. The facility must answer a series of questions that address how their employees executed a lift, what the patient’s physical capacity and weight was, and if lifting aids were necessary. The form asks whether a resident’s mental and physical capacities were assessed prior to the lift or transfer, and if an employee had been trained in body mechanics.
It also asks if an employee had successfully met all resident handling performance standards.
All of these measures have made a big difference in reducing lift-strain injuries at PCPMG facilities, Cody says. Compared with 2015, PCPMG’s 2016 lift-strain injury frequency and severity (cost) was down by 73 percent and 57 percent, respectively.
Educating employees, making sure they demonstrate proper lift techniques, and ensuring the facility has adequate equipment are key in fostering a safe environment for patients and workers, she says.
Overhauling Training Programs
Establishing a dedicated employee safety program has paid off in dividends for Branford Hills Health Care Center, a 190-bed skilled nursing center in Branford, Conn., that has 160 long-term and 30 short-term patients.
Administrator Janet Woxland, RN, BSN, MHCA, NHA, who has experience working in long term care centers and hospitals, took a hard look at all of the potential hazards that were causing injuries and other problems at her facility to see how she could create a safer environment for her employees.
After an internal review, she decided to overhaul the facility’s orientation process so that every staff member was educated thoroughly on the facility’s safety protocols. The new regimen includes mandatory fire safety and disaster training, as well as training in ergonomics, workplace violence, and handling of patients with dementia.
“My staff development coordinator, who became certified in dementia training, now educates staff during orientation about dementia, which has been a great help,” Woxland says.
The facility’s safety committee meets quarterly to review any employee injury. Every injury is investigated upon receiving the First Report of Injury. Once an injury is reported, a nurse educator responds by in-servicing and coaching the individual employee. The incident is analyzed, categorized, and recorded to identify trends, times, and location and is then recorded on a bulletin board in the employee lounge.
According to Woxland, this creates a visual environment of safety awareness.
Branford Hills is also diligent about tracking the use of housekeeping chemicals, whether it’s household cleaner, nail polish, or toner cartridges.
Employees get personal protective equipment like gloves and goggles, and each department in the facility has a safety data sheet for all chemicals. All the safety data sheets have pictograms so that everyone knows what each chemical looks like and what it is. In addition, housekeepers have binders in their carts that itemize every single chemical they would use, Woxland says.
The master book of all chemicals used in the facility can be located on each unit and in the maintenance office.
‘Back’ to School
Residents at Branford are aging in place, and at least 60 percent have a diagnosis of dementia. These residents often require specialized equipment for transfers to maintain their quality of life, Woxland says.
This is why each unit of the facility has Hoyer lifts and Sara lifts for use based on acuity level. The Hoyer lift allows the resident to be transferred without any physical participation by the resident. The Sara lift enables a patient with good trunk support to hold onto it with her hands and move from a sitting to a standing position.
“Given the number of residents on a unit and the level of acuity, some units have more lifts than others,” Woxland says.
Additionally, all of the facility’s licensed staff and CNAs are required to attend “back school” where they learn proper techniques for lifting residents and protecting their backs. The staff development registered nurse (RN) has to verify the competency of each employee based on observation and documents performance on a skilled checklist.
This attention to safety even applies to footwear. After their 90-day probationary period, all staff members get a free pair of slip-resistant shoes, which they can select from a catalog.
Through these efforts, Woxland says the facility has reduced its slips, trips, and falls by 65 percent over the past year.
Quarterly Meetings With families
The campaign for awareness needs to extend beyond the center’s employees to residents and their families as well.
Through letters, illustrative posters, and quarterly counseling meetings, Branford Hills educates families of residents about the lift equipment, why it is used, and how it benefits the resident and its employees. The center’s therapy department also attends the meetings and explains the team effort behind lifting decisions.
These educational efforts demonstrate how staff care about the safety of residents, according to Woxland. In turn, family members who hadn’t previously understood why their loved one required manual assistance, find these meetings to be very helpful—and leave with a better understanding of the issues.
Properly assessing the patient upon admission can also avoid these types of misunderstandings.
Assessment is key to identifying what’s needed to safely transfer the resident, Price of Erickson Living says. “Furthermore, upon any significant changes in conditions, we look to conduct another lift assessment.”
Erickson Living promotes the importance of utilizing lifts to keep its patients and residents safe. “But we go a step more: We empower our staff—nurses, aides, housekeepers—to observe any changes in residents and request a lift assessment,” recognizing that mobility and temperament can change from day to day.
“That’s been our approach, part of our culture. Everyone takes responsibility,” Price says.
In 2016, Erickson Living corporate got recognition for its safety programs when it received the Corporate Health Achievement Award from the American College of Occupational and Environmental Medicine. The award recognizes outstanding work in occupational and environmental health programs that produce measurable results.
“We know from research that a lot of workplace injuries result from unsafe behaviors rather than an unsafe environment,” Price says. “Focusing on behaviors is a vital part of our company’s philosophy and our management practice.”
Rewarding Staff for Teamwork
To change a safety culture, Woxland advises that managers have to look at their center with fresh eyes—as if they’re walking into it for the first time—and let their staff offer input toward solutions.
“You have to listen to your employees because many times they have the best answers for what you’re trying to resolve,” she says.
Offering rewards to improve safety is a great incentive. Branford Hills accomplished this by picking champions on each unit: those who were most committed to safety improvements and wanted to be part of the solution. These employees, mainly CNAs, perform safety rounds as part of their workday schedule and report any hazards or concerns they observed to the charge nurse, to discuss what improvements may be needed.
A rewards program doesn’t have to be dull, either. Some facilities hold special events during the year to build excitement for and promote safety initiatives.
For its annual safety challenge, one of Erickson Living’s communities in Pennsylvania decided to launch a campaign on decreasing back injuries related to lifting and transferring patients, and won an internal award for its efforts. Through the safe lifting program and other initiatives, the community saw a reduction in back injuries at its centers drop by 10 percent in just a year. In addition, the number of total days away from work and restricted duty declined from 304 to 100.
Nurses at the facility said staff took ownership of this initiative and that making improvements to the process resulted in better patient outcomes as well.
Branford hosts an annual Safety Mania event, “where my staff development RN sets up safety hazards in a room, and the staff member who identifies the most hazards gets a prize,” Woxland says.
The room might include a spilled water pitcher, a razor that should have been put away, a bed raised too high, or wires next to the bed or on the floor as a trip hazard. “We might put ketchup on a sheet simulating a body fluid, and the sheet would be rolled on the floor as an infection control hazard that should have been bagged,” she says.
Giving the employees the opportunity to provide comments on safety training empowers them, Woxland says. “It shows we really care about their safety and want to institute their ideas to make the building safer.”
Jennifer Lubell is a freelance writer living in the Washington, D.C., metropolitan area.