risk factors and impacts of occupational injury in … · this critical review reports the risk...

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Critical review

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For citation purposes: Miller K. Risk factors and impacts of occupational injury in healthcare workers: A critical review. OA Musculoskeletal Medicine 2013 Mar 01;1(1):4.

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Risk factors and impacts of occupational injury in healthcare workers: A critical review

K Miller1*

AbstractIntroductionThe high-risk, fast-paced healthca-re industry presents unique he-alth and safety challenges for hea-lthcare personnel, including exp-osure to psychological and phys-ical demands resulting in the inci-dence of musculoskeletal injuries of epidemic proportions. The dy-namic healthcare environment demonstrates that workers are prone to injury through a host of factors unique to them being directly involved in patient care. Just as heredity and environment interact to result in disease, no single risk factor is responsible for injury but rather a complex interaction of worker, patient, and hospital characteristics. This critical review reports the risk factors and impact of musculoskeletal injuries, with consideration for how these factors impact the worker, quality of care, and patient outcomes. The intent of this critical review is to summarize current literature, ide-ntify gaps in research, and broaden the questions that are asked as the efforts to reduce occupational inju-ry move forward, not to provide definitive risk factors and impacts for occupational injury.ConclusionThe risk factors of occupational injury are well documented; less understood is the impact of elevated incidence of occupational injury on patient safety. Nursing injury rates are linked to nursing shortages and less nursing time at the bedside,

both of which have been scientifically linked to negative patient outcomes. Further investigation is needed in this area not only due to the pain and suf-fering experienced by those directly affected, but also because of the or-ganizational impacts that indirectly affect patient care. The benefit of this research is to reveal the integral role the individual worker plays in patient outcomes, despite the quality of care they provide, a finding that could dra-matically change strategic priorities to deliver exemplary patient care and ensure the health and safety of work-ers, patients, and the public.

Introduction Driven by an ageing population and longer life expectancy, healthcare is one of fastest growing sectors of the economy, employing over 18 mil-lion workers in the United States and over 59 million worldwide1,2. This high-risk, fast-paced industry presents unique health and safety challenges for healthcare personnel, including exposure to psychologi-cal and physical demands resulting in the incidence of musculoskeletal injuries of epidemic proportions. Oc-cupational risk factors include heavy manual lifting, repetitive movement, poor posture, and continuous work. Overexertion represents one of the most disabling work-related injuries, representing approximately 50 lost workday injuries per 10,000 full-time equivalent (FTE) employees and more than $13 billion per year in di-rect costs, accounting for more than one-quarter of the overall national burden of occupational injury3,4. More than one-third of occupation-

al injuries in healthcare involve in-teraction with people other than the injured employee, most frequently

with a patient (28%), indicating the risk associated with patient han-dling5. Each day, more than 9,000 of the nation’s healthcare workers sus-tain a disabling injury while moving a patient6. Many experts believe this figure represents significant under-reporting of cases. Unfortunately, nurses accept occupational pain and injury as part of their job, with 52% to 63% of nurses reporting musculo-skeletal pain that lasts for more than 14 days7.

The dynamic healthcare environ-ment demonstrates that workers are prone to injury through a host of fac-tors unique to them being directly involved in patient care. These risk factors can be identified as character-istics of the worker, the patient, and the hospital (Figure 1). Occupational injury in healthcare workers leads to pain, disability, and lost time—all factors that contribute to decreased work effectiveness. The most obvi-ous impacts of work injury are those that are quantifiable, such as direct and indirect costs to the hospital, high turnover and staff shortage. This critical review will summarize current literature, identify gaps in research and broaden the questions that are asked as efforts to reduce occupational injury move forward. This critical review attempted to identify all articles that examine occupational musculoskeletal injury in healthcare personnel responsible for

* Corresponding author Email: [email protected] VA National Centre for Patient Safety, Ann Arbor, MI, USA

direct patient care. Exclusion criteria for articles included methodologies utilizing symptoms and frequency of pain as determinants (rather than injury) and review of healthcare personnel that do not have direct patient contact (e.g. maintenance, food service, laboratory). All articles

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Critical review


For cit ation purposes: Miller K. Risk factors and impacts of occupational injury in healthcare workers: A critical review. OA Musculoskeletal Medicine 2013 Mar 01;1(1):4.

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Regarding lifting and moving pa-tients, the obesity epidemic remains a considerable risk factor posing risk of injury to both the patient and the provider11. Morbidly obese patients pose an even greater threat, creat-ing significant physical challenges resulting in lost and restricted work-days for healthcare workers. Both frequency and severity of injuries escalate in bariatric units. While the bariatric patients represent 10% of the patient population, the corre-sponding injuries account for 30% of occupational injury. The majority of these injuries occur during man-ual performance required in patient handling tasks12.

Worker risk factors Occupational injury is the result of interaction between the affected person and a host of risk factors including those that are personal, non-occupational, occupational and psychosocial in nature. Research demonstrates that personal and non-occupational risk factors are consist-ent across industries and consistent in research assessing characteristics of individual healthcare workers. The most notable risk factors include age, gender, smoking, education and lifestyle habits. Advancing age rep-resents a statistically linear distribu-tion, as increasing age is associated with increasing risk13,14 Additionally, younger nurses or those with less seniority experience rates of injury similar to more experienced nurses who have accumulated more time in a nursing unit, particularly units that typically require frequent lifting15.Females, representing an over-

whelming proportion of the health-care workforce, have a higher incidence of falls, low back symp-toms, repetitive motion disorders and high-cost injury claims13. In comparison to all industries, health-care has the highest proportion of days-away-from-work cases of fe-male workers (81% of all incidents)5. Socioeconomic status, traditionally

health researchers chose various surveillance systems that included standardized operational databases, Occupational Safety and Health Ad-ministration (OSHA) logs, insurance data and facility injury data. This critical review reports the

Patient risk factorsThe patients, with whom healthcare workers interact, generate unique demands based on their physical and cognitive characteristics and requirements. High patient acuity and mobility limitations create chal-lenges for the healthcare provider, often increasing physical and men-tal stress8. Patient demands placed upon the providers by the conditions of the patients and/or the expecta-tions of their families, including tech-nological care and services, increase a provider’s workload, placing in-creased demands on the employee contributing to high musculoskeletal injury rates9,10.

Researchers of each study acquired and documented injury data in vari-ous forms. Worker’s compensation claims are considered to be particu-larly useful in assessing health condi-tions of occupational nature during the course of employment. In this review, these claims were the most popular method, as these data are easily obtained and provides addi-tional information including extend-ed health benefits, long-term disabili-ty claims, outpatient medical services to physicians, specialists and other health professionals, and inpatient hospitalizations. Other occupational

Figure 1: Characteristics of the worker, patient and hospital as risk factors and impacts of worker injury.

Discussion

were published in English anytime through December 2011.

risk factors and impact of musculoskeletal injuries, with consideration for how these factors impact the worker, quality of care and patient outcomes.

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The physical work environment can affect the worker in a multi-tude of ways, both physically and cognitively, and has been linked to job satisfaction, work performance, productivity, and ultimately, quality of care provided26. The physical en-vironment is often geared towards patient satisfaction, with a focus on a ‘healing environment’. The resulting environment may not be optimal for the healthcare worker if they impose unique demands for their workspace, such as a lack of storage, dim lighting or workflow conflict. The majority of overexertion injuries are the result of cumulative trauma and can manifest as symptoms of a poorly designed workplace, particularly considering an environment not conducive to safe patient handling tasks. No places to rest, hazardous equipment and noise levels have been identified as physi-cal environment characteristics that lead to unsafe situations and dan-gers16. In one study, nurses in both high and low claim rate hospitals ranked the physical work environ-ment as the second most important contributor of musculoskeletal in-jury, behind workload10.

Impacts Hospital impactsDirect costs include the cost for med-ical care and the compensation paid to injured workers while indirect costs include replacement of injured workers, additional training time by supervision and management, loss of productivity, decreased morale and other related issues. Both direct and indirect costs associated with occu-pational injury present a significant burden to the healthcare industry. In addition to quantifiable costs, in-juries indirectly contribute to patient safety in terms of lost productivity, change in workflow, disruptions, the loss of qualified nursing personnel and the resulting delivery of quality patient care. It has been estimated that the indirect cost can be greater than four times the direct cost27.

experience more sickness, burnout and job dissatisfaction than their part-time counterparts, further increasing their risk of injury10. Part-time and casual healthcare

workers do not experience the same injury rates as full-time workers but may be at increased risk for different reasons including exposure to more hazardous tasks, less access to rele-vant training and programs, and less job security21. Shift workers in any in-dustry are prone to decreased levels of cognitive functioning, inferior job performance and increased feelings of stress, all contributing to a greater number of occupational accidents as a result of circadian desynchroniza-tion22. In addition to the physical and cognitive demands of shift work, the hospital environment can be very different, with less staff available to assist in patient handling and higher patient staff ratios, both risk indica-tors for musculoskeletal injury23.

Hospital risk factors The organizational climate and safety culture (employee percep-tions of their organization’s com-mitment to safety) can significantly impact healthcare worker satisfac-tion and risk of occupational injury. Employee perceptions of supervi-sor support, work pressure, peer cohesion, autonomy, role ambigu-ity and conflict have been linked to occupational injury19,24. One study identified the following features especially damning: low nurse/phy-sician collaboration, low nurse man-agement, low professional practice, low opportunity for advancement and low unit decision- making25. The workplace safety culture is of increasing importance as organi-zational features including lack of training and administrative support effect and influence the adoption of safety behaviours. These blunt-end characteristics directly contribute to challenges felt at the sharp end including inadequate staff and high nurse−patient ratios.

linked to higher injury rates, does not appear to influence those same rates for healthcare workers. Rather, rates are attenuated after adjust-ing for psychosocial and ergonomic workplace exposures, suggesting that workplace differences may be the true predictor16,17. Stress, fatigue, burnout and frus-

tration play a crucial role in oc-cupational injury, with job strain demonstrated to be the most impor-tant predictor of functional health status18. Closely correlated with de-creased staffing levels, increased stress and job strain are the result of workload and increased physical work and psychological demands9,17. Obesity and poor health behaviours also contribute to increased risk of injury. Smoking cigarettes, lack of exercise and overeating (all coping mechanisms for stress) can further increase risk of injury15. These risk factors indicate a general lack of con-ditioning, poor physical abilities and poor health status. Furthermore, the frequency and severity of injuries in-crease for nurses weighing over 200 lbs11. Prior injury represents a sig-nificant risk factor for occupational injury, increasing frequency and severity of the outcome15,19.

The healthcare providers schedule impacts risk of occupational injury due to the stress placed on the indi-vidual worker as well as changes in the occupational environment dur-ing certain shifts. Important determi-nants of occupational injury risk and severity include working rotating shifts, working more than four night shifts in a row, working more than eight hours per shift, having reduced time between shifts, and working several consecutive workdays13. Ad-ditionally, studies indicate that work-ing full time, over time, and evening and night shifts increases risk. Such schedules include working longer hours and as a result, there is less time to recover from strain, height-ened fatigue and a loss of focus and concentration20. These employees

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healthcare provider and the patient. In industry, it is well known that an ergonomically designed workplace correlates with increased quantity and quality of work and is accompa-nied by simultaneous health benefits. It benefits the medical community to encourage and support ergonomic research in medicine, to ascertain new technical innovations and to in-tegrate these developments into the daily routine of the hospital. The cur-rent lack of ergonomically designed workspaces not only leads to muscu-loskeletal injury but disturbances in workflow and patient safety hazards. The medical community, academia and industry all should have a vested interest in this research and in future studies that are successful in meet-ing goals to reduce musculoskeletal injury.

An increasing number of studies indicate a strong correlation betwe-en patient safety and occupational safety in healthcare. Despite this re-search, hospitals continue to consid-er them in isolation. Employee heal-th and safety and patient safety are two initiatives with a common goal, the improvement of healthcare qua-lity and safety. As such, they should be incorporated into a single initiat-ive that utilizes novel techniques to improve both physical and cognitive aspects of healthcare. Interventions to help reduce work-related claims, including appropriate nurse-staffing levels, proper equipment and traini-ng, and reasonable job demands an-d workload will by their very natur-e improve patient safety. Organizat-ional and structural factors such as leadership vision and communicati-on create a positive work environm-ent. Changes to the physical enviro-nment range from costly restructur-ing and work area redesign to relat-ively inexpensive strategies includi-ng implementing safe lifting practic-es, offering educational programs, providing quiet rooms where nurses can relax, having ade-quate and functioning equipment available

hospital contributing to poor patient outcomes. Due to reduced staffing levels, workers are expected to per-form more physical activities within a given shift. In addition, the intensity of work has increased and there are fewer personnel to support the activ-ities. Unrealistic workloads prevent nurses from delivering a high quality of care to patients, creating more job stress, frustration and burnout.

Nursing injury rates are linked to nursing shortages and less nursing time at the bedside, both of which have been scientifically linked to negative patient outcomes30. Staff shortages have been linked to spe-cific patient outcomes including nosocomial infection rates, urinary tract infections, postoperative infec-tions and pressure ulcers; patient dissatisfaction with overall care and with pain management; and medica-tion errors and patient injury rates (specifically falls). It is estimated that the risk of death for surgical patients increases 7% for each additional pa-tient over four in a registered nurses workload, and 31% where nurse−pa-tient ratios are extremely high (eight patients per nurse)31. Staff shortages then increase the risk of occupation-al injury, creating a vicious cycle in the healthcare industry. Additionally, the industry must deal with unin-tended consequences of hiring tem-porary per diem nurses who may be less familiar with standard operat-ing procedures and equipment, fur-ther contributing to an unsafe work environment and creating concerns regarding competency, fatigue, and teamwork among nurses, doctors and support staff.

Conclusion The application of human factors and the establishment of patient safety initiatives over the past decade in-dicate progress is shifting the public discourse to systems thinking. These concepts highlight the need to reduce the risk of injury from the structure and process of care for both the

Worker impactsPrior injury is associated with in-creased risk for secondary injury and increased future risk for re-injury, as it raises susceptibility and changes one’s work habits. Exacerbated by healthcare demands, providers have reported proportions of persistent problems twice as high as other in-dustries, with employees reporting persistent medical problems 2 years (39%) and 5 years (23%) after an event28. The quandary is expected to persist as an aging population drives the prevalence of chronic conditions in the workforce higher.Occupational injury, illness, burnout

and disability contribute to absentee-ism among healthcare providers with a significant proportion related to musculoskeletal injury. Studies dem-onstrate a dose−response relation-ship between multi-morbidity and increased work absence but often the durations are not temporary29. Those suffering lifting-related injuries and/or chronic pain found their return to work so physically demanding they considered leaving patient care10. The economic implications of these rates are staggering, but the impacts of occupational injury affect the indi-vidual worker as well, contributing to burnout, frustration and perceived lack of social support from manage-ment and peers.

Patient impactsThe economic cost of occupational injury is well documented and of-ten the major focus for healthcare institutions. Less understood is the impact of elevated incidence of oc-cupational injury on patient safety. In addition to the pain and suffering experienced by those directly affect-ed, healthcare workers who recently suffered an injury, experience lost time and decreased work effective-ness leading to absenteeism and high turnover10,17,30. Research suggests that worker injury changes not only the individual worker’s style but on a larger scale, the workflow of the

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15. Owen B, Damron CF. Personal charac-teristics and back injury among hospital nursing personnel. Res Nurs Health 1984 Dec;7(4):305–13.16. d’Errico A, Punnett L, Cifuentes M,Boyer J, Tessler J, Gore R, et al. Hospital injury rates in relation to socioeconomic status and working conditions. Occup Environ Med 2007 May;64(5):325−33.17. Gillen M, Yen IH, Trupin L, Swig L, Ru-gulies R, Mullen K, et al. The association of socioeconomic status and psychosocial and physical workplace factors with mus-culoskeletal injury in hospital workers. American journal of industrial medicine 2007 Apr;50(4):245–60.18. Cheng Y, Kawachi I, Coackley H,Schwarz J, Colditz G. Association be-tween psychosocial work characteris-tics and health functioning in American women: prospective study. Br Med J 2000 May;320(7247):1432–6.19. Koehoorn M, Demers PA, Hertzman C, Village J, Kennedy SM. Work organization and musculoskeletal injuries among a co-hort of health care workers. Scand J Work Environ Health 2006 Aug;32(4):285–93.20. Fourtes L, Shi Y, Zhang M, Zwerling C,Schootman M. Epidemiology of back injury in university hospital nurses from review of workers’ compensation records and case-control survey. Occup Med (Lond) 1994 Sep;36(9):1022–6.21. Alamgir H, Yu S, Chavoshi N and Ngan K. Occupational injury among full-time, part-time and casual health care workers. J Occup Med 2008 Aug;58(5):348–54.22. Horwitz IB, McCall BP. The impactof shift work on the risk and sever-ity of injuries for hospital employees: an analysis using Oregon workers’ com-pensation data. Occup Med (Lond) 2004 Dec;54(8):556–63.23. Ngan K, Drebit S, Siow S, Yu S, KeenD, Alamgir H. Risks and causes of mus-culoskeletal injuries among health care workers. Occup Med 2010 Aug;60(5): 389–94.24. Boyer J, Galizzi M, Cifuentes M, d’Errico A, Gore R, Punnett L, et al. Ergonomic and socioeconomic risk factors for hospital workers’ compensation injury claims. Am J Ind Med 2009 Jul;52(7):551–62.25. Stone PW, Du Y, Gershon RM. Organi-zational climate and occupational health outcomes in hospital nurses. J Occup Environ Med 2007 Jan;49(1):50–8.26. Tanja-Dijkstra K, Pieterse M. Thepsychological effects of the physical

or exposures leading to injury or illness, 2007. Bureau of Labor Statistics, U.S. De-partment of Labor, Washington, DC, Sur-vey of Occupational Injuries and Illnesses in cooperation with participation State agencies, 2008.4. Liberty Mutual Research Institute forSafety. 2012 Liberty Mutual Workplace Safety Index. Hopkinton, MA; 2012.5. Bureau of Labor Statistics. Nonfatal oc-cupational injuries and illnesses requir-ing days away from work, 2011.Bureau of Labor Statistics, U.S. Department of Labor, Washington, DC, 2012.6. Charney W, Gasterlum R. Life teams—A one year study: Another success-ful story in an acute-care hospital. J Healthcare Safety, Compliance, Infect Control;2001;5(2):65–7.7. Nelson AL, Collin J, Knibbe H, Cook-son K, de Castro AB, Whipple KL. Safer patient handling. Nurs Manage 2007 Mar;38(3):26−32.8. Stone P, Gershon R. Nurse work envi-ronments and occupational safety in in-tensive care units. Policy Polit Nurs Pract 2006 Nov;7(4):240–7.9. Cohen M, Village J, Ostry AS, RatnerPA, Cvitkovich Y, Yassi A. Workload as a determinant of staff injury in intermedi-ate care. Int J Occup Environ Health 2004 Oct–Dec;10(4):375–83.10. Shamian J, O'Brien-Pallas L, ThomsonD, Alksnis C, Kerr MS. Nurse Absentee-ism, Stress and Workplace Injury: What are the contributing factors and what can/should be done about it? Int J Sociol Social Policy 2003;23:81–103.11. Humphreys S. Obesity in patients and nurses increases the nurse’s risk of inju-ry lifting patients. Bariatric nursing and surgical patient care. 2007 Mar;2(1): 3–6.12. Randall SB, Pories WJ, Pearson A,Drake D. Expanded OSHA 300 log as met-ric for bariatric patient-handling staff injuries. Surg Obes Relat Dis 2009 Jul–Aug;5(4):463–8.13. Thomas NI, Brown ND, Hodges LC,Gandy J, Lawson L, Lord JE, et al. Factors associated with work-related injury among hospital employees: a case-con-trol study. Am Assoc Occup Health Nurses J 2006 Jan;54(1):24–31.14. Drebit S, Shajari S, Alamgir H, Yu S,Keen D. Occupational and environmental risk factors for falls among workers in the healthcare sector. Ergonomics 2010 Apr;53(4):525−36.

for patient care and offering wellne-ss programs at the work site. In doi-ng so, there are additional downstr-eam benefits including increasing t-he length of clinicians’ careers, reducing staff shortages, adverse events and improving team morale.Further investigation is needed

in this area not only due to the pain and suffering experienced by those directly affected, but because of the organizational impacts that indirect-ly affect patient care. Future research should provide quantitative and qualitative insight into how the phys-ical work environment contributes to healthcare provider and patient safe-ty. In addition to subjective review, as noted in previous safety studies, research should also take into ac-count objective records and physical assessments, allowing for analysis of individual risk factors as well as analysing the interplay of multiple program initiatives and worker char-acteristics. Just as heredity and envi-ronment interact to result in disease, no single risk factor is responsible for injury but rather a complex in-teraction of worker, patient and hos-pital characteristics. The benefit of this research is to reveal the integral role the individual worker plays in patient outcomes, despite the qual-ity of care they provide, a finding that could dramatically change strategic priorities to deliver exemplary pa-tient care and ensure the health and safety of workers, patients and the public.

References 1. Centers for Disease Control and Pre-vention [Healthcare Workers]. Atlanta, GA. [updated February 14, 2012; cited March 15, 2012]. Available from: http://www.cdc.gov/niosh/topics/healthcare/2. World Health Organization. WorkingTogether for Health: World Health Report 2006. Geneva, Switzerland, 2006.3. Bureau of Labor Statistics. Table R8.Incidence rates for nonfatal occupation-al injuries and illnesses involving days away from work per 10,000 full-time workers by industry and selected events

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injury. Scand J Soc Med 1995 Jun; 23(2):121–8.29. Collins JJ, Baase CM, Sharda CE, Ozminkowski RJ, Nicholson S, Billotti GM, et al. The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. J Occup Environ Med 2005 Jun;47(6):547–57.

healthcare environment on healthcare perssonel. Cochrane Database Systems Review, 2011 Jan.27. Fragala G, Bailey L. Addressing oc-cupational strains and sprains. AAOHN 2003 Jun;51(6):252–9.28. Larsson T, Björnstig U. Persistent medical problems and permanent im-pairment five years after occupational

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