Chapter 39. Personal Safety for Nurses 

Alison M. Trinkoff, Jeanne M. Geiger-Brown, Claire C. Caruso, Jane A. Lipscomb, Meg 

Johantgen, Audrey L. Nelson, Barbara A. Sattler, Victoria L. Selby 

Background 

The safety of nurses from workplace-induced injuries and illnesses is important to nurses 

themselves as well as to the patients they serve. The presence of healthy and well-rested nurses is 

critical to providing vigilant monitoring, empathic patient care, and vigorous advocacy. Many 

workplace stressors that can produce diseases and injuries are present in nursing work 

environments. These stressors include factors related to the immediate work context, 

characteristics of the organization, and changes that are occurring external to the organization but 

throughout the health care industry.1 Nurses experience significant physical and psychological 

demands during their day, as well as a work safety climate that can be adverse. Pressures within 

organizations to downsize, use nurses employed under alternative arrangements (pool and 

traveling staff), and the turnaround time for patient care (early discharge, higher patient loads) 

are examples of factors that are determined at an organizational level. The external context 

within which nurses practice includes lean managed care contracts, increasing use of complex 

technological innovations, an older nurse workforce, and increasing numbers of very sick elderly 

patients (aging population). Factors at each of these levels can produce threats to nurses’ safety 

while on the job. 

The hazards of nursing work can impair health both acutely and in the long term. These 

health outcomes include musculoskeletal injuries/disorders, other injuries, infections, changes in 

mental health, and in the longer term, cardiovascular, metabolic, and neoplastic diseases. In this 

chapter we will present major research findings that link common work stressors and hazards to 

selected health outcomes. These stressors include aspects of the way work is organized in 

nursing (e.g., shift work, long hours, and overtime) and psychological job demands, such as work 

pace. In addition, aspects of direct care work that influence nurse safety will be discussed, 

including the impact of physical job demands such as patient lifting and awkward postures, 

protective devices to prevent needlesticks, chemical occupational exposures, and potential for 

violence. Where possible, interventions that have demonstrated effectiveness to reduce the risk 

of illness and injury will be presented, as well as gaps in knowledge that can spur new lines of 

research inquiry. 

Research Evidence 

Shift Work and Long Work Hours 

The relationship between work schedules and health and safety is complex and is influenced 

by characteristics of the work schedule (time of shift, direction and speed of rotation, pattern of 

days off, shift length, rest breaks), as well as characteristics of the job, the worker, and the work 

environment.2

 While the focus is on potential negative aspects, some workers experience benefits 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

from shift work and prefer it (e.g., incentive pay, reduced volume of activities and personnel 

when compared with day shift). 

Researchers theorize that shift work exerts adverse effects by disturbing circadian rhythms, 

sleep, and family and social life.2, 3 Disturbances in circadian rhythms may lead to reductions in 

the length and quality of sleep and may increase fatigue and sleepiness, as well as 

gastrointestinal, psychological, and cardiovascular symptoms. In addition, working at unusual 

times may make it difficult to interact with family and maintain other social contacts.4 Similarly, 

long work hours may reduce the time available for sleep, leading to sleep deprivation or 

disturbed sleep and incomplete recovery from work.5–7 This may adversely affect nervous, 

cardiovascular, metabolic, and immune functioning. Family and social contacts may also be 

reduced, which in turn may lead to physiological responses associated with stress. Long hours 

may also increase exposure times to workplace hazards such as chemicals; infectious agents; and 

physical, mental, and emotional demands. Long hours also may reduce time available for 

exercise or nutritious meals, and added job stress can increase smoking, alcohol consumption, 

and caffeine use. 

Risks Associated With Shift Work 

Sleep, sleepiness, performance, safety. Drake and coworkers8 indicated that 32 percent of 

night workers (majority of shift hours between 9 p.m. and 8 a.m.) and 26 percent of rotating shift 

workers (shifts that change periodically from days to evenings or nights) experienced long-term 

insomnia and excessive sleepiness and were unable to adapt their sleep adequately on these 

shifts. Sleep loss makes people sleepier while awake, which may affect the shift worker’s ability 

to perform activities safely and efficiently, both on and off the job. Increased sleepiness (or 

decreased alertness) in shift workers on the job has been demonstrated with subjective reports,9

objective performance testing,10 and EEG recordings showing brief, on-the-job sleep episodes.11

Sleepiness is most apparent during the night shift, and poor daytime sleep appears to be a 

contributing factor.12 A meta-analysis combining injury data from several studies indicated that 

injury risk increased by 18 percent during the afternoon/evening shift and 34 percent during the 

night shift compared to morning/day shift.13 These results are consistent with worksite 

observations of increased subjective sleepiness and decreased reaction time during night shifts, 

and progressive decreases in total sleep time from early to late in the workweek.14

Social and familial disruptions. Because shift workers often work in the evening and sleep 

during the day, they frequently sacrifice participation in social and family activities. 

Furthermore, shift workers in continuously operating organizations such as hospitals are 

regularly required to work weekends and holidays, when much social and family interaction 

occurs.15, 16 Consequently, too little time with family and friends is the most frequent and most 

negatively rated complaint among shift workers. The extent to which such disruptions occur 

depends both on the worker’s schedule, type of family, gender, presence of children, and the 

degree of flexibility in the worker’s social contacts and leisure pursuits.15–17 For families, shift 

work often conflicts with school activities and the times when formal child care services are 

available, making arranging for the care of children more challenging,17 affecting both the 

worker and the family’s social adjustments. 

Long-term effects and vulnerable groups. Although the specific contribution of shift work 

to other illnesses is not clear, several diseases have been associated with these work schedules. 

Gastrointestinal (GI) complaints are common in shift workers and could be due to changes in 

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Personal Safety for Nurses 

circadian rhythms of GI function, sleep deprivation leading to stress response and changes in 

immune function, or the types of foods that are available during these shifts.18, 19 Schernhammer 

and colleagues20 reported an increased risk of colon cancer in nurses working 3 or more nights 

per month for 15 or more years. 

Psychological complaints are frequently reported, including depression and other mood 

disturbances, personality changes, and relationship difficulties.21 A review of 17 studies suggests 

that shift work increases risk for cardiovascular disease by 40 percent compared with day 

workers.22 Possible mechanisms include decreased glucose tolerance, insulin resistance, elevated 

cortisol levels, and increased sympathetic activity. A systematic review of reproductive outcome 

studies concluded that shift work was associated with a modest increase in spontaneous abortion, 

preterm birth, and reduced fertility in women.23 The effect on reproduction in men was not 

analyzed due to an inadequate number of studies. A meta-analysis of 13 studies examining night 

work and breast cancer reported that night work was associated with a moderately elevated risk 

among women.

24 The authors hypothesized that exposure to light at night reduces melatonin 

levels, increasing risks for cancer. 

Shift work also may exacerbate preexisting chronic diseases, making it difficult to control 

symptoms and disease progression. Shift work interferes with treatment regimens that involve 

regular sleep times, avoiding sleep deprivation, controlling amounts and times of meals and 

exercise, or careful timing of medications that have circadian variations in effectiveness. Sood25

suggests several conditions that may be exacerbated by shift work: unstable angina or history of 

myocardial infarction, hypertension, insulin-dependent diabetes, asthma, psychiatric illnesses, 

substance abuse, GI diseases, sleep disorders, and epilepsy requiring medication. Costa26 adds to 

this list chronic renal impairment, thyroid and suprarenal pathologies, malignant tumors, and 

pregnancy. Aging is also associated with less tolerance of shift work, which may be due to agerelated changes in sleep that may make it more difficult for older people to initiate and maintain 

sleep at different times of the day.27 These sleep changes may begin as early as the 30s and 40s, 

so some workers who initially adapted well to shift work during their younger years may show 

more symptoms as they grow older. 

Risks Associated With Long Work Hours 

The number of studies examining long work hours is less extensive, but a growing number of 

findings suggest possible adverse effects. A meta-analysis by Sparks and colleagues5

 reports that 

overtime was associated with small but significant increases in adverse physical and 

psychological outcomes. A review by Spurgeon and colleagues6

 concluded that the adverse 

overtime effects were associated with greater than 50 hours of work per week, but little data are 

available about schedules with fewer than 50 hours. An integrative review by Caruso and 

colleagues28 reported that overtime was associated with poorer perceived general health, 

increased injury rates, more illnesses, or increased mortality in 16 of 22 recently published 

studies. Dembe and colleagues,29 examining data from the National Longitudinal Survey of 

Youth, found a dose-response relationship, such that as the number of work hours increased, 

injury rates increased correspondingly. Trinkoff and colleagues30, 31 found that long work hours 

were related to the incidence of musculoskeletal injuries and needlesticks in nurses. Overall, 

these studies indicate that caution is needed in implementing schedules with extended work 

hours. Determining the number of work hours critically associated with risk for a specific job 

would require examining how extended hours interact with other factors contributing to fatigue, 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

such as work load, competing responsibilities, and opportunities for rest and recovery. 

Additional information on the effect of long work hours can be found elsewhere in this book. 

Coping Strategies 

Efforts to promote adaptation to (or ease the difficulties of coping with) shift work and long 

work hours include strategies for employers and strategies for workers. Most suggestions to date 

were written for shift work, but they may also be relevant for long work hours. A sampling of 

strategies suggested in the literature for shift work include designing new work schedules and 

rest breaks during work, altering circadian rhythms with bright light or blue light, optimally 

timing physical activity or other work demands, improving physical conditioning, using caffeine, 

planning dietary regimens, stress reduction, support groups, and family counseling.32–39 Caldwell 

and Caldwell36 suggest using behavioral and administrative strategies fully before considering 

pharmacologic aids since these stimulants and sedatives can be addictive and questions remain 

about the safety and effectiveness of long-term use. Taking naps during work is another 

intervention that has been associated with improvements in alertness40, 41 and is an accepted 

practice in some Asian countries. More research is needed to determine the optimum length and 

timing of the nap and a practical environment at work to take a nap. Empirical evaluations and 

applications of the other techniques have begun and will be useful for some workers, but more 

research is needed to develop strategies that can be easily applied by workers in a wide range of 

demanding work schedule situations. Another type of strategy are work hour limits such as the 

recent Institute of Medicine recommendation42 (p. 13) that work hours for nurses be limited to 60 

hours per 7-day period and 12 hours per day. 

Nurse Injury and Disease Outcomes 

Musculoskeletal Injuries 

Few industries in the United States have undergone more sweeping changes over the past 

decade than the health care industry. Changes in health care, including restructuring and 

redesign, have led to increasingly heavy demands on nurses and other health care workers. 

Extended schedules and increased work pace, along with increased physical and psychological 

demands, have been related to musculoskeletal injuries and disorders (MSD).43 These demands 

have been found in laboratory and worker studies to increase the risk of musculoskeletal 

pain/disorders.44–47

Definitions for MSD vary, though most include pain in the affected body region (e.g., back 

or neck) for a specified duration or frequency,48 along with other related symptoms such 

numbness and tingling.49 Measurement of MSD also varies from study to study, with many 

studies relying on self-report and others requiring seeking care or obtaining testing or 

clarification/diagnosis by a clinician.48 Researchers are careful to rule out nonwork-related MSD 

from their studies. 

Health care workers are at extremely high risk of MSD, especially for back injuries. Health 

care workers are also overrepresented for upper extremity MSDs among workers’ compensation 

(WC) claims.50 In 2001, U.S. registered nurses (RNs) had 108,000 work-related MSDs involving 

lost work time, a rate similar to construction workers.51 In 2003, the incidence rate for nonfatal 

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Personal Safety for Nurses 

occupational injuries, many of which were MSDs, was 7.9 per 100 full time equivalents (FTEs) 

for hospital workers.52 

Studies have shown that MSDs lead to sick days, disability, and turnover. In a survey of 

more than 43,000 nursing personnel in five countries, 17–39 percent planned to leave their job in 

the next year due to physical and psychological demands.53 In previous research, the percentage 

of nurses reporting job change due to MSD ranged from 6 percent to 11 percent, depending on 

the body part injured (neck, shoulder, or back).54 Staffing has also been related to MSD, with 

lower staffing complements related to increased injuries. Between 1990 and 1994, the Minnesota 

Nurses Association collected injury and illness data from 12 hospitals in the Minneapolis-St. 

Paul area. The researchers found that when RN positions in the hospitals decreased by 9.2 

percent, the number of work-related injuries or illnesses among RNs increased by 65.2 percent. 

Lower staffing ratios for nurses and higher patient loads have both been shown to result in 

increased exposure to hazardous conditions and insufficient recovery time.55 In a review of 

evidence, the Institute of Medicine indicated that there was strong relationship between nursing 

home staffing and back injuries.56 In a recent study of the relationship of health care worker 

injuries to staffing in nursing homes, researchers indicated that staffing levels were significantly 

related to health care worker injury rates in nursing homes across three States.57 

Physical/postural risk factors and MSD. Health care work is highly physically/posturally 

demanding,54, 58, 59 and tasks requiring heavy lifting, bending and twisting, and other manual 

handling have been implicated in health care worker back injuries.60 In one study, nurses were 

found to be at particular risk of back injury during patient transfers, which require sudden 

movements in nonneutral postures.61, 62 Patient transfers also require flexion and rotation, 

increasing the injury risk due to a combination of compression, rotation, and shear forces.63–65

Highly demanding physical work was associated with 9–12 times the odds of having a neck, 

shoulder, or back MSD among nurses.54 Hoogendoorn and colleagues,66 using video 

observations and questionnaires in a 3-year study of health care workers, found that extreme 

flexion and frequent heavy lifting had a strong impact on worker low-back pain. Other analyses 

found that physical/postural risk factors were related to impaired sleep, pain medication use, and 

absenteeism.59 

Fewer studies have examined physical/postural risk factors in relation to health care worker 

neck and shoulder MSDs. Risk factors related to neck and shoulder pain include body placement 

in awkward postures that need to be maintained for long periods of time. Using direct 

observation, Kant and colleagues58 found that surgeons had extensive static postures, along with 

operating room nurses who were required to maintain tension on instruments, leading to 

substantial musculoskeletal stress of the head, neck, and back. Lifting and stooping were 

significantly associated with health care worker arm and neck complaints,67 whereas shoulder 

complaints were associated with pushing and pulling motions.68, 69 Heavy lifting and actions with 

arms above shoulder height were associated with shoulder pain or injury in health care workers 

and in other occupational groups.70–72 The evidence indicates that preventive interventions for 

MSD need to address physical/postural risk factors. 

Work schedules and MSD. The work schedule can affect the sleep–wake cycle, and 

working extended hours, such as 12+ hour shifts, can lead to MSD due to extended exposure to 

physical/postural risk factors and insufficient recovery time.73, 74 As physical/postural demands 

on the job increased for nurses, the likelihood of inadequate sleep also significantly increased.59

Workers on schedules requiring frequent shift rotation and long hours may also be at higher risk 

for MSD.75–78 In a survey of 1,428 RNs, more than one-third had extended work schedules, and 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

such schedules were associated with an increased likelihood of MSD.79 A later study found that 

long work hours were related to incident musculoskeletal injuries in nurses.30

In workers with employment-related myalgia, symptoms increased with each successive 

workday, and remitted only by the second day off.80 These workers had shorter periods of 

muscle rest, suggesting that continuous muscle tension was associated with musculoskeletal 

symptoms. In a British study of doctors-in-training, the fewer hours they slept and the more 

hours they worked, the more somatic symptoms, including MSD, they reported.81 

Schedule components significantly related to MSD include long work hours, mandatory 

overtime, working while sick or on days off, and having fewer than 10 hours between shifts.30

The new Institute of Medicine report, Keeping Patients Safe: Transforming the Work 

Environment of Nurses,42 incorporated Wave 1 findings on nurse scheduling. More than onethird of staff nurses typically worked 12 or more hours per day. Among those working 12+ 

hours, 37 percent rotated shifts. On-call requirements were also very common (41 percent of the 

sample). Despite the long hours, few nurses took breaks; two-thirds typically took one or no 

breaks during their shift. 

Mitigating MSD risks. Although two decades of research have demonstrated the workrelatedness of MSD, use of single-approach intervention methods to reduce MSD exposures 

(e.g., engineering controls, administrative changes, or worker training only) has shown 

inconsistent outcomes.82 This is likely due to the combination of factors related to MSD and the 

need for broad organizational involvement to mitigate MSD problems.83 Despite these concerns, 

important evidence-based successes have been demonstrated in reducing MSD, especially during 

patient lifting and transfer.84, 85 Interventions incorporating participatory ergonomics have been 

found to improve upon previous approaches by allowing for extensive worker input into the 

design and adoption of preventive practices.86, 87 In a participatory ergonomics approach, 

employees participate in the identification of ergonomic risk factors, brainstorm alternatives and 

solutions, handle implementation of controls, and assess control effectiveness along with 

symptom identification, ultimately becoming champions for ergonomics change.86 Participatory 

ergonomics also has the potential for changing the culture of health care organizations, as 

employees begin to use ergonomic principles to improve jobs and the workplace. Because 

participatory interventions incorporate both management commitments to reducing injuries, 

along with workers who are involved in developing solutions, positive and effective workplace 

changes can occur.88

Interventions for MSD. Three common interventions used to prevent work-related 

musculoskeletal injuries associated with patient handling are (1) classes in body mechanics, (2) 

training in safe lifting techniques, and (3) back belts. Despite their wide spread use, these 

strategies are based on tradition rather than scientific evidence; there is in fact strong evidence 

these strategies are not effective.85, 89 Recently there has been a major paradigm shift away from 

these approaches toward the following evidence-based practices: (1) patient handling 

equipment/devices, (2) no-lift policies, (3) training on proper use of patient handling 

equipment/devices, and (4) patient lift teams. Table 1 describes interventions and identifies 

challenges that have been associated with their implementation. 

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Personal Safety for Nurses 

Table 1. Evidence-Based Interventions for Safe Patient Handling 

Proposed 

Intervention 

Description Challenges to Implementation 

Patient 

handling 

equipment and 

devices 

Patient handling technologies include heightadjustable electric beds,90–92 mobile mechanical 

patient lifts,93–97ceiling-mounted lifts,98–100 frictionreducing devices/lateral transfer aids,101–104 bed 

repositioning,105–107etc. More complete listings of 

patient handling equipment and devices are 

available.108–110

 Cost 

 Assuring competency of all staff in its 

use 

 Integrating multiple technologies 

 Selecting the best technology to 

address the specific risks identified 

 Technology often takes more time 

than performing the task manually 

No-lift policies Regardless of the title, these policies focus on 

minimizing manual patient handling.84,111,112 No-lift 

policies have been developed through legislation 

or facility-based policies. National policies have 

been enacted in Europe and Canada. In the 

United States, State legislation related to manual 

patient lifting was recently passed in Texas and 

Washington. Facility-based policies are known as 

“no-lift policy,” “zero lift,” “minimal lift,” “lift-free,” or 

“safe patient handling and movement.” 

 Necessary equipment needs to be in 

place before the policy is 

implemented. 

 Nonpunitive approach is necessary 

for success. 

Training on 

proper use of 

equipment/ 

devices 

While traditional classes in body mechanics and 

lifting techniques are not effective, evidence 

supports the need for ongoing training in use of 

equipment and devices.84, 109, 113–115

 Training all staff, across shifts 

 Training on units with high staff 

turnover 

 Need to reinforce training over time 

 Need for “just-in-time” training when 

equipment is needed sporadically, 

such as bariatric device. 

Patient lift 

teams 

A lifting team is defined as “two physically fit 

people, competent in lifting techniques, working 

together to accomplish high-risk patient 

transfers.”116 This term is sometimes also referred 

to as “patient transfer team”, “lift team” or a 

combination of these phrases.116–125

 Logistics of providing lift team 

services 24 hours a day/ seven days 

a week 

 Cost 

 Managing workload and logistics of 

“unscheduled lifts” that emerge during 

typical workday 

 Addresses only patient lifts, ignoring 

other high-risk tasks such as 

repositioning, toileting, or bathing 

Promising new interventions that are still being tested include use of unit-based peer leaders, 

clinical tools (algorithms and patient assessment protocols), and after-action reviews. Table 2 

describes each intervention and identifies challenges associated with implementation. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Table 2. Interventions for Safe Patient Handling With Emerging Evidence 

Proposed 

Intervention 

Description Challenges to Implementation 

Peer leader 

education 

Traditional education approaches (didactic classes 

in risk, body mechanics, and training in lifting 

techniques) have not been effective in sustaining 

changes over time. Newer approaches to education 

and training have emerged, demonstrating early 

success with a need to study these trends over 

time. One new model that shows promise is use of 

local peer leaders. A peer leader is a nurse 

designated on each unit (or shift) who receives 

special training to work on site with colleagues to 

make practice changes to improve safety. Their 

roles include ongoing hazard evaluation of the work 

environment, assure competency in use of patient 

handling equipment and devices, help sustain the 

unit-based ergonomic program over time.109, 126 In 

the United States, peer safety leaders have been 

called Back Injury Resource Nurses (BIRNs),109 and 

Ergo Rangers,84 while in the Netherlands they are 

called Ergo Coaches. 

 Selecting the “right” peer leader 

who is effective in coaching peers 

to change behaviors 

 Incentives for peer leaders 

 Support and timely response by 

management to issues raised by 

peer leader 

Clinical tools 

(algorithms and 

patient 

assessment 

tools) 

Unfortunately, nurses have become accustomed to 

using whatever limited lifting aids are available, if 

they are available, rather than carefully matching 

equipment to specific patient characteristics. 

Cognitive aids can assist clinicians to apply 

research to practice, thereby reducing unnecessary 

variation in practice. Use of patient assessment 

protocols and algorithms can provide a standardized 

way to assess patients and make appropriate 

decisions about how to safely perform high-risk 

tasks.108, 109, 112, 127–129

 Training all staff, across shifts 

 Training on units with high staff 

turnover 

 Need to reinforce training over time 

 Integrating these clinical tools into 

routine processes, e.g., patient 

admission 

 Timely and effective 

communication of the assessment 

and plan to all staff 

After-action 

reviews (AAR) 

After-action review is a way for nurses to learn not 

only from their own mistakes and near misses, but 

also from the mishaps experienced by their 

coworkers. It is not unusual for many nurses on a 

unit to identify a hazard and work around it, only to 

have another nurse fall prey to this risk in the 

environment. Immediately after an accident or near 

miss, staff will meet informally to evaluate what 

happened and how to prevent its reoccurrence on 

the unit. In AARs, staff should feel free to share 

knowledge without fear of embarrassment or 

recrimination. AAR is compatible with established 

mechanisms for dealing with errors and near misses 

such as incident reporting and root-cause 

analysis.130, 131

 Time constraints 

 Support and timely response by 

management to issues raised by 

peer leader 

 

Given the complexity of this high-risk, high-volume, high-cost problem, multifaceted 

programs are more likely to be effective than any single intervention, indicating the need to build 

a culture/climate of safety into the organization and employ more than one evidence-based 

approach. A culture of safety in terms of worker injury prevention is defined somewhat 

differently from patient safety culture, though there is some overlap between the terms. Safety 

culture is considered to be the product of multiple goal-directed actions to improve safety in an 

organization.132 Nonetheless, empirical data supporting the impact of culture alone on reducing 

worker injuries are limited.

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Personal Safety for Nurses 

Needlesticks 

Health care workers continue to be exposed to the serious and sometimes life-threatening risk 

of blood-borne infections in a wide variety of occupations and health care settings. An estimated 

600,000 to 800,000 needlestick injuries occur annually,133, 134 about half of which go 

unreported.133, 135 It is estimated that each year more than 1,000 health care workers will contract 

a serious infection, such as hepatitis B or C virus or HIV, from a needlestick injury. An estimated 

50 to 247 health care workers are infected with hepatitis C virus (HCV) each year from workrelated needlesticks.136 At an average hospital, workers incur approximately 30 needlestick 

injuries per 100 beds per year.133 Nursing staff incur most needlesticks—54 percent of reported 

needlestick and sharp object injuries involve nurses.137 

After a needlestick injury, the risk of developing occupationally acquired hepatitis B virus 

(HBV) infection for the nonimmune health care worker ranges from 6 percent to 30 percent, 

depending on the hepatitis B antigen status of the source patient. The risk of transmission from a 

positive source for hepatitis C is between 0.4 percent and 1.8 percent, and the average risk of 

transmission of HIV is 0.3 percent.138 Risk of transmission increases if one is injured by a device 

visibly contaminated with blood, if the device is used to puncture the vascular system, or if the 

stick causes a deep injury. Health care workers, laundry workers, and housekeeping workers are 

often engaged in duties that expose them to high-risk needlestick injuries. 

The number of occupationally acquired HIV infections is underestimated by the national case 

surveillance system. This is related to the Centers for Disease Control and Prevention’s (CDC’s) 

strict definition of a documented HIV seroconversion temporally associated with an occupational 

HIV exposure and the fact that these are voluntary reports. CDC U.S. surveillance data over 20 

years include 57 health care workers with documented occupationally acquired HIV infection.139

A total of 88 percent of these infections resulted from percutaneous injuries. Of these infections, 

41 percent occurred after the procedure, 35 percent during a procedure, and 20 percent during 

disposal.139 Recent State-based surveillance programs in California and Massachusetts will 

provide more complete estimates of the incidents, devices involved, and circumstances 

surrounding sharp exposures.140

Despite the promulgation of the original bloodborne pathogen (BBP) standard in 1991 by the 

Occupational Safety and Health Administration (OSHA), percutaneous injuries continue to occur 

in unacceptably high numbers in health care workers. The requirement under the BBP standard 

that HBV vaccine be made available free of charge to health care workers has greatly reduced 

the consequences of exposure to this pathogen. Advances in the treatment of HIV infection with 

prophylaxis has improved the prognosis for those health care workers infected with HIVcontaminated blood. Tragically, there is no vaccine or treatment for HCV, so nurses and other 

health care workers exposed to HCV-contaminated blood suffer from the potential of contracting 

a life-threatening illness. As such, it is imperative that all health care workers, not only those 

working in the acute care setting or those who traditionally handle needles on a regular basis, 

receive every available protection from occupational exposure to blood and body fluids. 

The passage of the Federal Needlestick Safety and Prevention Act in 2000 has begun to 

afford health care workers better protection from this unnecessary and deadly hazard. Not only 

does the act amend the 1991 BBP standard to require that safer needles be made available, it also 

requires employers to solicit the input of front-line health care workers when making safe needle 

purchasing decisions. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Use of conventional needles in health care today has been compared with the use of 

unguarded machinery decades ago in the industrial workplace. Safer needle devices have 

integrated safety features designed into the product to prevent needlestick injuries. The term 

“safer needle device” is broad and includes many different devices, from those with a protective 

shield over the needle to those that are completely needle-free. Safer devices are categorized 

from passive to active, with passive devices offering the greatest protection because the safety 

feature is automatically triggered after use, without the need for health care workers to take any 

additional steps. An example of a passive device is a spring-loaded retractable syringe or selfblunting blood collection device. An example of an active safety mechanism is a sheathing 

needle that requires the worker to manually engage the safety sheath, frequently using their 

second hand and potentially resulting in more injuries. 

A comparison of 1993 and 2001 percutaneous injury rates for nurses documented a 51 

percent reduction in needlestick injuries, supporting the use of new technology in reducing 

percutaneous injury risk.141 More recently, results from a number of intervention studies have 

found the use of safer needles systems reduced injury.142–146 A study of safety needles at a 

tertiary-care hospital in Manhattan found a statistically significant reduction in the mean annual 

incidence of percutaneous injuries from 34.08 to14.25 per 1,000 FTE pre- versus 

postintervention. The reductions were observed across occupations, activities, times of injury, 

and devices.146 Other factors related to working conditions also may need to be addressed to 

prevent and reduce needlesticks.31 

While there has been widespread conversion to safer phlebotomy needles and intravenous 

catheters, for other devices such as laboratory equipment and surgical instruments, relatively 

small numbers of safer devices are in use. 

Chemical Occupational Exposures 

There are thousands of chemicals and other toxic substances to which nurses are exposed in 

practice. Hazardous chemical exposures can occur in a variety of forms—including aerosols, 

gases, and skin contaminants—from medications used in practice. Exposures can occur on an 

acute basis, up to chronic long-term exposures, depending upon practice sites and compounds 

administered; primary exposure routes are pulmonary and dermal.147 Substances commonly used 

in the health care setting can cause asthma or trigger asthma attacks, according to a recent 

report.148 The report explores the scientific evidence linking 11 substances to asthma, including 

cleaners and disinfectants, sterilants, latex, pesticides, volatile organic compounds (including 

formaldehyde), and pharmaceuticals. An important criterion for the selection of the substances in 

the report was the presence of safer alternative products or processes. The evidence is derived 

from an array of peer-reviewed sources of scientific information, such as the National Academy 

of Science Institute of Medicine. In this section, we will discuss some of the hazardous 

substances currently in use and provide references to obtain evidence on others, as well as for 

identifying safer alternatives. 

Volatile organic compounds. Volatile organic compounds (VOCs) are chemicals that 

readily evaporate at room temperature, thus allowing the chemicals to be easily inhaled. 

Formaldehyde and artificial fragrances are two such sources that have a ubiquitous presence in 

hospitals. A study of occupational exposure to artificial fragrances found that health care workers 

had the highest rate of allergic sensitivity.149 The fragrances are typically contained in devices 

that either aerosolize the chemicals into rooms or evaporate the fragrances from a solid form, 

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Personal Safety for Nurses 

thus producing VOCs. Although the Food and Drug Administration is responsible for regulating 

fragrances and other chemicals in personal care products, the majority of these compounds have 

not been tested for potential toxic human health effects.150 Strong odors, fumes, and perfumes are 

also potent triggers of asthma.151 Formaldehyde, a known carcinogen,152 is used in pathology and 

lab settings and is contained in bedding, drapes, carpets, acoustic ceiling tiles, and fabricated 

furniture. Artificial fragrances are used to address unpleasant odors. Purchasing low- and noVOC products, which are readily available (e.g., no-VOC paint), is a key to addressing this 

problem. Also ensuring adequate indoor air circulation, which can decrease the concentration of 

VOCs in the air, effectively decreases the “dose” of the chemicals being inhaled. 

Sterilants. As an example, ethylene oxide (EtO) and glutaraldehyde are commonly used in 

medical settings for sterilization. Nurses and other medical staff are exposed while cleaning 

equipment and work surfaces. Although both of these chemicals are powerful and effective, they 

are associated with serious human health risks. Glutaraldehyde is associated with respiratory 

irritation including asthma, skin irritation and dermatitis, and eye irritation and conjunctivitis.153

In fact, in a review of health effects of glutaraldehyde exposure, almost all case reports of 

occupational asthma were of endoscopy nurses.154

The National Institute for Environmental Health Sciences152 produces a report on 

carcinogens that summarizes the latest scientific evidence on the cancer-causing properties of 

many chemicals, including EtO,155 formaldehyde, and others that are present in health care. In 

this report, EtO is also listed as a known human carcinogen. EtO has been associated with 

increased incidence of certain types of cancer in workers with long-term exposures.156

Additionally, EtO is an eye and skin irritant and also may damage the central nervous system, 

liver, and kidneys.157 

Medications. Many medications and compounds in use in personal care products have 

known toxic effects. These have been comprehensively reviewed with a detailed summary of the 

evidence of environmental and personal hazards associated with these compounds by Daughton 

and Ternes.149 Although many medications can be hazardous to workers, those most commonly 

identified as hazardous to health care workers include antineoplastics and anesthesia. Anesthetic 

gases have been identified as particularly problematic, as gases escape into the air and can be 

inhaled by workers. Methods of induction have been studied in terms of worker exposure,158 with 

findings indicating that such exposures (measured by urinary metabolites) frequently exceed 

National Institute for Occupational Safety and Health (NIOSH) recommended limits.159 Hasei 

and colleagues160 found that intravenous induction posed a far lower risk of exposure to health 

care workers. 

There are also data to support the deleterious effects of exposure to antineoplastic drugs, 

especially an increased risk of spontaneous abortions among health care workers.161

Cytotoxicity, genotoxicity, terotogenicity, and carcinogenicity are associated with such 

exposures.152 For the past few decades, awareness of the risk of antineoplastic agents has been 

available, including guidelines for handling them published by the Occupational Safety and 

Health Administration.162 Nursing functions of particular risk, according to NIOSH, include 

medication administration, handling contaminated linens, exposure to human wastes, handling 

drug containers, cleaning drug preparation areas, being involved with special procedures, and 

disposal of containers and other wastes.163 Other research indicates that antineoplastics and 

cytostatics have been found in locations beyond the confines of the designated handling areas 

such as air vents, desks, countertops, and floors.164, 165

11
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Pesticides. Pesticide use, both inside and outside of hospitals and health facilities, is 

another cause for concern. Because of the special vulnerabilities of children and pregnant women 

to pesticide exposures, control of pesticide use in health care settings is particularly important. In 

a survey conducted by Health Care Without Harm, all hospitals surveyed reported some regular 

applications of pesticides inside the hospital building, outside on the grounds, or both.166 This 

report, Healthy Hospitals: Controlling Pests Without Harmful Pesticides, offers guidance on 

reducing pesticides and implementing safer integrated pest management techniques. Integrated 

pest management is a comprehensive approach to pest management that employs nontoxic and 

least-toxic products and processes to control pests. Beyond Pesticides, a 25-year-old organization 

that has been working with Health Care Without Harm on pesticide issues in the United States, is 

currently orchestrating several hospital-based pilot programs in Maryland.167 They are working 

with hospital environmental services to implement an integrated pest management approach that 

will work for hospitals. These collaborations will result in a set of best practices for a range of 

facility types—small community hospitals, inner-city university health centers, and others. 

Latex exposure. Latex allergy due to exposure to natural proteins in rubber latex is also a 

serious problem in health care workers. Diepgen168 estimated that the annual incidence rate 

among all workers is 0.5 to 1.9 cases per 1,000 full-time workers per year. Symptoms may start 

with contact dermatitis located in the glove area, and symptoms can become more severe, such 

as asthma or anaphylaxis. The course of latex allergy as described by Amr and Bollinger169

involves progressive impairment of nurses from continued exposure to latex, leading to an 

inability to continue working as nurses. In fact, the hazard from aerosolizing of latex particles 

attached to powder in latex gloves or from latex balloons bursting is of great concern, as these 

exposures can lead to occupational asthma.170 The American Nurses Association has issued a 

position statement to suggest actions to protect patients and nurses from latex allergy in all health 

care settings. These include use of low-allergen powder-free gloves and removal of latexcontaining products from the worksite throughout the facility to reduce the exposure at that 

institution.171 Hospital environments that have gone latex-free need to ensure that they are not 

allowing balloons into the facility. As balloons break they can contribute latex into the air that 

remains for up to 5 hours.172 

Summary of Key Issues Regarding Harmful Exposures 

An awareness of the repercussions of exposure to chemicals and toxins has prompted action 

to reduce such exposures in health care settings. Promotion of the availability of safer 

alternatives has gained momentum as a means to reduce exposures. There are resources available 

to assist advocates and decisionmakers. The Green Guide for Health Care is an extensive toolkit 

providing recommendations for design, construction, renovation, operations, and management of 

sustainable (causing reduced occupational and environmental effects) and healthier buildings.173 

Also, a clearinghouse of nontoxic alternatives to various medical and health care products is 

available from the Sustainable Hospitals Project.174 Green Link, a recently inaugurated 

newsletter, promotes healthier buildings and sustainable hospitals for patients and health care 

workers.175 In addition, the American Hospital Association and the Environmental Protection 

Agency have partnered, forming Hospitals for a Healthy Environment, promoting purchasing of 

environmentally preferable products.176 The focus on reducing chemical exposures will be 

increasingly important over the next decade, especially as the benefits for patient and worker 

health continue to be recognized. 

12
Personal Safety for Nurses 

Mental Health Effects of Nursing Work 

Working in nursing increases the risk of experiencing both minor and major psychiatric 

morbidity177, 178 with job strain contributing to this outcome.179–183 Minor psychiatric morbidities 

include feelings of tension, anger, anxiety, depressed mood, mental fatigue, and sleep 

disturbance;184 these are classified variously as burnout, subthreshold depression, or adjustment 

disorders. Mental disorders such as major depression, anxiety disorders, and psychotic disorders 

are less common, but they can be induced or exacerbated by work stress.184 A variety of 

exposure types are associated with psychiatric morbidity. These fall into two categories: the 

overall allostatic load demanded by the work, and the organization of the work, including 

schedule and such job demands as the emotional toll when caring for patients. 

Allostatic load is a theoretical concept whereby excessive demands and a persistent 

sympathetic (adrenergic) load on the body produce changes in neuronal, immune, and 

cardiovascular system structure and function, thus having a detrimental impact on bodily 

processes.183, 185–188 Changes in neuronal function are associated with anxiety and depression.185

Several types of psychosocial risk factors can contribute to this overall allostatic burden. High 

physical demands, fast-paced work, adverse work schedules, role stressors, career insecurity, 

difficult interpersonal relationships, nonstimulating jobs, and lack of autonomy have been 

associated with symptoms of anxiety and depression, several psychoses, and with substance use 

disorders.183, 189, 190 Some studies have even provided longitudinal evidence linking job demands, 

lack of autonomy, and monotony at work to affective and substance use disorders.183, 191, 193

Mental disorders in the workplace—depression in particular—have important consequences for 

quality of life, the costs and utilization of health care, safety, and productivity.190, 194

Extended work schedules have been associated with a variety of mental health indicators in 

nursing and in other occupations where these schedules are common. Proctor and colleagues195

found that both the number of overtime hours and the number of cumulative days worked by 

automotive workers were associated with changes in mood States such as depression and tension. 

Hospital interns reported subjective deterioration in mood after long shifts.196 Japanese managers 

reported decreased quality of life (validated by comparison to a measure of psychiatric distress) 

when working more than 10 hours per day consistently.197 French customs workers used 

antidepressants at a higher rate when assigned to shift schedules with rapid rotation.198 Shift 

work has been associated with more mental stress199 and higher levels of burnout200 among 

health care workers. Depression and anxiety have also been shown to vary with the level of work 

pace, variety, control, social support, and conflicting demands made on workers.191, 201 Thus with 

both unfavorable work conditions and extended work hours, the effect on mental health may be 

multiplied. Fatigue is thought to be a central nervous system stressor.195 

Nursing is emotionally demanding, with both emotional labor and the need to witness and 

bear with suffering taking its toll. Emotional labor is necessary to display socially appropriate 

emotions that are congruent with the job requirements in face-to-face interactions with patients. 

The more frequent and intense the interpersonal interactions are with others (staff, visitors, 

patients), requiring the nurse to expend emotional effort, the more likely the nurse will 

experience symptoms of burnout, including depersonalization and emotional exhaustion.202, 203

Witnessing the suffering of others occurs in a variety of nursing care settings, but is common 

when end-of-life suffering is unrelieved.205 Intense feelings of emotional pain can result and, if 

unresolved, can affect both physical health and family life.204, 205 

13
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Interventions to reduce work-related mental changes have focused on either changing the 

organization of work to reduce the stressors, or changing the workers’ ability to cope with stress 

by providing cognitive-behavioral interventions, relaxation techniques of various types, or 

multimodal strategies.184, 206 Although several nationwide initiatives on the prevention of mental 

disorders have emphasized the importance of addressing work organization factors,190, 194 only a 

small number of studies have evaluated this approach, and results have not shown an overall 

strong relationship.185 In nursing, Mimura and Griffiths206 conducted a systematic review of 

interventions for nurses to reduce their work stress. Two of the reviewed studies used 

organizational interventions (changing to individualized nursing care and primary nursing), and 

only one of the two was deemed “potentially effective.” Seven studies of strategies to help nurses 

manage their stress were presented; music, relaxation, exercise, humor, role-playing 

assertiveness, social support education, and cognitive techniques were among the stress-reducing 

strategies studied. The authors stated that no recommendations on the most effective approach 

were possible due to the small number of studies. In a larger meta-analysis of both nurses and 

other workers,183 a moderate effect for cognitive-behavioral interventions and multimodal 

interventions was found, along with a small but significant overall effect for relaxation 

techniques. Organizational interventions were not significant; however, the authors posit that 

combining individual-level skills (e.g., cognitive-behavioral) with organizational changes may be 

a fruitful area for future research. 

Violence 

From 1993 to1999, 1.7 million incidents of workplace violence occurred annually in the 

United States, with 12 percent of all victims reporting physical injuries.207 Six percent of the 

workplace crimes resulted in injury that required medical treatment. Yet, only about half (46 

percent) of all incidents were reported to the police. The health care sector leads all other 

industries, with 45 percent of all nonfatal assaults against workers resulting in lost workdays in 

the United States, according to the U.S. Bureau of Labor Statistics (BLS).208 The BLS rate of 

nonfatal assaults to workers in “nursing and personal care facilities” was 31.1 per 10,000, vs. 

only 2.8 per 10,000 in the private sector as a whole.208 In two Washington State psychiatric 

forensic facilities, 73 percent of staff surveyed had reported at least a minor injury related to an 

assault by a patient during the previous year; only 43 percent of those reporting moderate, 

severe, or disabling injuries related to such assaults had filed for WC. In these two facilities, the 

survey found an assault incidence rate of 415 per 100 employees per year, compared to hospital 

incident report rates of only 35 per 100.219 

Environmental and organizational factors have been associated with patient and family 

assaults on health care workers, including understaffing (especially during times of increased 

activity such as meal times), poor workplace security, unrestricted movement by the public 

around the facility, and transporting patients. The presence of security personnel reduces the rate 

of assaults, while increased risk is associated with the perception that administrators consider 

assaults to be part of the job, receiving assault prevention training, a high patient/personnel ratio, 

working primarily with mental health patients, and working with patients who have long hospital 

stays. 

Emergency department personnel also face a significant risk of injuries from assaults by 

patients or their families. Those carrying weapons in emergency departments create the 

opportunity for severe or fatal injuries. California and Washington State have enacted standards 

14
Personal Safety for Nurses 

requiring safeguards for emergency department workers. Although mental health and emergency 

departments have been the focus of attention and research on the subject, no department within a 

health care setting is immune from workplace violence. Consequently, violence prevention 

programs would be useful for all departments. 

The first report to the Nation on workplace violence underscores the lack of systematic 

national data collection on workplace assaults, the paucity of data evaluating violence prevention 

strategies, and the methodological flaws in published intervention research to date.210 As 

background to this report, Runyan and colleagues211 reviewed the violence prevention 

intervention literature and found five studies that evaluated violence prevention training 

interventions,212–216 two that examined postincident psychological debriefing programs,217, 218

and two that evaluated administrative controls to prevent violence.220-221 Findings from the 

studies were mixed, with six reporting a positive impact and three reporting no or a negative 

impact. All were quasi-experimental and without a formal control group. Runyan and colleagues 

criticized the design of published violence prevention interventions to date because of their lack 

of systematic rigor in the evaluation. She calls for greater reliance on conceptual and theoretical 

models to guide research as well as stronger evaluation designs. She further suggests that studies 

must evaluate “process, impact and outcome measures.”211 

Since Runyan’s review paper, Arnetz and Arnetz219 reported on a randomized controlled trial 

of 47 health care workplaces examining a violence prevention intervention involving 

“continuous registration” of violent events for 1 year with “structured feedback” from 

supervisors. This study found that the intervention hospitals reported significantly more violence 

incidents than the control hospitals. The authors attributed this finding to increased awareness of 

the violence and improved supervisory support at the intervention facilities. 

There is no Federal standard that requires workplace violence protections. California and 

Washington State both have legislation addressing workplace violence in health care settings. In 

1996, OSHA published Guidelines for Preventing Workplace Violence for Health Care and 

Social Service Workers.

222 The 1996 Federal guidelines provide a framework for addressing the 

problem of workplace violence and include the basic elements of any proactive health and safety 

program: management commitment and employee involvement, worksite analysis, hazard 

prevention and control, and training and education. The OSHA guidelines provide an outline for 

developing a violence prevention program, but since they are “performance based,” the challenge 

of developing a specific process for implementing the guidelines in a manner that will yield 

results is left to the employer. 

Between 2000 and 2004, Lipscomb and colleagues223 conducted an intervention effectiveness 

study to describe a comprehensive process for implementing the OSHA Violence Prevention 

Guidelines and evaluate its impact in the mental health setting. Program impact was evaluated by 

a combination of quantitative and qualitative assessments. A comparison of pre- and 

postintervention survey data indicated an improvement in staff perception of the quality of the 

facility’s violence prevention program as defined by the OSHA elements in both intervention 

and comparison facilities over the course of the project. Results of the comparison of the change 

in staff-reported physical assaults were equivocal. 

Many psychiatric settings now require that all patient care providers receive annual training 

in the management of aggressive patients, but few studies have examined the effectiveness of 

such training. Those investigators that have done so have generally found improvement in 

nurses’ knowledge, confidence, and safety after taking an aggressive behavior management 

program. However, implementation of comprehensive violence prevention programs that go 

15
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

beyond staff training will improve safety of the health care workplace for all workers. These 

advanced programs include the use of currently available engineering and administrative controls 

such as security alarm systems, adequate staffing, and training. 

Research Implications 

Challenges in Measuring Nursing Working Conditions and Nurse 

Safety Outcomes 

While there is increasing evidence linking nursing work environments to nurse health, much 

more effort has focused on understanding how work influences satisfaction and performance. 

Improving data and measures will allow better comparisons across studies and build evidence of 

which relationships are most important. Varied approaches are used to compile data about the 

nursing work environment. Measures of work characteristics have varied considerably and are 

most often related to the particular discipline and study objectives. In occupational health, the 

traditional assessments of exposure have expanded from obvious physical and chemical 

exposures to include psychosocial demands, physical demands, and leadership quality.224 These 

measures are used in individual studies or translated to a job exposure matrix where estimated 

levels of exposure to an agent or stressor are assigned to an occupation or group of 

occupations.225, 226 These approaches are more fully developed and utilized in Scandinavia and 

Europe, although the O*NET database describes job requirements, worker attributes, and the 

context of work (www.onetcenter.org). 

A self-administered paper-and-pencil or electronic questionnaire is probably the most 

common approach to gathering information from nurses. The advantages over observation or 

interviews are obvious: they are generally less costly, can be administered over a broader 

population, are more uniform and standardized, and confidentiality and anonymity can be more 

efficiently assured. Yet, these same advantages can also be disadvantages: nurses have varying 

motivations to respond, leading to response bias; questionnaires are often developed by 

researchers based on particular study goals, limiting comparison across studies; and there is no 

opportunity to clarify questions or solicit rich detail. The level of the data may also be unclear. 

Some items may explicitly reflect the work group or organization, while others may reflect both. 

Clarity is needed about how many respondents is optimum to represent a particular level of 

analysis. Where multiple nurses’ perceptions are solicited, all responses may be used to form an 

index or an average score. 

Nurse Health Outcomes 

Worker outcome data may be solicited from an individual through self-report interviews or 

questionnaires. These data are subject to the same limitations noted above, although nurse 

reports are more likely to yield detailed information about potential factors contributing to their 

health. Measuring nurse health outcomes also is challenging. No matter how data are collected, 

there can be some measurement error in assessing adverse health outcomes—and attributing 

them to the work environment. Many of these issues have been discussed in the sections on 

adverse health outcomes. For example, musculoskeletal injuries become chronic conditions and 

may not be attributed to the work. Likewise, mental health and substance abuse may be 

considered in isolation from the individual’s work experience. 

16
Personal Safety for Nurses 

Another source that is rarely used is administrative data (e.g., incident reports, OSHA logs, 

WC data).227 The Occupational Safety and Health Act (1970) requires employers to maintain 

records of serious workplace injuries and illnesses (29 USC section 657 c[2]). Unfortunately, 

these statistics may not reflect minor injuries requiring only first aid or injuries that can be 

episodic and remitting, such as back injuries, majors concerns for nurses. Data sources include 

logs maintained at the organizational level (OSHA Form 300), first reports of injury (FROI) 

documenting details of the injury (OSHA Form 301), and WC claims, when filed. The FROI 

may be used as the baseline data for entry into a WC system, although the two reports may be 

distinct. The FROIs serve as a more complete source of potentially claimable injuries to health 

care workers than WC data228 as they represent all reported injuries, even those that do not lead 

to lost work time or a medical claim. Relying on WC claims data without using FROI data may 

introduce systematic selection biases because studies have shown that WC claims are more likely 

to be filed by workers who are unionized, working for a company too small to be self-insured, or 

who are more severely injured.229 FROI data have been used to study injury in a population of 

home health workers230 and to find that staffing was related to injuries in nursing home staff.57

Yet FROI data are often unavailable to researchers or may contain injuries of limited severity. 

Somewhat distinct from the OSHA reporting requirements, employers are required to comply 

with State WC regulations. WC is concerned with compensating injured or ill workers, while the 

OSHA Occupational Injury and Illness Recording and Reporting Requirements Act is designed 

to develop a database that can improve understanding of injury and illness, with the intent to 

prevent them. Thus, certain injuries and illnesses may be reportable under both systems, while 

others will be reportable under State WC law or under the OSHA recordkeeping rule. State WC 

benefit requirements also vary, with some States not requiring lost time, but requiring that the 

employee sought medical care. Other States require a certain number of days of lost time before 

filing a FROI. Unfortunately, ascertainment of nursing health outcomes varies across these data. 

Even when analyzing WC claims or FROI data with presumably broader inclusion, some injuries 

will be missed. For example, injured workers may seek care from their regular health provider 

and fail to mention the work-relatedness of the injury. In a cross-sectional study of unionized 

autoworkers diagnosed with work-related MSDs, only 25 percent filed WC claims.231 In a 

population-based telephone survey, only 10.6 percent of workers reporting work-related MSDs 

had filed a WC claim.232 

The need for standardization in data collection and measuring both work environment and 

worker outcomes is not new. As noted by NIOSH,233 insufficient job data to link work factors to 

health outcomes is a barrier to research. An international conference on linked employeremployee data was held in 1998 to address issues of confidentiality, levels of analysis, and the 

need for coordination across Federal and State agencies.234 The work in Europe and Scandinavia 

builds upon international work and could become a model across many countries. Unfortunately, 

data policy changes at the Federal and local levels are often slow to occur, as modifications to 

existing systems require long and arduous lobbying, legislation, and procedure and policy 

development before implementation. Moreover, the WC regulations are primarily State driven, 

and this is unlikely to change. 

Researchers are encouraged to use established instruments and items, with established 

reliability and validity. If they are developing their own instruments, psychometric testing is 

essential. Findings benchmarked with other similar populations are useful to determine variation 

and explore sources of measurement error. When assessing work environments, the level of 

17
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

analysis for the measure must be explicit (e.g., work group, organization, or system). Analytical 

strategies should be used to account for the multilevel nature of the data. 

Administrative data for worker injuries can be very useful. Many health care organizations 

are implementing programs that are likely to affect both patient and worker safety, yet it may be 

difficult to efficiently evaluate the effectiveness of these programs. Ohio, for example, has used 

the claims data to support issuance and evaluation of safety grants used in lifting and other 

mechanical equipment purchases to reduce employee injuries.235

Conclusion 

In this chapter, we have focused on the major injury and safety issues for working nurses. 

Some of these issues have been thoroughly researched, with extensive evidence-based findings 

available for epidemiology and prevention, whereas others remain to be studied and explained. 

As indicated, there is great potential for preventing nurse injury, even though many risk factors 

have yet to be addressed. The benefits of improvements to nurse safety are great, both for 

retaining nurses and attracting new nurses into the profession. For example, work hours that are 

excessive adversely affect nurses’ health and thus can in turn adversely impact patient care. As 

many facilities are making important financial investments and system-level improvements to 

promote patient safety, it is important to leverage these efforts to improve worker safety as well. 

In the long run, these improvements will also benefit patients, as measures that are taken to 

improve safety for nurses should lead to a healthier and more effective workforce.

Search Strategy 

Relevant papers for this review were identified from Pubmed,® CINHAL,® as well as from 

cited literature, and from NIOSH publications up through 2007. Searches were also performed 

examining journals such as the American Journal of Industrial Medicine, American Journal of 

Public Health, and Scandinavian Journal of Work and Environmental Health. As our chapter 

encompassed multiple outcomes, search terms varied depending on the category, and included 

but were not limited to, e.g., occupational health, organization of work, shiftwork, back injuries, 

musculoskeletal disorders, chemical exposures, mental health, work stress, and workplace 

violence. 

18
Personal Safety for Nurses 

Author Affiliations*

Alison M. Trinkoff, Sc.D., R.N., F.A.A.N., professor, Work and Health Research Center, 

University of Maryland School of Nursing. E-mail: Trinkoff@son.umaryland.edu. 

Jeanne M. Geiger-Brown, Ph.D., R.N., assistant professor, Work and Health Research 

Center, University of Maryland School of Nursing. E-mail: jgeiger@son.umaryland.edu. 

Claire C. Caruso, Ph.D., R.N., research health scientist, U.S. Department of Health and 

Human Services, Public Health Service, Centers for Disease Control and Prevention, National 

Institute for Occupational Safety and Health, Division of Applied Research and Technology. Email: Zhl1@cdc.gov. 

Jane A. Lipscomb, Ph.D., R.N., F.A.A.N., professor and director, Work and Health Research 

Center, University of Maryland School of Nursing. E-mail: lipscomb@son.umaryland.edu. 

Meg Johantgen, Ph.D., R.N., associate professor, Work and Health Research Center, 

University of Maryland School of Nursing. E-mail: johantgen@son.umaryland.edu. 

Audrey L. Nelson, Ph.D., R.N., F.A.A.N., director, Patient Safety Center of Inquiry, James 

A. Haley VAMC, Tampa, FL. E-mail: Audrey.Nelson@va.gov. 

Barbara A. Sattler, R.N., Dr.P.H., F.A.A.N., professor, Environmental Health Education 

Center, University of Maryland School of Nursing. E-mail: Bsattler@son.umaryland.edu. 

Victoria L. Selby, R.N., B.S.N., research assistant, Work and Health Research Center, 

University of Maryland School of Nursing. E-mail: vselb001@umaryland.edu. 

 

*

 Disclaimer: The findings and conclusions in this chapter are those of the authors and do not necessarily represent 

the views of the National Institute for Occupational Safety and Health. 

19
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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30

Evidence Table. Personal Safety for NursesAuthor, year Safety issue Design type Outcome 

measure 

Setting population 

Intervention Findings reported b

Shift work and long work hoursCaldwell 200536 Shift work, long 

work hours 

Review Fatigue Medications Provides a short over

temazepam, zolpidemalertness-enhancing caffeine, modafinil, or compounds as well abefore choosing one fatigue. 

Caruso 200428 Long work hours Review Health 

disorders, safety, health behaviors 

In 16 of 22 studies, ovwith poorer perceived injury rates, more illnemortality. One meta-asuggested a possible preterm birth. Overtimunhealthy weight gain alcohol use in two of smoking in one of two neuropsychological testudy. 

Costa 200326 Shift work Review Health disorders Organization of shift s

ergonomic criteria ansurveillance are requadverse effects and ecope satisfactorily. Copsycho-physiological, factors that can influemaladaptation. 

Folkard 200513 Shift work, long 

shifts 

Review Safety Three main trends in 

is higher on the night extent the afternoon sshift; (ii) risk increaseespecially so if they aincreases with increahours. 
31

Author, year Safety issue Design type Outcome 

measure 

Setting population 

Intervention Findings reported b

Knauth 200334 Shift work Review Health, safety Prevention, 

compensatory measures 

Discusses measures optimize the well-beinidentify ill-health at an shift systems, taking aviews and circumstanstrategies to combat selsewhere. 

Knutsson 200318 Shift work Review Health disorders The strongest eviden

association of shift wodisease, coronary heacompromised pregna

Megdal 200524 Night work Metaanalysis Breast cancer 13 studies Studies on night shift 

risk collectively show breast cancer risk amestimate 1.48, 95% C

Revell 200535 Shift work, long 

work hours 

Review Circadian 

adaptation 

Light treatment Reviews studies in w

melatonin were admincounteract jet lag or tadaptation to night wolag could be preventeshifted before the fligand discusses the cothat they now recommworkers. 

MSD epidemiology Ariens 200244 Work-related neck 

musculoskeletal problems 

Longitudinal cohort study 

Frequency of sickness absence due to neck pain x3 days or more 

758 workers Found “work-related n

low decision authorityover work activities” aContent Questionnairfactors for absence fr
32

Author, year Safety issue Design type Outcome measure Setting population Intervention Findings reported bFredriksson 2002236 Work environment Population- based case control study Persons seeking health care for neck or shoulder pain 17,000 men and women ages 20–59, living in Norrtalje district, central Sweden There were associatio

and the physical and work environment. In perceived high worklofrequent hand or fingebending and twisting associated with seekishoulder pain,” whereexposure to vibrating women, high perceive(risk of injury, risk to wwork) combined to inccare. Maul 2003237 Course of work- related low-back pain over up to 8 years of followup Longitudinal study Low-back pain occurring in the past 12 months. 1–7 days = mild 8+ days = mod/severe pain Nurses working at a university hospital in Switzerland The prevalence of lowover the 8-year periodabout half reported thback pain at followupremaining experiencinand rest fewer days w

Bernard 199748 Work activities related to musculoskeletal problems An extensive review of over 600 epidemiologic studies Neck, shoulder, upper extremity (wrist, arm, hand) and back MSDs Variety of occupations Summarized evidenc

MSD. Findings includfor awkward and statiback MSD and postuTendinitis, hand, elborelated to repetition, fcombined. There is erelationship between neck and neck/shouldexertion and repetitioMSD. 
33

Author, year Safety issue Design type Outcome 

measure 

Setting population 

Intervention Findings reported b

Punnett and Wegman 2004 238

Work-related MSDs 

Review of studies with 94 article citations 

MSDs Variety of 

occupations 

Despite numerous stubetween MSD and octo be debate. From a epidemiologic literatuthe Institute of Mediciinternationally, concludata to support the imdemands on MSD. Rsufficient evidentiary motion, forceful exertand vibration. Nursing “high-risk sectors” for 4 times higher than th

Rogers 2005239 Work-related 

injuries 

Literature review Best practices Focus groups with hospital nurses Observation of hospital ergonomic hazards 

Nurse MSD Hospital 

nurses in North Carolina 

Evidence on MSD epsummarized, along waddressing many ergto nurse MSD. Preventive interventiorecommendations pro

Trinkoff 200630 Work schedule 

including work hours, mandatory overtime and oncall 

Three-wave longitudinal study 

Reported neck, shoulder, and back MSD cases Nordic questionnaire 

2,617 registered nurses working in nursing in the past year 

Hours/days per week to increased MSD; wodays off/vacation daycall, with <10 hrs betwrelated to increased Mto exposure to physic

Needlesticks and sharpsDement 2004240 Sharps exposure Surveillance Blood and body 

fluids 

24,000 health care workers employed in a universitybased tertiary care hospital 

2,730 BBF exposures resulting in an overall events/100 FTEs and percutaneous exposuwere observed for hoanesthetists, inpatienand surgical/operating of percutaneous expowere found to decreahowever, exposure raappear to be increasi
34

Author, year Safety issue Design type Outcome measure Setting population Intervention Findings reported bSohn 2004145, 146 Sharps exposure Research report Percutaneous injuries New York City tertiary care hospital Safer needle system composed of various safety- engineered devices A statistically significa

annual number of per34.08 to 14.25 per 1,0postintervention. Trinkoff 200731 Needlestick injuries and consequences, sharps exposure by positions specialty and work setting, work schedule Three-wave longitudinal study Reported prevalent (past year) and incident needlesticks (measured longitudinally) 2,273 registered nurses working in nursing in the past year Specialties with higheneedlesticks: emergecath lab/diagnostics (

increased hours/day, nonday shifts significaneedlesticks. Vaughn 2004241 Sharps exposure Research report Adherence to safe needle precautions Non-Federal general hospitals in Iowa Survey of infection co

health care workers fopredictors of consisteinfection control hoursfrequency of standard (OR = 1.11), providinequipment (OR = 1.8systems (OR = 1.42), for safety (OR = 1.05

Mental health Van der Klink 2001184 Stress-related psychological problems; 

intervention studies 

Outcomes 

include quality of worklife, psychologic resources, physiologic responses, complaints, absenteeism 

48 experimental studies 

Cognitivebehavioral interventions, multimodal interventions, relaxation techniques, organizationfocused interventions 

Moderate effect for comultimodal interventioSmall effect for relaxaNo significant effect fointervention. 
35

Author, year Safety issue Design type Outcome 

measure 

Setting population 

Intervention Findings reported b

ViolenceDuhart 2001207 Violence Survey report Workplace 

violent crime 

National survey 

Department of JusticeVictimization Survey, assessing the incidenworkplace violence, rincidents per year. Raoccupation, demograthe relationship of vic

Gerberich 2004242

Violence in health care 

Nested casecontrol study Assault MN RNs Incidence of physical 

persons per year. Amcontrol subjects, odds increased in nursing hfacilities (2.6; 95% co1.9–3.6), emergency = 1.3–12.8), and psyc95% CI = 1.1–3.7); in as daylight" (2.2; 95% each additional hour oCI = 0.99–1.11). Riskcarrying cellular telep(0.3; 95% CI = 0.2–0.

Runyan, 2000 211

Violence Review Workplace 

assault 

Literature search and violence intervention articles including the only 9 studies involvininterventions. Results were equivocal. Resemethods studying inteworkplace violence a

Chemical exposuresBuckley 2002149 Fragrance 

exposures 

Physiological assessment 

Allergic reactions 

Multiple occupations 

Health care workers hof allergic sensitivity t

Daughton 1999150 Exposure to pharmaceuticals 

and personal care products 

Review Adverse effects Review of toxic pharm

care products in the evarious drugs, disinfescreen, nutritional sup
36

Author, year Safety issue Design type Outcome measure Setting population Intervention Findings reported bDranitsaris 2005161 Cytotoxic drug exposure Meta- analysis Adverse health effects Spontaneous abortion, congenital malformations, stillbirths Health care workers Risk of spontaneous 

handling cytotoxic dru

Sattler 2007243 Hospital environment Literature review Adverse health effects, compromise of the environment Patients, health care workers, and the community Review of products u

and their adverse heaalternative product se

Takigawa 2006154 Exposure to glutaraldehyde Review Adverse health effects Multiple occupations Review of toxicity of g

workplace exposure. asthma and skin reacmany findings from ex