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An occupational health and safety interactive systems model explicating accident/injury causation
Jan Pincombe University of Wollongong
Pincombe, Jan, An occupational health and safety interactive systems model expli- cating accident/injury causation, Doctor of Philosophy thesis, Department of Nursing, University of Wollongong, 1990. http://ro.uow.edu.au/theses/1612
This paper is posted at Research Online.
AN OCCUPATIONAL HEALTH AND SAFETY JNTERACTIVE
SYSTEMS MODEL EXPLICATING ACCIDENT/INJURY
CAUSATION
A thesis submitted in fulfdment of the requirements
for the award of the degree of
DOCTOR OF PHILOSOPHY
from
THE UNIVERSITY OF WOLLONGONG
by
Jan Pincombe RN, RM, RIN, BA (University of Western Australia),
Post Grad Dip. (UWA), M. Appl. Sci. (WAIT).
DEPARTMENT OF NURSING
1990 I certify that the work contained in this thesis has not been submitted for a degree to any other university or institution. The thesis contains my work entirely.
Signed 1
ACKNOWLEDGEMENTS
My grateful thanks to Professor David Griffiths, Professor of Statistics, (Head of
School), The University of Wollongong for his guidance and statistical advice to enable the completion of this thesis. I am deeply apprecitative of his understanding of the topic and his willingness to impart his knowledge and support. I am very grateful for his consistently positive and supportive approach which has allowed me to complete this thesis.
My deep appreciation and acknowledgement to Professor Wai-On Phoon, Professor of
Occupational Health, The University of Sydney and Director of Worksafe. Professor
Phoon has provided meticulous criticism for the theoretical underpinnings of the study and the literature review for which I am deeply grateful. He has also understood the value of the study and has provided me with an appreciation of scholarship. I particularly thank him for his sympathetic view and his understanding for the difficulties nurse academics encounter in a sometimes hostile environment.
I acknowledge the contribution of the registered nurses from the nursing staff of the hospitals involved in the study. I thank the nursing students for their co-operation and willingness to participate. I gratefully acknowledge the help and support of the lUawarra
Area Health Service for their permission to carry out the study and their cooperation in accessing the injured nurses in this study. The latter I could not have achieved without their help and my thanks go to Ms. Sue Chapman and staff in the personnel department.
Thankyou to my colleagues within the University for their help and encouragement through a particularly difficult period of my life. I would like to express my thanks to
Dr. John Patterson, Alison Elliott, Neil Hall and Dr. Peter Milbum. My grateful thanks to Dr. Arthur Smith for providing constructive criticism and, enabling me to make changes to strengthen the arguments contained in this work. u
My thanks are extended to Professor Sandra Speedy, The Nursing Department, The
University of Wollongong and Doctor Graham Speedy for their faith and support and to my friends Kerry Duggan, Mary Martin and Margaret Wallace. Appreciation goes to my nursing colleagues, in particular Professor Allan Pearson, Professor of Nursing,
Deakin University, Sister Pamela Joyce and Lesley Wilkes, The Catholic College and
Professor Betty Anderson, The Western Sydney University, for their warmth and encouragement.
I would like to acknowledge the help and advice of Dr. Ken Russell, consultant statistician to the Mathematics Department, The University of Wollongong for his reading of the thesis, particularly the methodology and results chapters. I am grateful for his wry sense of humour as well as his statistical knowledge.
I am indebted to my husband, Adrian for helping me to survive. My deepest thanks to my two children, Brandon and Shauna. m
ABSTRACT
This study is concerned with the development of an occupational health and safety model, which provides an explanation for accident/injury causation in nurses. A multiple causation theoretical approach was adopted. The model shows that there are four input determinants, (namely, educational, environmental, management and social) that contribute towards accident/injury causation. Three main processes also contribute, specifically client/patient cenh-ed, organisational and nurse centred processes.
The model was developed using both qualitative and quantitative methods. The first stage of the study consisted of collecting data from nurses using an open-ended interview (technique). Content analysis was applied to the resultant responses from which a data gathering instrument was developed. A pilot study was conducted to enunciate specific hypotheses, test the content validity of the instrument and to develop a nursing model.
The main research instrument, designated as The Occupational Health and Safety
Nursing Instrument (OH&SNI) was administered to registered nurses from four hospitals and three groups of nursing students from one tertiary institution. Two hundred and sixty seven registered nurses from a defined area health service, and from hospitals associated with the clinical teaching of the tertiary nursing programme were involved in the study. One hundred and eighty-four nursing students participated in the study.
One general research question and seven hypotheses were postulated to investigate the applicability of inputs and processes articulated in the model. Chi-square results revealed attitudinal trends for the four groups of registered nurses and three groups of nursing students in the study. Registered nurses' and nursing students' responses were reduced to a two by two contingency table to check differences in acceptance ("strongly agree/agree") and rejection ("disagree/sQ-ongly disagree") levels. The factors in the IV. model were supported when each question from the respondents was tested on an acceptance or rejection level (tested in each case by the chi-squared goodness of fit statistic). Case history data collected from a small number of injured nurses also gave further support to the model.
The model showed inputs and processes interacted to explain accident/injury causation and demonstrated support for a multiple causation theory explanation. The model showed that certain preventive measures can be effected to help prevent accident/injury causation. CONTENTS
Pa CHAPTER ONE: INTRODUCTION
1.1 Introduction 1
1.2 Background 1
1.3 Statement of the Problem 4-6
1.4 Purpose of the Study 6
1.5 Theoretical Framework 7-10
1.5.1 SituationModelsof Accident Causation 10-16 1.5.2 Multicausality Theory 16-18 1.5.3 Summary 18 1.5.4 Nursing Models 19-26 1.5.5 Summary 27 1.6 General Aims and Directions for the Development of an Occupational Health and Safety Model
1.6.1 Introduction 28 1.6.2 Grounded Theory Approach 28 1.6.3 Main Study 29 1.6.4 General Research Statement 30
1.7 Definition of Terms 30
1.8 Outhne of the Thesis 30
CHAPTER TWO: LITERATURE REVIEW
2.1 Introduction 31
2.2 Historical Perspectives 32
2.3 The Williams'Report 34-37
2.4 Changes to Occupational Health and Safety Laws 37-39
2.5 The Workers' Compensation Act, 1987 39
2.5.1 The Woodhouse Committee 39 2.5.2 The New South Wales Law Reform Commission 40 2.5.3 The Workers' Compensation Act, 1987 40-42 2.5.4 Compensation Studies and Accident Statistics 42-48
2.6 Back Injury Studies 48-49 2.6.1 International Back Injury Studies 49-62 2.6.2 Austi-alian Studies 62-67 2.6.3 Maximum Loads in Industry 67-70 2.6.4 Methodologies used to Investigate Low Back Pain 70-77 2.6.5 Summary 77-78 Vl
2.7 Nosocomial Infections 78
2.7.1 Needleprick Injury 78 2.7.2 Hepatitis B Needleprick Injuries 79-88 2.7.3 Needleprick Injuries and Acquired Immunodeficiency Syndrome (AIDS) Studies 88-98 2.7.4 Summary 98 2.7.5 Legionnaires' Disease as an Occupational Risk 99-102 2.7.6 Summary 102 2.8 Assault as an Occupational Risk Factor 102-107 2.8.1 Summary 107
2.9 Anaesthetic Gases as an Occupational Risk Factor 108-115 2.9.1 Summary 115
2.10 Dermatitis as an Occupational Health Risk 115-116 2.10.1 Summary 116
2.11 The Risk of Ionising Radiation to Nurses 117 2.11.1 Summary 118
2.12 Repetitive Strain Injury (RSI) 118-119 2.12.1 Summary 119
2.13 Overview 119-120
2.14 Recommendations for Research Investigations 120-121
CHAPTER THREE: PILOT STUDY
3.1 Introduction 122
3.2 Development of the Pilot Suidy 122
3.2.1 Development of die Instrument 123-124
3.2.2 Pilot of die Instrument in the Chnical Area 124-125
3.3 Results fi-om die pilot Study 125
3.3.1 Demographic Data: Registered Nurses 125-127 3.3.2 Demographic Data: Nursing Students 127 3.3.3 Descriptive Data: Registered Nurses 127-129 3.3.4 Descriptive Data: Nursing Students 129-131 3.3.5 Accident and Injury Descriptive Information 131 -134 3.3.6 Attitudinal and Open-Ended Responses 135-139 3.3.7 Summary 139-140 3.3.8 Recommendations 140-141 CHAPTER FOUR: METHODOLOGY:MAIN STUDY
4.1 Introduction 142
4.2 Research Design 142-148
4.3 Selection of Subjects 143
4.3.1 Subjects 143 4.3.2 Registered Nurse Population 143-149 4.3.3 Nursing Smdent Population 149-152 vu
4.4 Research Instrument 153-154
4.5 Data Collection and Recording 155 4.5.1 Method: Registered Nurses 155 4.5.2 Method: Nursing Students 155 4.5.3 Method of Scoring 156 4.5.4 Training Sessions 156 4.5.5 Content Validity of Occupational Health & Safety Nursing Instrument 156 4.5.6 Reliability Estimates 157
4.6 Statistical Analyses 157
4.7 Statistical Significance Level and Limitations 159
4.7.1 Significance Level 159 4.7.2 Power of the Test 159 4.7.3 Restrictions on the use of the Chi-square Statistic 160 4.7.4 Sampling Problems and Non-Responders 162-165 4.7.5 Limitations 165
4.8 The General Research Question and Hypotheses 165-166
CHAPTER nVE:RESULTS
5.1 Introduction 167
5.2 Analysis of Participants'Responses 167-173 5.3 The Need for Educational Inputs to Avoid Accidents/Injuries 173-183 5.3.1 Summary 183-185 5.4 Hypothesis Testing the Influence of Environmental Inputs and their Conttibution Towards Accident/injury Causation 185-191 5.4.1 Summary 191-192
5.5 Hypothesis Testing the Influence of Management Inputs and their Contribution Towards Accident/Injury Causation 192-202 5.5.1 Summary 202-204
5.6 Hypothesis Testing the Influence of Nurses' Social Expectations and Performance and their Conttibution Towards Accident/Injury Causation 204-212 5.6.1 Summary 212-213
5.7 Hypothesis Testing Nurses' Attitudes Towards the Type of Organisational Processes Contributing Towards Accident/Injury Causation 213-216 5.7.1 Summary 216
5.8 Hypodiesis Testing Nurses' Attitudes Towards Physical Injury, Verbal and Physical Abuse and Infectious diseases as Client/Patient Centred Processes Contributing Towards Accident/Injury Causation 217-226 5.8.1 Summary 226-227
5.9 Hypothesis Testing Nurses' Attitudes Towards the Type of Nurse Cend-ed Processes Contributing Towards Accident/Injury Causation 227-249 5.9.1 Summary 249-251
5.10 The Reliabihty Results for the Occupational Health and Safety Nursing Instt^ument 251-252 vm 5.11 Content Validity of the Occupational Health and Safety Nursmg Insttument 252-253
CHAPTER SIX: DISCUSSION
6.1 Intt-oduction 254 6.2 Elucidation of a Nursing Model 254-256
6.2.1 Inputs 256 6.2.l.i Educational Inputs 256 6.2.Lii Environmental Inputs 256 6.2.l.iii Management Inputs 257 6.2.l.iv Social Inputs 257 6.2.l.v Inputs Summary 258 6.2.2 Processes 259 6.2.2.i Client/Patient processes 259 6.2.2.ii Nurse-Centred Processes 260 6.2.2.iii Organisational Processes 260 6.2.2.iy Processes Summary 261
6.2.3 Outputs 261 6.2.4 Summary of the Model 262 6.2.4.i Definition 262 6.2.4.ii Goals 263 6.2.4.iii Relationships 263 6.2.4. iv Structure 263 6.2.4. v Assumptions 263
6.3 The Need for Educational Inputs to Avoid Accidents/Injuries 264-270 6.3.1 Summary 270
6.4 Environmental Inputs Contributing Towards Accidents/Injuries 271-273 6.4.1 Summary - 273-274
6.5 The Influence of Management Inputs and their Role in Accident/Injury Causation 274-278 6.5.1 Summary 278-279
6.6 The Influence of Social Expectations and Performance and their Contribution Towards Accident/Injury Causation 279-282 6.6.1 Summary 282
6.7 The Influence of Organisational Processes and their Contribution Towards Accident/Injury Causation. 283-284 6.7.1 Summary 284
6.8 Client/Patient Centred Processes and their Effect in the Accident/Injury Sequence 284-287 6.8.1 Summary 288
6.9 Nurse Centred Processes and their Perceived Contribution Towards Accident/Injury Causation 288-295 6.9.1 Summary 295
6.10 The Reliability Coefficient of The OH&SNI 296 IX
6.11 Content Validity 297
6.12 Summary 298-301
CHAPTER SEVEN: AN OCCUPATIONAL HEALTH AND SAFETY INTERACTIVE SYSTEMS MODEL
7.1 Intt-oduction 302
7.2 Instt-umentation 302
7.3 Selection of Subjects 303
7.4 Demographic Data 303-304
7.5 Individual Profiles 304-316 7.5.1 Non-responders 316-317 7.5.2 Conclusions 317
CHAPTER EIGHT: RECOMMENDATIONS AND CONCLUSIONS
8.1 Intt-oduction 318-320
8.2 Investigations 320
8.2.1 Descriptive Data: Registered Nurses 320
8.2.2 Descriptive Data: Nursing Students 320
8.3 The Occupational Health and Safety Interactive Systems Model 321
8.4 The Need for Educational Inputs 321-322
8.5 Environmental Inputs and their Contribution Towards Accident/ Injury Causation 324-325 8.6 The Influence of Management Inputs and their Role in Accident/ Injury Causation 325-327 8.7 The Influence of Social Expectations and Performance and their Contribution Towards Accident/Injury Causation 327-328 8.8 The Influence of Organisational Processes and their Contribtuion Towards Accident/Injury Causation 328-329 8.9 Chent/Patient Centred Processes and thek Effect in die Accident/ Injury Causation Sequence 329-330
8.10 Nurse Centred Processes and their Contribution Towards Accident/ Injury Causation 330-332 8.11 The Reliability Coefficient of the OH&SNI 332
8.12 Content Validity 332
8.13 Recommendations and Conclusions 333-336 LLST OF TABLES
Page Table 2.1 Nurses' Back Pain Prevalence Data 61 Table 3.1 Position in the Clinical Setting: Registered Nurses 126
Table 3.2 Nursing Certificates: Registered Nurses 126
Table 3.3 Area of Work SpeciaUty 126
Table 3.4 Age Ranges: Registered Nurses 128
Table 3.5 Weight Ranges: Registered Nurses 128
Table 3.6 Height Ranges: Registered Nurses 129
Table 3.7 Marital Status: Registered Nurses 129
Table 3.8 Age Ranges: Nursing Students 129
Table 3.9 Weight Ranges: Nursing Students 130
Table 3.10 Height Ranges: Nursing Students 130
Table 3.11 Marital Status: Nursing Students 131 Table 3.12 Opinion for Prescribed Safe Load for Lifting: Registered Nurses and Nursing Students 133 Table 3.13 Open-Ended Comments from Sub-Section A: Registered Nurses 135 Table 3.14 Open-Ended Comments from Sub-Section A: Nursing Students 136 Table 3.15 Open-Ended Responses to Sub-Section B: Registered Nurses 137 Table 3.16 Open-Ended Responses to Sub-Section B: Registered Nurses 137 Table 3.17 Open-Ended Comments for Sub- Section C: Registered Nurses 138 Table 3.18 Open-Ended Responses from Sub-Section D: Registered Nurses 138 Table 4.1 Age Ranges: Registered Nurses 144 Table 4.2 Gender: Registered Nurses 145 Table 4.3 Marital Status: Registered Nurses 145 Table 4.4 Weight Ranges: Registered Nurses 146
Table 4.5 Height Ranges: Registered Nurses 146
Table 4.6 Position in the Clinical Setting: Registered Nurses 147 XI
Table 4.7 Nursing Certificates Held by Registered Nurses 147 Table 4.8 Area of Work Specialty: Registered Nurses 148
Table 4.9 The Highest Secondary Education Level Achieved by Registered Nurses 148 Table 4.10 The Highest Tertiary Qualification Held by Registered Nurses 149 Table 4.11 Age Ranges: Nursing Students 150 Table 4.12 Gender: Nursing Students 150 Table 4.13 Marital Status: Nursing Students 151 Table 4.14 Prior Nursing Experience: Nursing Students 151 Table 4.15 Previous Nursing Experience: Nursing Students 151 Table 4.16 Weight Ranges: Nursing Students 152 Table 4.17 Height Ranges: Nursing Students 152 Table 5.1 Results of Accident/Injury Causation: Registered Nurses 170-171 Table 5.2 Results of Accident/Injury Causation: Nursing Students 172 Table 5.3 Opinions for Prescribed Safe Load for Lifting: Registered Nurses 173 Table 5.4 Opinions for Prescribed Safe Load for Lifting: Nursing Students 174 Table 5.5 Responses for Registered Nurses and Nursing Students to: "Nurses often Work When They Have Back Pain". 175 Table 5.6 Responses for Registered Nurses and Nursing Students to: " Mechanical Devices are Available to Help Lift Heavy Patients" 176 Table 5.7 Responses for Registered Nurses and Nursing Students to: "Mechanical Devices are Always Used if the Patient is too heavy to Lift" 177
Table 5.8 Responses for Registered Nurses and Nursing Students to: "Nurses Often Lift more than the Prescribed Load" 179
Table 5.9 Responses for Registered Nurses and Nursing Students to: "Nurses Always Think First About the Mechanics of Lifting Before they Lift a Patient" 180
Table 5.10 Responses for Registered Nurses and Nursing Students to: Attendance at Training Sessions on Occupational Health and Safety Issues Since Graduation" 181
Table 5.11 Responses for Registered Nurses and Nursing Students to: "The Type of In-Service Attended" 182 xu Table 5.12 Responses for Registered Nurses and Nursing Students to: "Legionnaires' Disease is an Occupational Health Risk for Nurses" 186 Table 5.13 Responses for Registered Nurses and Nursing Students to: "Anaesdietic Gases are not a Source of Concern to Nurses While They are Working in the Operating Theatre" 187 Table 5.14 Responses for Registered Nurses and Nursing Students to: "Dermatitis is not a Common Occupational Hazard for Nurses" 188 Table 5.15 Responses for Registered Nurses and Nursing Students to: "Slipping on Wet Floors Cause Accidents/Injuries to Nurses" 189 Table 5.16 Responses for Registered Nurses and Nursmg Students to: "Nurses are Often Injured Due to the Poor Design of the Environment" 190 Table 5.17 Responses for Registered Nurses and Nursing Students to: "Employer/Institution Having an Occupational Health and Safety Committee" 192 Table 5.18 Responses for Registered Nurses and Nursing Students to: "Nursing Representation on Occupational Health and Safety Committees" 193 Table 5.19 Responses for Registered Nurses and Nursing Students to: "Employer/Instittitions' Occupational Healdi and Safety Units for Staff" 194 Table 5.20 Responses for Registered Nurses and Nursing Students to: "Hepatitis B Immunisation" 194 Table 5.21 Responses for Registered Nurses and Nursing Students to: "Extra Nursing Staff are Always Available to Help Lift Heavy Patients" 195 Table 5.22 Responses for Registered Nurses and Nursing Students to: "Nurses Fill out an Accident/Injury Form Every Time They are Involved in an Acciden^njury" 196 Table 5.23 Responses for Registered Nurses and Nursing Students to: "Registered Nurses Make Judgements About The Seriousness of Patients' Accidents/Injuries Before Deciding to Report it" 198
Table 5.24 Responses for Registered Nurses and Nursing Students to: "Administrative Staff Encourage Nurses to Report Their Accidents/Injuries" 199 Table 5.25 Responses for Registered Nurses and Nursing Students to: "Administrative Staff Encourage Nurses to Report Patients' Accidents/Injuries" 200 Table 5.26 Responses for Registered Nurses and Nursing Students to: "Administrative Staff Make Decisions About The Importance of Nurses' Accidents/Injuries in the Reporting Process" 201 XUl
Table 5.27 Responses for Registered Nurses and Nursing Students to: "Have you Performed Nursing Care When You Have Had Back Pain?" 204
Table 5.28 Responses for Registered Nurses and Nursing Students to: "I Always Report Patients' Accidents/Injuries However Trivial" 205
Table 5.29 Responses for Registered Nurses and Nursing Students to: "I Often Neglect to Report My Own Accidents/Injuries" 206 Table 5.30 Responses for Registered Nurses and Nursing Students to: "I Know Some Registered Nurses are Disinclinded to Report Patients' Trivial Injuries" 208
Table 5.31 Responses for Registered Nurses and Nursing Students to: "Nurses do not Like to Claim Compensation for Accidents/ Injuries" 209
Table 5.32 Responses for Registered Nurses and Nursing Students to: "Nurses who Take Time off for Accidents/Injuries are Thought to be Mahngerers" 211
Table 5.33 Responses for Registered Nurses and Nursing Students to: You Can Usually get Extra Help form Wardspersons to Lift Heavy Patients" 214
Table 5.34 Responses for Registered Nurses and Nursing Students to: "Wardspersons are Always Wilhng to Help Nurses Lift Heavy Patients" 215
Table 5.35 Responses for Registered Nurses and Nursing Students to: "Have You Ever Been Physically Injured by a patient?" 217 Table 5.36 Responses for Registered Nurses and Nursing Students to: "Nurses Worry About Contracting Hepatitis B From a Needleprick Injury" 218
Table 5.37 Responses for Registered Nurses and Nursing Students to: "Nurses Worry About Contt-acting AIDS ft-om a Needleprick Injury" 219
Table 5.38 Responses for Registered Nurses and Nursing Students to: "Nurses are more Concerned About Contracting AIDS from an Infectious Source than Hepatitis B" 220
Table 5.39 Responses for Registered Nurses and Nursing Students to: "Nurses are Never Hit/Kicked by Patients" 221 Table 5.40 Responses for Registered Nurses and Nursing Students to: "Sometimes Nurses are Physically Assatdted by their Patients" 222
Table 5.41 Responses for Registered Nurses and Nursing Students to: Nurses Understand That Being Hit/Kicked by a Patient is a Fact of Life, Although They do not Condone It" 223 xiv Table 5.42 Responses for Registered Nurses and Nursing Students to: "It is not Unusual for Nurses to be Verbally Abused by Their Patients" 225
Table 5.43 Responses for Registered Nurses and Nursing Students to: "Have You Missed Any Work/Studies Due to Accidents/ Injuries in the Workplace?" 228
Table 5.44 Responses for Registered Nurses and Nursmg Students to: Have You Been Entitled to Claim Compensation and Have not Done So?" 229
Table 5.45 Responses for Registered Nurses and Nursing Students to: "Have you ever Filled out and Accident Form for a Patient?" 230 Table 5.46 Responses for Registered Nurses and Nursing Students to: "Needle-prick Injuries Often go Unreported" 231 Table 5.47 Responses for Registered Nurses and Nursing Students to: "Safety Proceedures Protect Nurses from Radiation Hazards" 232 Table 5.48 Responses for Registered Nurses and Nursing Students to: "Safety Procedures for Nurses are Always Followed During Patients' X-Ray Examinations" 233
Table 5.49 Responses for Registered Nurses and Nursing Students to: "Nurses Have no need to be Concerned About the Effect of Radiation on their Bodies" 234
Table 5.50 Responses for Registered Nurses and Nursing Students to: "Teratogenic Agents are a Hazard to Nursing Personnel" 235 Table 5.51 Responses for Registered Nurses and Nursing Students to: "Chemical Agents used for Sterilising Methods do Not Cause Accidents/Injuries to Nurses" 236
Table 5.52 Responses for Registered Nurses and Nursing Students to: "Nurses Often Sustain Bums from Sterihsers" 237 Table 5.53 Responses for Registered Nurses and Nursing Students to: "RSI is not a Common Occupational Hazard for Nurses" 239
Table 5.54 Responses for Registered Nurses and Nursing Students to: Nurses Never have to Lift Patients that are too Heavy for Them" 240
Table 5.55 Responses for Registered Nurses and Nursing Students to: "Back Injuries Are Not a Problem for Nurses" 241
Table 5.56 Responses for Registered Nurses and Nursing Students to: "Other Nurses Report Every Personal Accident they are Involved in" 242
Table 5.57 Responses for Registered Nurses and Nursing Students to: "Nursing Students Report Every Personal Accident/Injury they are Involved in" 243 XV Table 5.58 Responses for Registered Nurses and Nursing Students to: "I am Never too Busy to Report my Own Accidents/Injuries" 244
Table 5.59 Responses for Registered Nurses and Nursing Students to; "I Know Other Nurses Have Time to Report Their Own Accidents/Injuries" 246 Table 5.60 Responses for Registered Nurses and Nursing Students to: "Nurses Always Report Patients' Accidents/Injuries" 247 Table 5.61 Responses for Registered Nurses and Nursing Students to: "Domestic Staff Are More Inclined to Report Their AccidentsAnjuries than Nurses" 248 Table 5.62 Responses for Registered Nurses and Nursing Students to: "Reliability Estimates for Registered Nurses and Nursing Students" 252 Table 7.1 Injury Reports for Hospital D Registered Nurses: For the Years 1984 and 1985. 316 xvi
LLST OF FTfiURES
Page
1.1 Represenatation of Greenwood and Newbolds' (1919) Results (Arbous, 1951, 354).
1.2 Representation of the Concept of Loss Control Management (Bird and Loftus, 1976,39). 12 1.3 Representation of Accident Results (Bird and Loftus, 1976,48) 14
1.4 Weavers' "revised domino" Theory. (Heinrich, Petersen and Roos, 1980). 16 1.5 Roys' Systems Model (Marriner, 1986,301) 23 1.6 Johnsons' Behavioural System Model (Marriner, 1986, 287) 26 2.1 "The Table of Mains", The Sydney Morning Herald, June 23, 1987,4) 41 2.2 Employment Injuries Estimates for Wollongong and South Coast, Based onl985 NSW Incidence and Cost Figures and 1987 Labour Force Estimates Published by the Austt-alian Bureau of Statistics, South Coast Workers Occupational Health Centre, September, 1987, Appendix B, 10. 47-48 2.3 Figure showing "Statutory Maximum Loads for Manual Lifting" (National Occupational Health and Safety Commission, Safe Manual Handling, Discussion Paper and Draft Code of Practice, December, 1986,14). 69
2.4 Figure showing "Protocol for the Follow-up of accidental Needleprick exposures to biological specimens of HIV seropositive individuals" (Kuhls and Cherry, 1987, 213). 96
6.1 Schematic Representation of the Model 255 XVll
LIST OF APPENDICES
Appendix A Nursing Students' Open-ended Interviews
Appendix B Registered Nurses' Open-ended Interviews
Appendix C Content Analysis: Registered Nurses' and Nursing Students' Open-ended Responses
Appendix D Instrument for Testing Content Validity
Appendix E Results of Validity Statements: Chnical Experts
Appendix F Occupational Health and Safety Nursing Instrument: Unrevised Edition
Appendix G Raw Data: Pilot Study
Appendix H Reliabihty Estimates using The P*roduct-Moment Correlation Coefficient: Registered Nurses
Appendix I Reliability Estimates using The Product-Moment Correlation Coefficient: Nursing Students
Appendix J Occupational Health and Safety Nursing Instrument: Revised Edition
Appendix K Causation Interview Instrument CHAPTER ONE INTRODUCTION
1.1 Introduction
It has been consistently demonstrated that nursing environments are dangerous (Lewy,
1981; DeRonde and Mason, 1984 and Sttinger, 1984). Occupational hazards and work- related injuries cause distt^ess and pain, loss of work or study time, and (although more rarely in the case of registered nursing staff than in some other occupations) provoke action to seek compensation (Arad and Ryan, 1986). It would appear also that the attitudes of the nursing profession to accidents and injuries are critical, since an
appreciation of these attitudes must contribute to the design of action to promote a safer
and healthier work environment. For these reasons further investigation into accidents
and injuries in the nurses' workplace is needed.
Very few investigations have been carried out in this area of nursing research and even in industry in general, Merritt (1985) argues that there is a lamentable lack of understanding of industrial injury and disease. She stresses the fact that very littie is known about the mechanisms of accidents and why disease-producing situations continue to exist.
Because of the nature of nursing and the care that is provided by nursing professionals, nurses are subject to a unique set of hazards and potentials for injury. Nurses' health risks and propensity to accident and injury are complicated by their area of physical, social and organisational work. The extent of the interaction of these factors needs to be investigated.
1.2 Background
In 1985, The New South Wales Government transferred all basic general nurse education programmes from hospital-based training schools to the tertiary sector. The Policy
Statement of the Goals in Nursing Education (1976), pursued the objective that all basic nursing programmes for professional nurses should be established at not less than the level of a tertiary diploma (UG2 level).
Only a small number of registered nurses currentiy in the workforce has had access to tertiary training. Thus, at present within the nursing profession, a majority of registered nurses have been educated in hospital-based 'schools'. In contrast, nursing students are presently being educated in tertiary programmes that offer three year diploma level courses. The level of training they receive, their perception of injury and disease potential, and their acceptance into the workforce, provide a basis of comparison with the hospital-trained nurses.
The newly introduced Occupational Health and Safety Act 1983 has had widespread effects throughout management of industry (Campbell,1985) and other organisations
(Reece,1985), but as yet no documented evidence exists in the nursing literature of its effect on the nursing profession. The nursing workforce comprises thousands of employees in New South Wales (35,000), the majority of whom are women. As well, there is a large student population (Garcia & Curtin, 1988). Denning (1985) states that most research into the occupational health and safety area has involved male-oriented tasks and, where women in the workforce have been investigated, two extreme views predominate. One view is that women are "more fragile, less reliable" and "go sick" more often than men; the other view is that there are absolutely no differences between men and women employees (Denning, 1985, p. 14). Since nursing has traditionally been a female-oriented workforce an investigation into the Act's effect in the nursing profession would appear timely.
Many other industries and professions deal widi manufacturing or marketing of a product or products. In contrast nursing is a service-oriented industry intimately involved with the care of individuals. Nurses are directiy responsible and accountable for client safety and the delivery of safe nursing practice. Therefore the litigious aspects of nursing care
(negligence and vicarious liability) need also to be considered. The attitude of nurses to workers' compensation is inextricably concerned with the nursing profession's attitude to occupational health and safety in general. It would seem that many nurses continue to work while they have lower back and other types of injuries and it would appear timely to investigate the influence of the nursing profession's intimate caring and compassionate involvement with patients on the implications of the
Occupational Health and Safety Act. (Lewy, 1981.) Occupational injury and disease in
Australia are estimated to be quite high and statistics show that:
"The overall cost of industrial accidents in Austraha has been estimated at $6.5 billion a year. In most years, the number of days lost from occupational injury and disease is almost twice the number lost as a result of strike action"
(The Editor, The Australian Nurses Journal 1986 a, 37).
These figures relate to the whole Australian national workforce and at present there is no comparable subset of data available for nurses (Rice, 1986). By August, 1989, the
Federal Minister for Industt^ial Relations released figures to show that work related back injuries cost $4 million per working day. He released statistics to show there were
100,000 work related back injuries per year (The Editor, 1989,12).
Evidence from the literature indicates that only 20 per cent of nursing accidents are reported (The Editor, The Austrahan Nurses Journal, 1986, 37). Little is known of the risks to Australian health personnel from occupational health injuries and disease although the literature is punctuated with journal articles citing specific nursing occupational risks. Piesse (1986) believes few nurses seek legal redress and she suggests nurses' use of a "bandaid" solution by using sick leave or accrued days off only hide the problem.
A recent Canadian report on a study involving nurses from Vancouver General Hospital showed "...an average of 60 to 90 new workers' compensation claims monthly". demonsQ-ating the high level of occupational hazards involved in the hospital environment
(Sttinger, 1984, 19).
1.3 Statement of the Problem
The problem of accidents/injury in any industry clearly revolves around investigating why accidents and disease-producing situations occur, (Merritt, 1985). Problems specific to the nursing profession that warrant investigation include the following:
1. There is an absence of state and national wide statistical information for collating
accurate information and determining patterns and types of injuries for nurses.
For example: the incidence of physical/assault injuries sustained firom patients;
the amount of time lost due to accidents/ injuries; and whether nurses are entitled
to claim compensation but fail to exercise their right; are currently inadequately
addressed.
2. Further to the problems stated in point 1, a baseline of information needs to be
generated about the type of accidents/ injuries sustained by registered nurses and
whether a pattern emerges to determine the nature of accident/injury occurrence,
also needs to be explored. A helpful reference point would be a comparison
between registered nurses working in different hospitals and first, second, and
third year nursing students to investigate whether there is a change of attitude
during students' educative course, and, if so, at what stage. Also, their
experiences (and student nurses) would provide a useful baseline for current and
future comparisons.
3. Because very little is known about the attitudes of nurses towards occupational
health and safety issues, a comparison between registered nurses and nursing
students is necessary to reveal any differences and similarities in the way they
approach occupational and safety issues. 4. Provision of training in occupational health and safety by employers is unknown.
Little is known about in-service training experiences of registered nurses once
they have graduated and have entered the workforce. The extent to which current
occupational health and safety information is being made available to registered
nurses is unknown. If opportunities have been made available, it seems important
to discover the extent of training that has been provided and the general level of
knowledge within the intended recipient population.
5. Because back injuries constitute a major occupational hazard for nurses, it would
be timely to discover the loads nurses believe they can safely lift, and to identify
their perceptions about the prescribed load for safe lifting. It would also appear
necessary to investigate the type of behaviour nurses engaged in when they
experienced back pain. Do they continue to perform nursing care while they have
an episode of back pain and if so, why do they continue ?
6. Immunisation patterns within the registered nurse population need investigation
given the risk of exposure to occupationally acquired disease, particularly hepatitis
B. Trends in immunisation patterns need to be estabhshed to provide a baseline
from which to make predictions and comparisons.
7. Changes in the Occupational Health and Safety Act state the need for employers
(employing 20 persons or more) and employees to establish occupational health
and safety committees. The current knowledge of nurses on the provisions of the
Occupational Health and Safety Act and their participation on such committees
needs investigating.
8. An important factor missing in the literature is the beliefs nurses have about the
causation of accidents/injuries in theu" profession. 9. There is a need to explain the causes of accidents and injuries sustained by nurses,
and an important step in this process is the development of a nursing
accident/injury causation model.
10. Finally, a careful search of the literature has not revealed a data gathering
instrument to investigate registered nurses' and student nurses' awareness of and
attitudes towards occupational health and safety nursing variables. Therefore the
development of such an instrument is necessary. In conjunction with the
development of a data gathering instrument, it is necessary that the rehability and
validity of any such instt^ument be tested.
1.4 Purpose of the Studv
The purpose of this study was as follows:
1. To investigate registered nurses' and nursing students' experiences and beHefs
about the occurrence of different types of accident or injury; including the
following;
i. nurses' attitudes towards occupational health and safety nursing issues.
ii. nurses' willingness to claim compensation for injuries sustained in the work
place.
iii. nurses' behefs about the safe load for hfting.
2. To determine hepatitis B immunisation patterns within the defined registered
nurse population.
3. To determine the availability and nature of in-service training programmes in
occupational health and safety for nurses in the work place. 7
4. To investigate nurses' knowledge about occupational health and safety
committees (and nursing representation on these committees) within the nurses
professional practice area.
5. To develop an occupational health and safety nursing model and test its validity
with injured nurses.
6. To construct a suitable instrument for gathering occupational health and safety
nursing data for this study and determine the reliability and validity of the newly
designed instrument.
7. To develop an instrument based on the occupational health and safety nursing
model and trial it with a small number of injured nurses.
1.5 Theoretical Framework
In this section theoretical approaches to identify issues in the occupational health and safety area will be explored. This will be followed by an examination of existing nursing models which provide a starting point for this study.
The theoretical approaches towards accident causation in the occupational health and safety area have been many but the two most constant and popular have been: the concept of accident-proneness [which was developed from the behavioural view (Brown, 1981)], and an explanation in terms of situational causes. Most current researchers (Crawford,
1971; Henderson, 1971; Sampson, 1971; and Viney, 1971) reject "accident-proneness" as an explanatory concept for the occurrence of accidents basing the rejection on several grounds, including the denial of the concept of the careless worker (Mathews, 1985). 8
Brown (1981, 54) argues that although an "accident-proneness" concept has been disproved epidemiological evidence supports:
"... that at any one time a small percentage of the workers have the majority of the accidents. What seems to happen is that the membership in the small percentage of the population that are having the accidents does not stay constant".
The sort of variation discussed by Brown (1981) may occur by chance, and much of the literature is not relevant to an explanation of accident occurrence. In fact this is an example of statistical information that needs to be very carefully interpreted, since such occurences may merely represent randomness and further inspection is needed to demonstrate that accident-proneness or some other phenomenon was needed to explain the data. Such matters are discussed in detail by Arbous (1951) and Kerrich (1951).
In 1951, Arbous (1951, 343) and Kerrich (1951) investigated accident statistics and the concept of accident-proneness, and argued that data associated with;
"...this problem are extraordinarily complicated, and the inter relationship between causes so intticate, that it is difficult to set up adequate conditions of experimental control, and to isolate the part played by the various determining causes".
Arbous (1951) stated that the original concept of accident-proneness evolved from the study by Greenwood and Woods in 1919 and was summarised in
Arbous (1951) by Vernon as follows:
"The statistical study of the condition now widely known as accident- proneness was initiated by Greenwood and Woods in 1919, when they investigated the frequency with which accidents occurred in groups of munition women engaged on various machine operations required in the manufacture of shells. They pointed out that while many of the women suffered no accidents at all, others suffered once or twice, and a few of them more frequentiy. The distribution of the accidents incurred might be due to simple chance , in the same sense that the chance of drawing e.g. the ace of spades from a well shuffled pack of cards, would be once in every 52 trails on an average. Or again the workers might all start equal, but an individual who suffered one accident by pure chance might in consequence have her probability of suffering further accidents increased or decreased. The pain and inconvenience incurred might make her more careful in the future, and so reduce her liability. On the other hand it might increase her nervousness, and thereby predispose her to more accidents. Accidents disttibuted on this basis may, therefore, be called biassed. Still again, we may suppose diat all workers did'not start equal, but that some were from the outset more liable to suffer casualties than others. The accidents would then be disttibuted on die basis of unequal liabilities."
(Arbous, 1951, 353.)
Arbous (1951) stated that Vemon was suggesting that there were three clear hypotheses which were compared to die "classical experiment" by Greenwood and Newbold (1919). To illustt-ate these hypotheses, three statistical models were developed and fitted to the number of accidents mcured by women over a thkteen month period. The results of the number of accidents and their fit to the three dieoretical frequencies are illusttrated below. Please see print copy for image
Figure 1.1 Representation of Greenwood and Newbolds' (1919) results (Arbous, 1951, 354.)
Arbous (1951) discussed in some detail the three hypotheses and their relationship to the data presented above. He concluded that the old approach to accident-proneness was "sterile and effete", and the "application of drawing conclusions from fitting theoretical curves to observed univariate frequency disttibutions" was restictive and unproductive. (Arbous, 1951, 362.) Rather he summarised the position as; 10
"(a) A population can be considered homogeneous (H) with respect to (i) personal attributes, (ii) environmental factors. If a population is homogeneous (H) with respect to both (i) and (ii), the a Poisson distribution of accidents will follow, (see Kerrich).
If on the other hand, if the observed distribution is found to be Poisson, then the population may well be H with respect to both (i) and (ii); but it does not necessarily have to be so, so other, as yet untried, hypotheses may give rise to the same observations. (b) If a population is non-homogeneous (H) with respect to either (i) or (ii), or both, the a Non-Poisson disttibution of accidents will follow(which may be Negative Binomial). On the other hand, if the observed distribution is found to be Non- Poisson, then this may well be explained by the non-homogeneity (H) of the population with regard to either (i) or (ii), or both; but, again, this does not necessarily follow, for other hypotheses,(see above) may well give rise to the same results. (c) The dilemma is reached when it is realised that, even if the hypothesis of non-homogeneity (H) is accepted as the true explanation of the observed Non-Poisson frequency distribution, one still does not know whether this is due to non-homogeneity (H) in either (i) or (ii), or both- and this is the heart of the problem, and the cause of all the confusion and wishful-thinking today. For people have been only too ready to assume that the Non-Poisson (which may be Negative Binomi_al) observed frequency distribution means non-homogeneity (H), and have then gone on to glibly to attt-ibute this to (i) personal attributes alone, in an attempt to shift the blame from the environment to the individual by calling people, and not work-places, accident- prone."
(Arbous, 1951, 362-363).
1.5.1 Situation Models of Accident Causation
The following discussion of a "situation" model is presented more comprehensively in this section because of its relevance to the development of a theoretical basis for this study. A "situation" model of accident causation is reflected in the "domino theory"
(Heinrich, 1959). This model embraces the human aspect, the machine and the environment. In the following section a brief historical overview of situation models of accident causation is presented. 11
The domino theory was first proposed by Heinrich during the 1930's and he postulated a sequence of events which occur in chronological order leading up to an accident, namely: "event a - event b - event c- accident- effect " [(Ridley, 1986, 134)].
Heinrich's theory contains five stages in the sequence of events which leads to an
accident and the subsequent injury. They are;
" a) Ancestty and social environment, leading to b) fault of person, constituting the proximate reason for c) an unsafe act and/or mechanical hazard, which results in d) the accident, which leads to e) the injury "
(Ridley, 1986, 134).
These stages Heinrich proposes are akin to five dominoes standing in line. When the first
domino falls, it displaces the one next to it, and in turn, others in the line. Heinrich
suggests if the accident or injury is to be prevented, removal of one of the first dominos
will stop the sequence and prevent inevitable accident or injury. The most appropriate
"domino" to remove, because it embodies the variables most susceptible to management
or engineering control, is the third domino. Adams (1976) has criticised Heinrichs'
propensity to support the "fault-of-the-person" concept, and suggested this view
seriously weakened Heinrichs' argument indicating that accidents were preventable.
(Adams, 1976, 28)
The domino theory was updated by Bird and Loftus (1976) who introduced the concept of managerial error into the accident sequence. They retained the notion of the five dominoes but introduced five key "loss control" functions, namely;
1. Lack of Contt-ol-management, 2. Basic cause(s)- origins, 3. Immediate cause(s)- symptoms, 4. Incident-contact, 5. People-property-loss.
These are illustrated in Figure 1.2. 12
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Figure 1.2. Representation of the concept of Loss Control Management (Bird and Loftus, 1976, 39). The first domino in Bird and Loftus' theory represents lack of control which they equate with ..."general regulation, curbing, restraining or holding back of losses" (Heinrich, Petersen and Roos, 1980, 24.). They argue the circumstances that may lead to a loss producing event are due to lack of control by management. The four functions of professional managers in Bird and Loftus' opinion are: planning, organising, leading, and controlling. Causes of lack of control by management, a lack which is symbolised by die fall of the first domino, include:
"a) an inadequate program and inadequate program knowledge, (b) inadequate program standards and inadequate knowledge of program standards, (c) failure to perform to standards or to manage employee compliance to standards."
(Bird and Loftus, 1976, 42)
The second domino in Bird and Loftus' sequence is "basic causes" and these are also a function of lack of management control. Specifically they reflect two factors; i) personal factors, which may include: lack of knowledge or skill, physical or
mental "problems", and "improper motivation", and , ii) job factors, which may consist of inadequate work standards, normal wear and
tear, abnormal usage, inadequate purchasing standards, and inadequate design or
maintenance (Bird and Loftus, 1976, 43). 13
The third domino, "Immediate Cause(s)", refers to substandard practice/ conditions and/or errors. These may be due to: i) "unsafe practices" and Bird and Loftus suggest thirteen causes such as improper
lifting, failure to warn or secure, horseplay, and drinking or drugs, and ii) "ten unsafe conditions", which include for example, excessive noise, radiation
exposure, congestion. The authors emphasise the need to elucidate the immediate
cause.
The incident or contact is represented by the fourth domino. Contact is ..." an undesired event that could or does make contact with a source of energy above the threshold limit of body or structure." (Bird and Loftus, 1976, 46).
Bird and Loftus argue that an incident resulting in physical harm or property damage may be classified as an accident. Research demonstrates that most incidents that happen do not harm the individual or result in property damage, however investigations into the cause of incidents is warranted as information could be provided to control or prevent an incident occurring that could lead to an accident in the future. If causes are not elucidated and contt^olled then according to Bird and Loftus, the fourth domino will fall and an accident will occur.
The fifth domino represents the actual accident which may cause harm to the individual or result in property loss. The loss may be categorised as, minor, serious, major or catastrophic as illustrated in Figure 1.3. 14
Please see print copy for image
Figure 1.3. Representation of accident results. (Bird and Loftus, 1976,48).
Bird and Loftus highlight the cost of accidents and in particular point to the high cost of uninsured property damage as well as compensation and medical costs. They emphasise the potential for multiple causation at each stage of the accident sequence and the interrelationship of factors that continue the domino effect.
Bird and Loftus (1976) however have not appreciated the difficulty in finding and investigating the basic cause of accidents. An accident causation theory needs to define the possible basic causes or the means to track down those causes. Bird and Loftus fundamentally blame management ( see 1. lack of management) whereas it seems likely that some accidents have causes which are not controllable by management, for example individual causes, one example of this would be an alcohol dependant employee who caused accidents due to their health problem, community attitudes would be another. It would appear that tracing the causes of accidents was fundamental to any theory that investigated accident caustion.
Adams (1976) in Heinrich, Petersen and Roos (1980) also argued for an accident sequence based on the domino theory. He added two error concepts: the idea of 15 operational errors, which he hypothesised occurred at the level of the second domino; and the notion of tactical errors, which he argued occurred at the third domino level. Adams (1976) suggested Heinrichs' domino theory laid the foundations for a philosophy of accident prevention and ...."is still the underlying rationale of practically all safety programmes". (Adams, 1976, 27.)
Weaver (1971) in Heinrich, Petersen and Roos (1980) suggested a further modification to the domino theory, focussing on the third and fourth domino. He examined the concept of symptomatology of operational error (Weaver in Heinrich, Petersen and Roos, 1980, 29-30). In particular he investigated "what" caused the accident, "why" the unsafe act and/or condition was permitted, and "whether" supervisory management had the expertise to prevent the accident. He stressed the need to locate and define operational error. Weavers' theory is depicted in Figure 1.4.
Zabetakis (1975) also added a new concept to the existing domino theory; the notion that "the direct cause is an unplanned release of energy and/or hazardous material" (Zabetakis in, Heinrich, Peterson and Roos, 1980, p. 32.). The concept of an unplanned transfer or release of energy causing an accident has been adopted by theorists who hold a "multiple causation " view of the accident sequence. 16
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Figure 1.4. Weaver's "revised domino" theory. (Heinrich, Petersen and Roos, 1980, 31). 1.5.2. Multicausality Theory
The domino theory was considered by Petersen (1978), to have been interpreted too narrowly by researchers and the result has been so limiting as to prevent investigation of the root causes of accidents. The multicausality theory rests on the notion that there may be more than one cause to any accident. These causes coincide with Heinrichs' third domino and each of the multiple causes may itself be multifaceted. The process of following each possible cause back to its roots during an accident investigation has been called ...."fault tt-ee analysis" (Nertney, 1977, 32).
The multiple causation theory, according to Ridley (1986), has evolved from accident epidemiology. Gordon (1949) suggested that epidemiological techniques could be applied in the investigation of accidents. His view was that consideration needed to be given to the interaction between three variables: the host, the agent and the environment, and that an accident was a consequence of a set of complex operations that could not be explained by just one of the variables. 17
Petersen (1978,18) argued that to elicit the causes of accidents, "fundamental root causes need to be established". These must then be removed if recurrences are to be prevented. He suggested root causes may be due to, ...."management's policies and procedure, supervision and its effectiveness, training, etc." (Petersen, 1978, 18).
Five principles were outlined by Petersen to provide a conceptual framework for industrial safety.
Principle 1 ... "An unsafe act, an unsafe condition and an accident are all symptoms of something wrong in the management system" (Petersen, 1978, 18).
Petersen states that researchers have had a tendency to select only one unsafe act and/or one unsafe condition and then remove that one condition or act. In contrast to this approach, the theory of multiple causation argues that all the contributing factors should be traced to determine the underlying cause(s). He suggests also that in employing this approach the aim should not be to find fault with the organisational system but to effect appropriate changes to improve it.
Principle 2 ... "We can predict that certain sets of circumstances will produce severe injuries. These circumstances can be identified and controlled" (Petersen, 1978, 23). Petersen suggests that through the application of principle two, severity of accidents can be predicted (in some circumstances) and thus severity can be investigated rather than focussing merely on the frequency of accident occurence. Evidence in America from the National Safety Council indicated that while there has been:
"... an 80 percent reduction in the frequency rate over the last 40 years the same source shows that during this period there has only been a 72 percent reduction in the fatal and permanent total rate, and a 63 percent reduction in the permanent partial disability rate." (Petersen, 1978, 23) 18
Principle 3 Petersen suggested that.
"Safety should be managed like any other company function. Management should direct the safety effort by setting achievable goals and by planning, organising, and controlling to achieve them."
(Petersen, 1978, 24)
Petersen asserted principle three was the most important as it restated the idea ... "that safety is analogous with quality, cost and quantity of production" (Petersen, 1978, 24). Petersen was critical of management, stating that although management may have given support it has not brought safety into the management function.
Principle 4 Petersen argued principle four was, ..."The key to effective line safety performance is management procedures that fix accountability." (Petersen, 1978, 24). Petersen argued that accountability was vital as it made principle three work which was critical in the measurement of results.
Principle 5 Petersen suggested a better way to accomplish aims in safety was to investigate the problems with the management system which permited accidents to occur, radier than investigate what is wrong with people.
Petersen states:
"The function of safety is to locate and define the operational errors that allow accidents to occur. This function can be carried out in two ways: (1) by asking why accidents happen- searching for their root causes- and (2) by asking whether certain known effective controls are being utilised" (Petersen, 1978, 25.)
Although Petersen accepts the importance of estabhshing the fundamental root causes of 19 accidents he does not pursue this important point further, instead he places the ressponsiblility for accidents with management ( see Principle 1). He argues that if diey (that is management) control the fundamental causes, they can reduce accidents. However, the domino theories provide little information about fundamental root causes and there is a need for a theory to provide some stt-ucture and detail on these causes and to predict some course of action which will be effective in reducing accidents.
1.5.3. Summarv
Heinrichs' domino theory and the modifications to the model by Adams (1976); Weaver (in Heinrich, Petersen and Roos (1980), Zabetakis (1975) and Petersen (1978) will be tested as a theory for this study, by investigating whether nurses perceive there are more than one cause contributing to accidents/injuries. The multicausality theory supports the notion that there may be more than one cause to any accident; and it embraces the human aspect, the machine and the environment and hypothesises a logical approach to accident prevention, (see Adams, 1976). However, it has been established that a need to provide a more detailed approach to the basic causes is essential in any theory development (see criticism of Petersen and the domino theory). Because of these reasons the decision was taken by the investigator to test a causality theory for this study by including questions within the framework of the main survey to investigate causality.
1.5.4. Nursing Models
In this section an appreciation of concepts of nursing is developed. In particular an examination is made of the ideas of holism, humanistic nursing and various approaches to nursing models that have been adopted by some nursing theorists. Nursing models that have been examined in the literature have been adapted for educational frameworks 20
for underpinning curticulum models (for example, Henderson, 1966; Levine, 1967;
Levine, 1973; Rhiel and Roy, 1974; Roy, 1976) for application to nursing practice, (for
example, Orlando, 1961; Rogers' general systems model, 1970; Watson, 1979; Orem,
1985); and for research (for example, Abdellah, 1971). In this section an examination of
two nursing models articulated by Roy and Johnson are discussed as they propose a
systems theory approach to nursing care which is the concept analysis envisaged by the
investigator. Concept analysis is defined by Chinn and Jacobs (1983) as the ...
"systematic process of designating the nature and essential features associated with a
concept", (Chinn and Jacobs, 1983, 202) and this approach has been adopted in the
current study.
In the context of the exploration and development of a nursing model, the parameters of
nursing practice and nursing education are now defined. Nursing is concerned about
caring for the "whole" individual. The application of the term "holism" in nursing has
been derived from the concept of evolution articulated by Smuts. He suggested:
"...evolution demonstrated underlying patterns that indicated the gradual development and stratification of a progressive series of wholes, stretching from the inorganic beginnings to the highest levels of spuitual creations"
(Smuts, 1926, 82.)
An holistic approach to nursing involves the caring for the individual as an interacting
unified whole and emphasises an approach which keeps.
"...the self-identity of the whole person in mind and must strive to understand simultaneously the relationship of the 'part' of the individual under concern to the totality of the individuals' interactions and the relationship of the whole to its parts"
(Krieger, 1981,4.)
Nursing is both a science and an art. Humanistic nursing has been put forth as a concept 21 by several nursing theorists, (see Marriner, 1986). Humanistic nursing has been defined by Paterson and Zderad in these terms:
"Nursing is an experience lived between human beings. Each nursing situation reciprocally evokes and affects the expression and manifestations of these human beings' capacity for and condition of existence.
...Humanistic nursing embraces more than a benevolent, technically competent, subject-object one-way relationship guided by a nurse on behalf of another. Rather it dictates that nursing is a responsible, searching, transactional relationship whose meaningfulness demands conceptualisation found on a nurses' existential awareness of self and of the odier"
(Paterson and Zderad, 1976, 3.)
Nurses are intimately involved with providing total nursing care to clients. Most nurses
beheve humans are "biopsychosocial beings" but individual nurses may vary in how they
practice nursing interventions, (Kozier and Erb, 1985, 309).
The way in which individual nurses practice nursing varies according to their beliefs
about a theoretical basis for nursing. Some nurses support a systems theory approach to
nursing practice.
Kozier and Erb (1985) argue that because; ..."humans are biopsychosocial beings, their
biologic; psychologic, social and spiritual components can be regarded as systems with
hierarchic subsystems" (Kozier and Erb, 1985, 309).
Biological sub-systems are relatively easy to define, (for example circulatory, neurologic
and reproductive), and they can be further divided through to cellular divisions. Some nursing theorists have explained the biological system in different ways, for example, by activities of daily living or needs. In her explanation of the individuals' requirements
Henderson (1966) lists fourteen basic needs;
" 1. Breathe normally 2. Eat and drink adequately 3. Eliminate body wastes 22
4. Move and maintain desirable position 5. Sleep and rest 6. Select suitable clothes-dress 7. Maintain body temperature within normal range by adjusting clothing and modifying die environment 8. Keep the body clean and well groomed and protect the integument 9. Avoid dangers in the environment and avoid injuring others 10. Communicate with others in expressing, needs, fears or opinions 11. Worship according to one's faith 12. Work in such a way that there is a sense of accompHshment 13. Play or participate in various forms of recreation 14. Learn, discover or satisfy the curiosity that leads to normal development and health and use the available health facilities"
(Henderson, 1966, 49.)
Psychological and social sub-systems have also been defined by nursing theorists. Roy
(1980) outhned her interpretation of psychological and social sub-systems in a systems theory approach to nursing. Roy views the person as an adaptive system and argues that nursing assists the person in their adaptation to the environment. The individual receives input from the self and environment and adaptation happens when the individual responds positively to environmental changes (Marriner, 1987, 302). Roy's psychological and social sub-systems possess two internal processor mechanisms, namely the regulator and cognator, and four adaptative modes, (physiologic needs, self- concept, role function and interdependence).
The cognator and regulator activity constitute methods of coping and are the control processes. According to Roy,..." the person utilizes cognator and regulator mechanisms to adapt to the changing environment. Cognator and regulator activity is effected through the four adaptative modes" (Roy and Roberts, 1981, 71).
The four adaptative modes consist of:
1. Physiologic needs
2. Self-concept which include,
i) Physical self 23
ii) Moral-ethical self
iii) Self-consistency
iv) Self-ideal and expectancy
v) Self-esteem.
3. Role function
4. Interdependence.
Output in Roys' model can be either adaptive which leads to health, or ineffective responses which causes disruption to the individual's integrity. Roy's model is depicted in Figure 1.5.
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Figure 1.5. Roy's systems model. (Marriner, 1986, 302).
Roy's model defines the individual as a biopsychosocial person and proposes that
nursing is viewed as an interpersonal process. In her analysis of nursing the client is
centt'al to her model and nursing actions are "directed to reducing or removing stunuU and
to enhancing the adaptive level of die individual" (Chinn and Jacobs, 1983, 56).
Roy (1980) outiines eight basic assumptions inherent in her model:
" 1. The person is a biopsychosocial being.
2. The person is in constant interaction with a changing environment. 24
3. To cope with a changing world, the person uses both innate and acquired
mechanisms, which are biologic, psychologic, and social in origin.
4. Health and illness are one inevitable dimension of the person's life.
5. To respond positively to environmental changes, the person must adapt.
6. The person's adaptation is a function of the stimulus he is exposed to and his
adaptation level.
7. The person's adaptation level is such that it comprises a zone indicating the range
of stimulation that will lead to a positive response.
8. The person is conceptualised as having four modes of adaptation: physiologic needs,
self-concept, role function, independence relations"
(Roy, 1980, 180-182.)
Although Roy has articulated the relationship of basic concepts to nursing, the individual, health, and the environment, her model does not focus on the nurse as a recipient of inputs from the environment. Roy does not define the nurses' personal interaction with the nurses' environment. The model is focused towards the client and the nursing of the client. The role of accident causation is not addressed. However, Roy does establish the importance of the nurse-patient relationship as an extra environmental factor (apart from the usual worker-machine, worker-worker, worker-management factors that are generalisable to any work situation) germane to the development of an accident causation model for nurses.
Other nursing theorists have approached a systems theory concept differentiy. For example, Johnson's (1980) theoretical assertion is in terms of a behavioural system theory which possesses two major systems consisting of:
1. The patient (which constitutes the behavioural system) and 2. Nursing. 25
1. The patient.
The patient, according to Johnson, possesses seven intertelated subsystems which have specialised tasks to perform. The seven subsystems Johnson identifies these as: i. Attachment-affiliative subsystem.
This according to Marriner (1986) is the most critical as it provides the basis for all social organisation. ii. Dependency subsystem.
This subsystem achieves a nurturing response by promoting helping behaviour. iii. and iv. Biologic subsystems.
These effectively involve ingestion (iii) and ehmination (iv) and are associated with psychological and biological considerations (Marriner, 1986). These subsystems are concemed with eating and elimination behaviours. v . Sexual subsystem.
This subsystem includes both procreation and gratification. vi. Aggressive subsystem.
Johnsons' aggressive subsystem evolved from the writings of ethologists for example
Lorenz and Feshbach in Marriner argues the primary intent of aggressive behaviour is to harm others and is learned, although a mediating influence of social mores exists and
..."people and thek property need to be protected" (Marriner, 1986, 286). vii. Achievement subsystem.
It is this part of the subsystem that seeks to manipulate the environment and includes, intellectual, creative, mechanical and social skills (Johnson, 1980).
2. Nursing (which reflects the external regulatory force).
Nursing is the second major system and is defined by Johnson as "...an external force acting to preserve the organisation of the patients' behaviour while the patient is under stress of imposing regulatory mechanisms or by providing resources" (Johnson, 1980,
118.) 26
Johnson's model is depicted in Figure 1.6. Please see print copy for image
Figure 1.6. Johnson's Behavioural System Model. (Marriner, 1986, 287).
The two nursing models articulated by Roy and Johnson are examples of the approach
put forth by nurses who support a systems approach to nursing care. Johnsons' model
similarly Roys' model, provide the need for any accident caution explanation to include
the nurse-patient relationship as a integral factor in any nursing model. In a review of
the theoretical nursing literature the orientation of most studies has been directed towards
patient care rather than a perception of nurses in the workplace. The contextual effects of
physical, social and organisational occupational health and safety variables impinging on
the nurse in the workplace have received very little attention. In this intended research a
model of occupational health and safety nursing model is developed. A careful search of
the literature has not revealed a nursing model in this area. This thesis therefore develops
a tentative model, based on research findings. The development of the model
incorporates a recognition of the requirement that, "Multiple studies must be conducted
in order to determine how well a theory describes reality and thus how useful it is for
guiding clinical practice" (Bums and Grove, 1987, 167). It is proposed that the model 27
developed in this study will assist management in the identification and control of the cause of accidents. However, as suggested by Burns and Grove other studies in the future can be carried out to test the realism of this intended model and this study will be confined to the development of the model with limited testing of its validity.
Chinn and Jacobs (1987) have defined a model to be;
"anything that represents perceived reality. A conceptual or theoretical model or framework implies words and symbols that represent the complex abstractions in intertelationship. The term "model", when unmodified by the term "conceptual" or "theoretical" often refers to a physical representation of some object."
(Chinn and Jacobs, 1987, 84.)
In this research a theoretical model is adopted as the operational definition, that is," a structure comprised of concepts related in some way to form" (Chinn and Jacobs, 1987,
207.)
Roy and Johnsons' models do not provide a conceptual interrelationship between the nurse and the occupational health and safety nursing environment, nor do they meet the criterion for the development of a theoretical model for this study, namely that the model must provide an explanation of accident causation. A need therefore exists to develop for this study a model which provides a partial explanation of accident causation in nursing practice.
1.5.5. Summary
A nursing model for occupational health and safety is anticipated. The evidence suggests that a multicausality approach stemming from Heinrichs' (1959) domino model appears to be valid as a theoretical framework to test hypotheses and multicausal factors. The multicausaUty theory is sympathetic to a predominately humanistic and hohstic viewpoint consistent with the investigators' theoretical beliefs about nursing. This theory is investigated in the following way. 28
1.6 General Aims and Directions for the Develooment of an Occupational
Health and Safetv Nursing Model
1.6.1. Introduction
On the basis of the foregoing, it is necessary to establish a knowledge base from which an accident and injury model will be developed. This will then provide a basis for better occupational health and safety training and education for nurses. At this stage of the study it was not possible to define specific hypotheses and as an alternative the following methodology is adopted.
The essential problem is oriented around, "what are the causes of accidents?". Available accident statistics do not contain information about causes, for example, compensation statistics from the Government Insurance Office and hospital records reveal simplistic data which only examine the type and or cost of accidents. In order to explore the causes of accidents it is necessary to use the expertise of the nursing community, to attempt to reveal more comphrensive information about the causes of accidents.In order to reveal this information an empirical research approach will be utilised.
1.6.2. Grounded Theory Approach
A grounded theory approach is envisaged as a first step in the development of an occupational health and safety model. Grounded theory was first used by Glaser and
Strauss, 1966 who suggested it could be used as a:
"systematic way to derive theories that illuminate behaviour and the social world, grounded theory has many uses. Like most forms of qualitative research, grounded theory makes its greatest contribution area which little research has been done. In these areas, theory testing cannot be done since the variables relevant to the concepts have not yet been identified."
(Chenitz and Swanson, 1986, 7.) 29
Grounded theory methodology consists of either interviewing subjects or collecting case studies, which are then evaluated by a comparative method, which seeks to elucidate similarities and differences from the recorded data. Categories are then formulated and,
"often the words of subjects themselves are used" (Chenitz and Swanson, 1986, 8).
These categories can then be developed into hypotheses which can be further tested.
In a grounded theory approach, "sampling procedures rest on the idea of representativeness" and the "initial sample is determined to examine the phenomena where it is found to exist" (Chenitz and Swanson, 1986, 9). In this proposed study a small group of nurses will be interviewed with a view to isolate some general categories of accident causation. It was expected that although these resultant ideas may be valid they may not be the only major categories. Therefore from these categories a series of statements have been generated to form the basis of a survey instrument. The survey instrument was also designed to investigate the views of nurses about accident causation.
1.6.3. Main Studv
The main study involved registered nurses working in public hospitals and nursing students from a tertiary institution. It is understood the views expressed by registered nurses will be forged by experience, compared to those of nursing students, whose views will be largely uninfluenced by experience thereby highlighting the experiential factor held by registered nurses thus helping to identify causes of accidents. Because environmental factors may also influence accident causation, differences between registered nurses employed in different hospitals will be explored. Similar differences may also exist between first, second and third year nursing students. These factors will also be examined. 30
1.6.4. General Research Statement
To identify, describe and provide a theoretical analysis and framework for accident causation within the context of a clinical nursing environment.
1.7 Definition of Terms
1. A supervisory nurse is a senior registered nurse who administers a section within
a hospital or community setting.
2. A unit nurse manager is a senior registered nurse who is responsible for the
management of nursing care in a hospital/community setting.
3. A registered nurse is an individual who has completed a three-year programme in
nursing and is qualified, registered, and authorised to practice nursing by the
Nurses' Board of New South Wales.
4. A diploma nursing student is an individual who is enrolled in a three year diploma
in nursing studies at a tertiary institution.
5. The term Occupational Health and Safety will be used interchangeably with the
term Occupational Health understanding that the later term includes "the four topics
of Occupational Medicine, Occupational Hygiene, Occupational Safety and
Occupational Welfare".
1.8 Outline of Thesis
The remainder of the thesis adopts the following presentation. In Chapter 2 the literature is reviewed, indicating the areas that need to be researched. A pilot study is described in
Chapter 3. The methodology adopted for the study is outhned in Chapter 4 followed by the results in Chapter 5 and discussion of the results in Chapter 6. The validation of the model is presented in Chapter 7. In Chapter 8, the conclusions based on this investigation and recommendations are stated. CHAPTER TWO 31
LITERATURE REVIEW
2.1 Introduction
This thesis investigates nurses and the effects of occupational health and safety issues on the nursing profession. Nurses provide a twenty-four hour care-giving service and are recognised as being in a high risk category for accident occurrence (Hefferin and Hill, 1976; Casey, 1986). This high exposure to risk is explored and evidence investigated to show whether management has been slow to implement occupational health and safety programmes (Omen and Morris, 1984) and preventative strategies. Because nursing is a predominantiy female profession, special emphasis will be directed to the particular hazards that women encounter in their nursing environment.
Nursing is a profession that has been practised for centuries. However it was not until Nightingale in the 1800's stated her belief that the nursing profession was quite distinct from the medical profession, and the knowledge base required for the two disciplines was quite different, that nursing began to emerge as a discipline with its own definitions and ideas (Chinn and Jacobs, 1983). Nightingale defined her ideas about the distinction between nursing and medicine as follows:
"It is often thought that medicine is the curative process. It is no such thing: medicine is the surgery of function, surgery proper is that of limbs and organs. Neither can do anything but remove obsttiictions; neither can cure; nature alone cures. Surgery removes the bullet out of the limb, which is an obsttruction to cure, but nature heals the wound. So it is with medicine; the function of an organ becomes obsttiicted; medicine so far as we know, assists nature to remove the obstruction, but does nothing more. And what nursing has to do in either case, is to put the patient in the best condition for nature to act upon him." (Nightingale, 1860, (reprinted 1969) 133)
Since Nightingales' declaration, nursing as a profession has had to challenge and defend its right to be viewed as a discipline distinct from medicine (Nightingale, 1860). 32
Although Nightingale provided the theoretical and practical foundations for nursing, it
was not until the 1950's that the nursing profession began to develop a scientific
approach to nursing and nursing theories specifically relevant to nursing. As a
consequence some nursing researchers have been prepared to label frameworks from
other disciplines as "theories" while deprecating their own discipline (Flaskerud and
Halloran, 1980). It is not my intention to deprecate existing nursing theories but rather to
provide a departure point by utilising a multiple causative theory of accident occurrence
and developing an occupational health and safety nursing model.
In this review of the related literature, the findings from the Robens Committee and the
Williams Report on their relevance to nursing are discussed, followed by an analysis of
the New South Wales Occupational Health and Safety Act, 1983. Further studies are
presented which specifically examine occupational health and safety issues within the
nursing context.
2.2 Historical Perspectives
In the United Kingdom in 1970, Lord Robens was appointed as chairman of a committee
to investigate the area of safety and health at work (Ridley, 1986). The Robens'
Committee, as it became known, sought to bring the existing fragmentary health and
safety regulations under one cohesive legislative framework. In the United Kingdom
prior to the implementation of the Robens' Findings the situation resembled the
Australian mileau. Both countries possessed outdated, fragmentary legislation to deal
with a complex area. The findings from the Robens' Committee were to influence the
outcome of the New South Wales Williams' Report.
The results from the Robens' Committee were presented to the Secretary of State for Employment in 1972. It was the first time such an enquiry had been carried out and Ridley (1986) highlights the main features of the recommendations: 33
"1) Replace the mass of existing safety legislation with one Act applying generally to all persons at work. 2) Replace the mass of detail with a few simple and easily assimilated precepts of general applications. 3) Change methods of enforcement so that prosecution is not always the first resort. 4) Ensure that occupational safety should also protect visitors and the public. 5) Place more emphasis on safe system of work rather than technical standards. 6) Actively involve the workers in the procedure for accident prevention at their place of work." (Ridley, 1986, 23)
According to Ridley (1986), an important part of the Act also allowed for the formulation of The Health and Safety Commission to possess a co-ordinating enforcement power, thus providing greater powers to inspectors.
The Robens' Committee findings resulted in the Health and Safety at Work, etc. Act 1974 being passed. Both the Report findings and the subsequent Act of 1974 provoked criticism. Merritt (1986), in her discussion of the Robens' Report findings separates her discussion into two sections, firsdy The Report and secondly the Act 1974. She states it is difficult to argue with the criticisms of the existing legislation made by the Robens' Committee, but maintains the analyses and recommendations made by the Committee were contentious. Merritt (1986) takes issue with the way the committee wrote the report and the possibility of interpreting accidents at work being caused by apathetic workers. Although the Report does not specifically name the workers as being the "guilty" parties, apparentiy many who had read the report interpreted it this way. Watson (1981) supports this view when she argues: "Robens (1972) identified worker apathy as responsible for industt-ial injury" (Watson, 1981, 384).
There were other areas of concern and Merritt (1986) was particularly critical of the paternalistic tenor of the report, towards both workers and management. Self-regulation was an area that the Committee did envisage as an important element. 34
The direct effect of the Act on the nursing profession was quite limited. However, the report did comment on nurse training in the occupational health and safety area:
"Pre-registration training of nurses contains very littie education about the effects of work upon health and disease. Some schools of nursing, particularly in industrial areas, do attempt to give their pupils nodding acquaintance with the problems around them but for the most part such examples are rare. Like medical training the whole field of nursing education is in a state of flux. Degree courses in nursing are appearing in some universities and these do contain more teaching on occupational health nursing but this is very limited in the face of other competing demands in the syllabus."
(Robens, A., "Report of the Committee", 1972 (b), 640)
The report also commented on post-registration courses:
"The Royal College of Nursing grants an occupational health nursing certificate to students who satisfy its entry requirements (which require previous practical nursing experience in industry), its educational requirements (which require a period of formal instruction, full or part- time) and who pass its examination. A number of local technical colleges have sought and obtained recognition from the RCN to conduct courses locally. Over the years this supplement to the RCN's own training courses should produce a larger cadre of trained occupational health nurses"
(Robens, A., "Report of the Committee", 1972 (b), 640)
Although there appears to be a willingness on behalf of the Committee to recognise the importance of instruction for nurses in the area of occupational health and safety, it does not address the problem of the at-risk nurse.
2.3 The Williams Report
The first enquiry by the NSW Government into occupational health and safety was carried out in 1979. A retired industrial magistrate, T.G. Williams headed the commission (de Michiel, 1981). The Williams' Report was presented to the Minister for
Industtrial Relations in June, 1981 and tabled in Parliament in August, 1981. At the time of the enquiry there was considerable suspicion generated due to the way the committee was formed, the discretionary powers of the committee and the short amount of time 35 individuals and organisations were given to write submissions. Because of this and the alleged semi-secret aspect of the committee a group of interested individuals convened a "co-ordinating committee" (de Michiel,1981). When the Report was released it was criticised due to the timing of its release as the NSW budget and state elections were announced at the same time and de Michiel (1981) claimed attention was deliberately diverted from the Report.
The Williams' Report functioned in the same way the Robens' Committee findingsha d in the United Kingdom, and it was a forerunner of the Occupational Health and Safety Act, 1983 with much of the future legislation being out hned in the Williams' Report. de Michiel (1981) discussed some of the positive recommendations of the Report. They included, "Worker-participation, workers' access to information, a right to refuse to perform unsafe work, and a single Act to rectify the deficiencies of the present fragmented legislation" (de Michiel, 1981, 238.)
As with the Robens' Committee recommendations, the Williams' Report proposed a single act to cover occupational Health and Safety areas thus bring together the existing fragmentary legislation.
An interesting feature of the Williams' Report was the notion that ill-health was related to the occupational environment. Williams indicated the need for occupational related disease and industrial accidents to be treated as indivisible concepts (Merritt, 1986). In the past these concepts had always been treated as separate entities. It seemed sensible to include occupational disease and industrial accidents together and this is evident in the nursing literature which seeks to link occupational disease and accidents together.
The Williams' Report expressed concern regarding the escalating total accident compensation payouts. The rapid increase in compensation payouts Williams was 36 concerned about was also a general concern in industry. It seems, however, that Australian nurses are reluctant to claim compensation [(Arad and Ryan, 1986) see Section 2.6.2)].
Comments about nursing in the Williams' Report were along the same lines as those included in the Robens' Committee findings and were confined to the lack of adequate undergraduate and post-graduate courses in the area of occupational health and safety. Wilhams stated:
"In die field of occupational nursing training, despite the earnest effort of a number of dedicated nursing sisters, the same picture and the same needs present themselves. Occupational Health Nursing Associations in New South Wales, Victoria and South Austt-alia amalgamated into a Federal body in 1976. Over a period from about 1950, courses in varying lengdis were made available, and in 1963 with the assistance of the now Commonwealth Institute of Health, a course was devised and presented which was repeated irregularly until 1975, when it was abandoned in favour of an elective in the one year community nursing programme of the New South Wales College of Nursing, when it was incorporated in the college of Health Sciences"
(Williams, 1981,76.)
Again, as with the Robens' Report there is a preoccupation with the place nurses should play in providing a service and little attention to the needs of nurses as a professional body in die health care industt-y. Certainly the point Williams raised in paragraph 4.215 of the Report was relevant:
"Most nurses in Austi'alia, not having a first degree are ineligible for the Master's programme. Primary nursing training may in the foreseeable future be the subject of a degree course, in at least some states of Australia." (Wilhams, 1981,76.)
There is no direct reference to protection of nurses in their environment and the most relevant decision in the Williams' Report for nurses was the proposed inclusion of employee participation in joint safety committees. Employee participation on joint safety committees was legitimised in The Occupational Health and Safety Act, 1983 thus giving all workers (including nurses), representation on joint safety committees. 37
Another area of concern expressed by researchers at the time of the Williams' Report was the omission of problems that directly related to women and migrants in the workforce
(Graycar, 1982; Altman and Strange, 1982; Boehringer, 1980). Again this is an area of direct concern for nurses as women represent the largest group in the nursing profession.
The Williams' Report was tabled in Parliament in 1981 amid much criticism and the decisions in the Report were formulated into legislation in The Occupational Health and
Safety Act, 1983.
2.4 Changes to Occupational Health and Safetv Laws
Changes to occupational health and safety laws were evidenced throughout Australia
during the 1980's. Impetus to reform was provided by the Labour Federal Government
when it came to power in 1983. An Interim National Occupational Health and Safety
Commission was convened on 10 November, 1983 and consisted of representatives
from the State and Federal Governments, The Australian Congress of Trade Unions and
the Confederation of Australian Industry (Merritt, 1986, 521). The Commission released
its' Report on May, 1984 and outlined what it believed to be the four essential
components for a national occupational health and safety strategy. These objectives
focussed on the need for, "prevention, equity, participation and responsibility" in
occupational health and safety legislation (Merritt, 1986, 522).
Legislative reform based on a "Robens-style" approach was introduced into four
Australian states, namely South Australia, Tasmania, Victoria and New South Wales.
Western Australia and the Commonwealth Government adopted a similar approach to each other. Western Australia, unlike the other states made changes to existing occupational health and safety laws in two stages. Firsfly by establishing the
Occupational Health and Safety Welfare Act of 1984, to be followed by a further Act which would provide legislation to ensure duties on employers and representation of workers. 38
Queensland and the Northern Territory retained the concept of the old factories-type style legislation, although Merritt, (1986) suggested changes were foreshadowed by these states when they called for submissions. The Queensland Government called for submissions in 1985, heralding possible reform to that states' occupational health and safety laws, and in the Northern Territory, the Work Health Bill was presented before parliament for discussion during 1986. For the purpose of this literature review a more comprehensive examination of the New South Wales Occupational Health and Safety
Act, 1983 and the Workers' Compensation Act, 1987 will be presented.
The New South Wales Occupational Health and Safety Act, 1983 was promulgated on
4th May, 1983 and represented a "new style legislation" (Marks, 1985; Merritt, 1986).
The Act covered, "all places where persons perform work either as employees or self- employed persons throughout New South Wales" (Marks, 1985, 1).
This differed from the existing legislation as it applied to defined places of work where as previously only the location was stipulated, for example, a mine. In the new Act, obligations and responsibilities would be imposed on employees as well as "...persons who supply plant and substances for use at work, on persons who occupy premises which are used by persons at work, and on persons who install plant for use at places of work" (Marks, 1985, 1).
Marks, (1985) believed the legislation to be more far-reaching than any prior legislation.
Merritt (1986) agreed with this statement and although there were some limitations. The
Act contained "... a wider sphere of operation" (Merritt, 1986, 420). Again the nursing literature has not explored the ramifications of The Act as it pertains to the nursing profession. This needs to be an area of investigation for any study into the attitudes of the nursing profession as they relate to occupational health and safety. 39
The unpact of the Act for nurses is the Section in The Act [sec. 23 (l)(a)] which requkes committees to be established in workplaces which employ 20 or more persons. As most hospitals employ at least this number of nurses the Act applies to all hospitals involved in this intended research. There is an established need to investigate the knowledge possessed by nurses about the existence of Occupational Health and Safety Committees and the representation of nurses on existing committees to ensure their views are represented.
2.5 The Workers' Compensation Act. 1987
The Workers' Compensation Act, 1987 was heralded by controversy in the NSW press. "Compo-war where bans will hurt" gained the front page news story in April, 1987, (The Editor, The Sydney Morning Herald, April 7, 1987) "An all out strike in Wollongong" was the response from workers in Wollongong and a "A Fudge on Compensation" appeared in the paper and editorial column of The Sydney Morning Herald (The Editor, The Sydney Morning Herald, October, 7, 1987).
In this section the changes to the Workers' Compensation Act will be discussed as will the effect the Act has on the nursing profession.
2.5.1 The Woodhouse Committee
The Woodhouse Committee was convened in 1974 as a national committee to investigate compensation and rehabilitation in Austt^alia. The recommendations from diis committee consisted of:
"A National Compensation scheme which was to provide earnings related benefits on a no-fault basis to all people suffering disability, whether by reason of injury or illness." ... "It was to replace not only the common law negligence action and the workers' compensation system but also much of the social security system." (Outline of Issues Paper, Accident Compensation, 1982, 3) 40
The recommendations from the Woodhouse Committee were not implemented because of the inherent problems of commonwealth constitutional authority being unable to implement federal findings at state jurisdiction level.
2.5.2 New South Wales Law Reform Commission
A commission chaired by Professor Ronald Sackville was set up in 1982 to investigate accident compensation in NSW. The terms of reference were broad and the commission was vested with instructions to explore the notion of a no-fault compensation scheme.
The existing compensation arrangements consisted of four major systems for compensating accident victims and their families, namely:
"the common law negligence action the workers' compensation system limited statutory schemes such as criminal and sporting injuries schemes the social security system financed by the commonwealth"
(Outlineof Issues Paper, 1982, 4).
The Law Reform Commission recommendations suggested four possible approaches.
Firstly, the existing system be accepted with some modifications; secondly, a no-fault system as a supplement to the common law; thirdly, a no-fault system to replace the
Common Law; and fourthly, an approach that recommended a comprehensive no-fault accident compensation scheme (Outhneof Issues Paper, 1982, 67).
2.5.3. The Workers' Compensation Act. 1987
The new Workers' Compensation Act was inttroduced on the 1st July, 1987 and with the introduction of the new Act the right to sue at common law was lost. Only injuries that occurred prior to the 1st July, 1987 allowed claimants the right to sue at common law
(O'Brien, 1987, 17).
The new system intt-oduced a no-fault system of compensation and the final decision for 41
compensation would be now made by a bureaucrat rather than the courts. The decision according to the media was to be made by ..."non-legal review officers and medical panels and the only right of appeal except on questions of law, will be to non-legal commissioner" (Coulthart, The Sydney Morning Herald, June 23, 1987 ).
Lump sum payments were to be made only to permanently disabled workers and to the family of a worker who was actually killed on the job. Workers injuries will be assessed according to "The Table of Maims" and workers made to be paid accordingly (See Figure 2.1). For example, total loss of sight was worth $31,000, although the amount was later increased to $80,000.
Please see print copy for image
Figure 2.1: "The Table of Maims", The Sydney Mornmg Herald, June 23, 1987, 4.)
Pain and suffering payments were uicreased from $20,000 to $40,000 after consultation
with the trade unions. (Workers' Compensation Act, 1987, No. 70, 55)
O'Brien (1987) listed additional disabilities that were added to the existing Table of
Maims, namely,
"Impairment of the back Impairment of the neck Impairment of the pelvis Total and incurable loss of mental powers, involving inability to work Quadraplegia or total impairment of die spine" (O'Brien, 1987, 18). 42
Regulations regarding compensation were changed. Under the old Act it was possible for workers to redeem their whole future entitlement as a lump sum. With the advent of the new Act workers can only redeem a lump sum if the worker is 55 years or over and the employer is able to make a lump sum payment.
Rehabilitation was an area emphasised in the new Act. Part 6 of the Workers' Compensation 1987 Act dealt with rehabilitation of injured workers. The Act declared employers were required to establish rehabilitation programmes or vocational programmes for injured workers (Workers' Compensation Act, 1987, 109). O'Brien highlighted in his article the greater emphasis displayed within the Act towards rehabilitation of the injured worker to improve their chances of returning to work and in suitable employment (O'Brien,1987, 15). This part of the Act would have relevance to the nursing profession, particularly for those nurses who return to work after having recovered from a back injury but confined to "tight duties".
An important gain for the nursing profession in the area of compensation was the The High Court ruling "Workers' Compensation must be paid to an injured worker on his/her days off" (O'Brien, 1987, 18).
The new compensation Act was met with criticism from a variety of sources, due to the loss of the common law right to sue for damages in court (The Editor, Law Society Journal, 1986).
2.5.4 Compensation Studies and Accident Statistics
Training programmes in occupational health and safety have been found to successfully reduce compensation premiums. A safety training programme was introduced in 1977 at Mona Vale Hospital, NSW. The services of the National Safety Council of Austt-alia were used to implement the training programme which consisted of two days per month. 43 with supervisor training at a total cost of $6,000. The writer (anonymous, 1980) reported on the effectiveness of the programme in reducing the Hospitals Workers' Compensation premium in one year by 29%. The rate of accident occurrence was also reduced with a subsequent reduction in lost working hours. The training programme was directed towards general safety features, for example, organisational improvement, fire hazard control and worker participation. The programme, according to the writer was successful. However, there was no reference to the part played by nurses in the programme, and whether they were involved in the worker participation or organisational modes of the training programme. Due to the success of the programme the hospital was able to reduce the training programme to six days per year at a cost of $5,000.
Stubbs (1981) reported on accidents caused by manual handling in the construction and telecommunication industries, as well as the nursing profession. He revealed after examination of" three-day-plus accident reports (2,437) it was noted that posterior tmnk injuries constituted 22.4% of all injuries, material handling giving rise to 45.9% of these injuries" in the construction industry (Stubbs, 1981, 23). Detailed examination of accident records over a 12 month period involving 100,000 engineers in the communication industry demonstrated "posterior trunk injuries constituted one-quarter of all accidents, material handling giving rise to two-thirds of these injuries, and a mean accident rate of three-day-plus accidents of 22.4 per 1,000 men at risk was observed" (Stubbs, 1981, 84.) The predominately female nursing profession, he reported as experiencing 20,000 incidents of back injuries each year, largely caused by lifting patients, which was responsible for 49-70% of cases.
Wood, (1983) reported on an increased number of employee claims for Workers Compensation at The Alfred Hospital, Victoria. There was a 60% rise from July 1976 to June 1978 in claims by hospital staff. Wood investigated number of lost time due to injuries which he defined as. 44
"... an injury arising out of or in the courses of employment which causes absence of the injured person to exceed at least one full day or shift or shift subsequent to the day or shift which the injury occurs"
(Wood, 1983,18).
The number of lost time incidences due to injuries for nursing staff was 100, with 40 for
hospital services, 27 for catering staff, 12 for engineering and 21 "others". A training
programme was introduced based on three modules, namely education, engineering and
enforcement. In June, 1982 the number of lost time injuries had been reduced
considerably, with 19 for hospital services, 15 for nursing, 11 for catering, six for
engineering and seven for "others". The training programme was considered by hospital
administrators to be effective in reducing injuries.
A training programme in safety and back injury prevention was also found to be
successful by Watt and Mancy, (1983). Abnormally high rates of back injuries at The
Julie Farr Centre, South Australia prompted the introduction of a training programme
with the result of halving a six figure workers compensation premium. (Watt and Mancy,
1983, 4).
Compensation claims for back strains and injuries were investigated by Klein, Jensen,
Lee and Sanderson (1984) in 24 states in USA. Compared to miscellaneous labourers with 12,608 claims representing 12.3 claims per 100 workers, nursing aides had 11,949 claims or three point six claims per 100 workers with 2,056 practical nurses representing
2.8 claims per 100 workers. Practical nurses represented the second lowest in compensation claims with construction workers as the lowest, (2.8 per 100 workers).
Swaffield (1985) reported on the escalation of lifting problems in injury claims for nurses in the United Kingdom. The COHSE's legal department was estimated to have handled "425 hfting cases in 1983, out of a total of 2,000 injury claims" (Swaffield,
1985, 28). The main contributing factor according to claimants was staff shortages. The 45
legal officer believed the increase was due to "escalating staff cuts and cuts in maintenance programmes for equipment" (Swaffied, 1985, 28). A major problem according to the legal officer involved proving liability in individual cases and the inconsistencies in the outcomes, for example he was awarded 38,000 sterling pounds for one nurse who was helping the ward sister when she suddenly "let go" compared to a case where the patient sagged and the nurse sustained the load of the patient; in this case the nurse received nothing. A positive outcome resulted from the Peterborough General
Hospital case after seven nurses had been injured. The NUPE were successful in gaining a settlement of 64,000 sterling pounds for the claimants which resulted in
Peterborough General Hospital Board introducing a preventive programme at the hospital for staff.
Jensen (1987), in his study of injury and employment work-related back injuries in the
USA, used injury and employment information accessed from workers' compensation data from the US Bureau of Labour Statistics. Three categories of nurses were involved in the study, namely, registered nurses, licensed practical nurses, nursing aides along with orderlies and attendants from four states in the USA. The measure used was an incidence ratio (IR) defined by Jensen as "the number of cases arising from a population in a year divided by the average number of people in the population" (Jensen, 1987, 32).
The IR measure was applied to the number of workers' compensation cases involving the
"year of occurrence, year case caused by agency, part of the body injured, nature of injury or illness, industry of employment and claimants' occupation" (Jensen, 1987,
31).
Included in the first analysis were 21 other occupational groups plus the three nursing personnel groups. The Friedman Rank Sum Test was applied to the data to elicit a rank- order analysis. It showed a significant difference for the IR measure and occupational group at the 0.001 significance level. Nursing aids, orderlies and attendants ranged from rankings of one to three, licensed practical nurses ranged from rankings of three to five and registered nurses rankings ranged from seven to nine (out of 21 occupational groups) for the four states. 46
Jensen, (1987) stated the intentions of his study was to provide information background as a basis for nurses to apply for research grants, identify risk groups within the nursing profession and highlight research problems that "address critical needs" for reducing the incidence of nurses' back injuries (Jensen, 1987, 34). He also argued for more "on-site analyses" of patient-handling tasks nurses are involved in (Jensen, 1987, 34). Jensen's study highlights the ease with which American nurse researchers can access data about nurses' injuries and compensation. AusQ-alia does possess an instrumentality (The Australian Bureau of Statistics) similar to the centralised US Bureau of Labor Statistics Supplementary Data System where information about nurses' injuries and compensation data can be accessed. However, it is not possible to access information about nurses injuries/accidents and compensation claims via the Australian government organisation. Data that have been obtained in Australia and have been reported in the literature are limited and obscure. For example. Hurst, (1986) reported rather generalised data:
"Thirty percent of all compensation claims in Australia are back related and an English survey showed that nurses lost three quarters of a million working days a year through back pain, twice the national average. For example, it was indicated that in the course of one hours' work two nurses in a geriatric hospital had lifted the equivalent of two and a half tons in attending to patients' needs" (Hurst, 1986, 60.) Some comparative data have been elicited from employment injuries estimates for Wollongong and NSW South Coast (1987) and showed the health industries' incidence of employment injuries to be relatively low (47.3 per 1,000 workers) compared to other industries (see figure 2.2). By comparison the coal mining industry showed an incidence of 293.7 per 1,000 workers, food, beverages and tobacco, manufacturing industry showed an incidence of 84.4 per 1,000 workers and the construction industry 133.5 per 1,000 workers. The community services figures compare favourably with other industries, however, the data include all health workers and does not separately categorise nursing staff. These reported figures highlight the difficulties in obtaining reliable injury, accident and compensation data pertaining to nurses as they do not appear as a separate group. 47
EMPLOYMENT INJURIES: NUMBER AND INCIDENCE
Injury by accident
Industry Permanent disability Temporary Total Fatal- —disability cases Incidence Total Partial
Agriculture, forestry, fishing & hunting 12 6 130 3,272 3,420 89.9 Mining- 10 1 76 7,452 7,539 259.9 Coal 8 - 42 6,314 6,364 293.7 Other 2 1 341,138 1,175 160.1
Manufacturing- 38 2 621 31,333 31,994 84.4 Food, beverages & Tobacco 6 - 91 5,862 5,959 112.2 Textiles, clothing & Footwear 1 - 17 1,494 1,512 48.8 Wood, wood products & furniture 4 1 59 2,359 2.423 91.1 Paper, paper products, printing & Publishing 2 - 37 1,840 1,879 47.0 Chemicals, petroleum & coal products 1 - 25 1,630 1,656 69.3 Non-metallic mineral products 3 - 39 1,477 1,519 99.8 Basic metal products 5 - 64 3,258 3,327 80.9 Engineering, type not specified 1 - 32 1,581 1,614 Fabricated metal products 4 - 92 3,504 3,600 109.6 Transport equipment 4 1 51 2,472 2,528 123.7 Other machinery & equipment 3 - 94 4,526 4,623 79.7 Miscellaneous manufacturing 4 - 20 1,330 1,354 71.1
Electricity, gas & water 5 1 41 3,567 3,614 69.1 Construction 20 1 210 ]13,16 3 13,394 133.5 Wholesale trade 13 - 57 4,416 4,486 33.1 Retail trade 4 2 149 8,533 8,688 36.5 Transport, storage & communication- 212 164 5,517 5,704 73.5 continued on the following page 48
EMPLOYMENT INJURIES: NUMBER AND INCIDENCE CONTINUED
Injury by accident
Industry Permanent disability Temporary Total Fatal- disability cases Incidence Total Partial
Road transport 16 1 73 2,871 2,961 87.2 Other 5 1 91 2,646 2.743 62.0 Finance, property & business services 7 2 46 3,463 3.518 18.1 Public administration & defence 2 - 8 1,437 1,447 20.9 Community services 11 2 123 10,487 10,623 31.2 Health 5 2 75 6,512 6.594 47.3 Education, museum &. library services 3 - 22 1,865 1,890 13.5 Other 3 - 26 2,110 2,139 34.9 Recreation, personal & other services 9 - 103 4,088 4,200 37.3 Total 152 19 1,729 96,728 98,628 55.7
(a) Number of injuries per 1,000 workers, (b) Injuries in "Engineering, type not specified" have been included in the other footnoted categories when calculating incidence, (c) Includes industries not classified for lack of sufficient data
Figure 2.2: Employment Injuries Estimates for Wollongong and South Coast, Based on 1985 NSW Incidence and Cost figures and 1987 Labour Force Estimates published by the Australian Bureau of Statistics, South Coast Workers Occupational Health Centre, September, 1987, Appendix B,10.
2.6 Back Injury Studies Back injuries and low back pain are well documented in the nursing literature. Cust, Pearson and Mair, (1972) define low back pain as "...pain in the lower back, regardless of diagnosis, but excluding any pain due to known gynaecological or urinary tract causes" (Cust et al, 1972, 169). In the following sections studies that have investigated back pain in nurses will be discussed. There is no attempt to review all published articles relating to back pain in other occupations. This part of the review will also address the Hterature that examines some of the methodologies that have been applied to back pain research in general (see Section 2.6.4.).
Owen and Damron, (1984) discussed the high incidence of occupational injury due to 49
low back pain and stated back injuries are responsible for the largest amount of
compensation and greatest number of lost work days in industry in the USA. This is
evidenced in the nursing profession with nurses experiencing low back pain caused
mainly by lifting and transferring patients (Owen and Damron, 1984). These injuries
according to Knutson, (1976) consist mainly of strains and injuries to low back
musculature. The situation is similar in Australia where nurses have been shown to
sustain high rates of back injuries in comparison to workers in other occupations
(Ferguson, 1970; Bruce and Mancy, 1982; Gregory, 1987).
"Even when there are two nurses to do the hfting, it can still be a daunting task. The loading of the muscles in the lower back increases when the body is bent forwards, making it difficult to lift a weight of as little as 20 kilograms in this position". (Denning, 1985, 14)
Skovron, Mulvihill, Sterling, Nordin, Tougas, Gallagher and Speidling (1987) found in
their study of 787 nursing staff at two acute hospitals that recent back pain was
significantly associated with the job category registered nurse. The categories consisted
of administrative and supervisory registered nurse, nurse educator and non-registered
nurse. The researcher found younger age was a significant variable associated with low
back pain as was greater satisfaction in relationships with co-workers (Skovron et
al.,1987, 359). The researchers suggested exploration of other factors such as in-service
education, training, exercise programmes and pre-employment education, which they
believed may reveal useful information in preventing back pain.
2.6.1 International Back Injury Studies
Magora, (1970) investigated the relationship between occupation and low back pain for
eight occupational groups. The results showed that low back pain was experienced by
16.8% of nurses; second only to heavy industrial workers with 21.6% of workers experiencing low back pain. There was a significant difference between the low back pain group and control group for the subjective assessment of work type performance. It 50
was reported 61.7% of nurses with low back pain indicated that hard physical effort was responsible compared with 14% of the contt"ol group. The researchers suggested occupational physical demand was an important factor in the appearance of low back pain.
Dehlin and Lindberg, (1975) carried out a paradigm to investigate the lifting burden for one nursing aide, who provided nursing care to 16 patients and was employed in a geriatric ward. A description of the nursing aide was provided who was 20 years of age, 164 cms in height and weighed 55 kg. She had no previous history of low back pain or diseases of the joints and had been working in the ward for approximately one year. The 16 patients involved in the research had a variety of diagnoses (for example three patients were hemiplegics, two of these patients had associated aphasia). Only one patient requked a two-person lift. Three lifting operations were studied; namely, 1) sliding the patient up in the bed towards the pillow, 2) transfer from the bed to a chair and 3) transfer from the chair to the bed. Horizontal and vertical forces were measured by a force-plate. The nursing aide stood on the force-plate as she executed the lift and the instrument transformed vertical and horizontal forces into electrical signals. These signals were measured and recorded on a Minograf No 34, as well, all Hfts were photographed at the same time as the measurements were recorded.
The results showed that the nursing aide exceeded the maximum permissible lifting burden several times during the measurements. Maximum permissible lifting burdens were defined in the study after Poulsen, (1970) and Poulsen and Jorgensen, (1971) cited in Dehlin and Lindberg, (1975, 75) as.
"the maximum burden for a 25-year old women of 160 cm height when lifting from floor to table height should be 45 kp, the permissible single lift 31 kp, and the permissible repeated lift (up to 6 times per minute) 22 kp."
Although the research was thorough in terms of measuring forces of lifting a burden. 51
only one subject was involved in the research and therefore generalisation to other
populations is not possible because of the very small sample size.
Dehlin, Hedenrud and Horal, (1976) demonstrated in their study of 267 female nursing
aides in a Swedish geriatric hospital that there was no relationship between the
incidence of low-back pain and different kinds of lifting techniques. They investigated
back symptoms to determine the "incidence of cervical, thoracic and lumbar spine
symptoms with special reference to the latter" (Dehlin et al., 1976, 47). A questionnaire
based on research carried out by Hirsch, Jonsson and Lewin, (1969); Horal, (1969)
and Westrin, (1973) was administered to 269 nursing aides (98%) employed in the
hospital. The study identified a group of nursing aides who had experienced low-back
symptoms prior to commencing nursing and found that this group ("43-group") did
not reveal a " greater frequency of on-going low-back symptoms as compared with the
"83-group" (Dehhn et al., 1976, 53). The "83-group" was defined as those nursing
aides who had developed low-back symptoms after commencing nursing.
Eighty percent of the 83 nursing aides who had developed low-back symptoms after
starting nursing considered their type of work was responsible for their low-back
problems. The authors of the research correctiy cautioned readers about the differences
in definitions employed in other studies when investigating the incidence of back
symptoms. Indifference to this point could lead to major confounding problems when
trying to identify individual variables related to low-back symptoms.
Dehlin, Berg, Andersson and Grimby (1981,1) investigated the effect of "physical
training and ergonomic counselling in the psychological perception of work and the
frequency and serverity of low-back symptoms." The study comprised 45 nursing
aides out of a population of approximately 280 nursing aides working in a Swedish
geriatric hospital. The hospital consisted of 20 wards with 575 patients. The 45 52
subjects in the study suffered from some degree of low-back insufficiency with the symptoms described by the researchers as;
"tiredness, weakness and stiffness of the lumbar spine, sometimes with dull ache in the lumbar area. The symptoms varied in intensity and duration and were usually more pronounced when the back was under mechanical stress. The symptoms appeared at least once a week and all participants had had their symptoms for at least six months"
(Dehlin et al., 1982, 2.)
The subjects were allocated to three groups. Group 1 comprised 15 nursing aides (13 completed the programme) and they received physical training aimed to enhance their fitness level. The second group (group 11) consisted of 14 nursing aides (11 subjects completed the programme) who were given ergonomic counselling in lifting technique.
The third group (group 111) consisted of a control group.
To measure the treatment effect the three groups were administered pre and post test the following;
1. A Likert type questionnaire to measure their psychological perception of work.
2. A subjective assessment of low-back insufficiency by questionnah-e.
3. Physical working capacity estimations were measured using a mechanical braked bicycle with ergometer and subjects' heart rates were recorded for the last minute of two six minute periods with a 50 W and lOOW load.
4. Subjects were also asked whether they used the mechanical lifter. A series of questions with an associated rating scale consisting of; "often, fairly often, neither often nor seldom, rather seldom", were given to each subject to fill out (Dehlin et al.,
1981,4).
5. Information designed to elicit subjects' physical exercise levels after the study was also sought.
The results demonstt^ated a significant difference for groups 1 and 11 on pre-test scores for psychological perception of work for the "perceived need for education"
(Dehlin et al., 1981,4). There were no statistically significant results for the three 53 groups for any of the other variables that were tested. The researchers acknowledged the difficulties in generalising the findings from the study to other populations due to the small sample size. They also reported the reluctance of some subjects to participate in training which limited the experimental design. The results from the study indicated that general physical training or ergonomic instruction did not appear to have an effect on the psychological perception of work or low-back symptoms. Although the researchers acknowledged the limitations of the small sample size, there was no discussion with respect to the level of low-back insufficiency in the population from which the sample was chosen, and therefore selection bias could be a problem.
In the United Kingdom the problem has been well researched. Cust, et al., (1972) investigated the prevalence of low back pain in a population of 1,599 nurses and a comparison group of 949 teachers. Nine hundred and eleven nurses returned their completed questionnaire. The results showed a significant difference between teachers and nurses in the occupational low back pain group, with 19.9% of female nurses and 12.8% of teachers experiencing low back pain being caused by work (Cust et al., 1972, 171). The highest incidence of low back pain was found in nurses in the one to four years of service group and between the ages of 21 to 25. There was a relationship between nurses being over or under weight physically and low back pain. The most common precipitating event for low back pain was lifting patients. The researchers used teachers as a control for their study and due to the differences in occupation, for example nurses would be expected to routinely hft patients whereas teachers would not, and the use of teachers as a control group limits the findingsi n the study. Snook, Campanelli and Hart, (1978) examined the effects of training in lifting methods and found there was little value in training. Rodgers (1985) in contrast, supported the view that there appeared to be a need for adequate time for skill acquisition, associated with expert instruction in the most recent training methods, as well as, supervised training for staff in the workplace.Her study examined the characteristics of a positive 54
ward lifting environment using a questionnaire containing a 5-point Likert scale developed by Fretwell (1980). Her sample consisted of a small number of nurses
(N=95) and did not report on personal or demographic variables, nor was there any published information on the number and type of wards where nurses were working.
However the results revealed that;
"Good staff relationships and all trained staff teaching were strong characteristics of a highly ranked ward, where lifting was taught more frequently and where the physiotherapist was more likely to teach than in low ranked wards"
(Rodgers, 1985, 43.)
St-Vincent, Lortie and Tellier, in Buckle, (1987) investigated the influence of safe lifting training methods involving 33 trained orderlies using an observational method. Training was based on the teaching of general principles applied to handling tasks. The six major principles which were taught to the subjects and assessed by two observers [who were trained by observing a video displaying 44 handling tasks associated with patient handling operations to ensure" intra- and inter observer reproducibility", observers were exposed to diis condition twice"], consisted of the following;
"1) working with the knees extremely bent, 2) the feet far apart, 3) pointed in direction of the movement, 4) with the back stt-aight, 5) during the effort, with the back posture constant, and 6) carrying out the movement using the lower limbs exclusively"
(St-Vincent et al., 1987, 161.)
The results showed that only 1 % of the cases involved in the study applied all six principles simultaneously. In contrast to what was taught, orderlies executed handling tasks with "the legs stt-aight, the feet parallel and close together, with the back somewhat bent; during the effort of the back moves" (St-Vincent et al., 1987,
162). The researchers also found that the principle most applied (that is in 33% of cases) was the use of the legs, however contrary to teaching instructions in 81% of cases the legs were used together with the back and arms, rather than by themselves. 55
The researchers concluded that application of correct training principles were very rarely applied and that "actual training programs are not an effective prevention
sfrategy because the methods which are taught are rarely used" (St-Vincent et al.,
1987,164). It was suggested that in order to plan more reahstic prevention strategies a
better understanding of the constraints encountered during patient handling was
needed. It would appear further studies are warranted to investigate whether these
findings could be replicated with nurses, although confounding factors may result
from the difference in the amount of theoretical and supervised clinical instruction
received by orderlies compared to nurses and these variables would need to be
controlled.
Stubbs, Rivers, Hudson, and Worringham (1981) in their investigation into back pain
found one in every six nurses in England was likely to experience back pain due to hfting
a patient. The sample they studied consisted of 3,600 nurses and the results showed
44% of back pain episodes occurred while the nurse was on duty and 84% of incidents
were caused by patient handling (Stubbs et al., 1981). The information they elicited
indicated "...9% of nurses have no tuition in lifting, 57% have six hours or less and only
34% have more than six hours, in both ward and classroom combined" (Stubbs et al.,
1981, 857). The researchers did not clearly state the incidence of injury in terms of the position of the nurse or their clinical designation, for example community nurses, trainees and quahfied nursing staff were not differentiated in the study.
Stubbs, Buckle, Hudson, Rivers and Worringham (1983a) in a survey of 3,912 nurses suggested 750,000 days were lost annually due to back pain. One in six nurses attributed the cause of the pain to patient-handling incidents. The researchers suggested there was a need for further epidemiological data to be collected and for ergonomic assessment of tasks performed by nurses.
Four different methods of Hfting a 53 kilogram subject were investigated by Stubbs, 56
Buckle, Hudson and Rivers (1983b). They used eight student nurses in four different lifting paradigms and the results showed that the Australian (shoulder) lift produced the least stress as measured by intra-abdominal pressure (LAP). The difficulties associated with a very small sample size was reported by the researchers and that statistical procedures were not applied for the same reason, only trends were reported. A study with a representative sample of nurses would need to be undertaken to generalise results.
Stubbs et al., (1983b) questioned the role of training for nurses and role of pre- employment selection techniques and emphasised the need for a "... broader ergonomic approach" and "...the place of training within safer systems of work" (Stubbs et al.,
1983b, 778-779).
Owen and Damron, (1984) compared 32 back injured female nursing subjects and 32 non-back injured female nursing staff. Each group contained 21 registered nurses and eleven nursing assistants. The results from demographic data found nurses injured their backs at an earlier age than other industrial workers. The researchers suggested this was because nurses are often unable to apply biomechanical principles of lifting and they often lift "... loads greater than 35% of their body weight" (Owen and Damron, 1984
311). The results were complicated because groups consisted of two quite separate populations that is registered nurses and nursing assistants. Therefore it is not possible to generalise these findings to other registered nurses. However, it highlights the need to investigate how much nurses "perceive" they can safely hft.
Physical characteristics and back pain incidence were highlighted by Owen and Damron,
(1984) as representing an area of controversy. For example, Tauber, (1970) demonstrated that tall subjects had a greater incidence of low back injury than short subjects. Overweight and underweight were found to increase the incidence of back injury (Cust et al., 1972). Several other groups of researchers, found weight and height characteristics did not appear found to affect the incidence of low back pain (Rowe, 57
1971; Westrin, Hirsch and Lindegard, 1972; Chaffin and Park, 1973 and Dehlin,
Hedenrud, and Horal, 1976). Because of the inconsistencies found by these researchers it would appear necessary to include personal characteristics when investigating the incidence of back pain.
Harber, Billet, Gutowski, SooHoo, Lew and Roman, (1985) included 600 registered nurses, 400 licensed vocational nurses, administrative staff and unit service co-ordinators in a study on low back pain. A questionnaire was administered to the subjects seeking data on personal descriptors, nursing employment history and questions concerning occupational low-back pain. Information was sought on the levels of episodic chronic back pain occurring within the preceding six months. A follow-up questionnaire was administered within a two-week recall period of the original survey instrument. A total of 550 subjects returned the questionnaire, and the findings revealed that"... more than
40% of the staff reported at least one episode of back pain that developed at work during a two-week period" (Harber et al., 1985, 522).
The researchers also found nurses were inclined to Q'eat themselves or seek medical advice during "hallway" consultations from physicians. They recommended a nursing ergonomic consultant be trained to provide support to die nursing staff. They also argued that mechanical devices should be available for nurses, worksites redesigned and formal research into the epidemiology, etiology and prevention of backpain needed to be implemented (Harber et al, 1985).
An interesting study was carried out by Videman, Nurminen, Tola, Kuorinka,
Vanharanta and Troup, (1984) into low back pain experienced by qualified nurses and nursing aides. The variables examined were low back pain/sciatica and age, work-load, free time activities, menstruation, pregnancies and number of children. The study found significant differences between the two groups for low back pain/sciatica with back injury and disability pension more common in nursing aides. The findings for both 58
groups of subjects under the age of 30 years indicated heaviness of work was related to low back pain. The researchers concluded prevention should be directed towards reducing physical work-load associated with patient-handUng.
Stubbs, (1985) is cited by The Editor, Nursing Times News as arguing that the problem of nurses and back pain affected "... one in six nurses and resulted in over 760,(X)0 days lost to the NHS each year through illness" (The Editor, Nursing Times News, 1985, 5).
A straight forward economic, cost benefit analysis would also have been useful, which could provide an economic rationale for change in the context of policy studies.
Back pain was found to be a main or contributing cause for 12% of all nurses leaving the nursing profession in England (Stubbs, Buckle, Hudson, Rivers and Baty, 1986). This information was elicited from 1,008 nurse leavers involved in National Health Service
Nurses and nursing auxiliaries survey. The results showed 11.9% of those leaving the nursing profession permanently did so because of back pain. The researchers concluded, "...there is no evidence that die cost of wastage due to back pain or any other occupational disease has been considered" and,
"Costs include not only the relatively rare costs of compensation and legal action, but also the indirect costs of recruiting, retraining and possible low morale in wards experiencing high turnover"
(Stubbsetal, 1986, 333.)
The method utilised by the researchers was a self-administered pre-coded questionnaire which investigated nurses, 1) long-term re-employment plans, 2) reasons for leaving their present employment and 3) brief personal and current employment details. A mailing technique was used and questionnaires were sent to nurse leavers in 15 District
Health Authorities in England responsible for 29,795 beds. A stt^atified sampling method was implemented due to the variety of nursing categories within the sample, for example community and hospital-based nurses were two such categories. The response rate consisted of 46.1% of nurses from 15 Districts with a standard deviation of 20.7%, the latter demonstrating the significant variation between health districts. The researchers 59
atttibuted the low response rate to some questionnaires being distributed by the Wages
Offices, and by key people from two districts being either sick or affected by reorganisation by the National Health Service. An analysis was carried out for evidence of response bias however.
"there was no significant difference between high and low response Districts with respect to grade, speciality and sex between all leavers and respondents and with those experiencing a) back pain before nursing and (b) those reporting back pain as a reason for leaving"
(Stubbs, et al., 1986, 330.)
The low response rate was believed by the researchers to be due to the method of distribution and as a consquence combined all data for analysis. A full account of the procedure adopted by Stubbs, et al., (1986) to investigate response bias is reported in Chapter 4, Section 4.7.4.
Pre-employment screening was recommended by some researchers (Heap, 1987).
However Anderson (1986) argued personal characteristics such as age, weight and structural defects of the spinal column appeared not to predispose towards back pain.
A five year study of low back pain injuries in nursing staff was carried out by Heap,
(1987). Absenteeism due to back pain caused by patient handling was investigated in one health district in the United Kingdom which employed 3,778 nurses. Over the five year study the results showed a reduction in the number of nursing staff injured from 43 to 29 per year/per 1,000 at the end of the 5 year period. Heap, (1987) suggested three possible explanations as to why this may be so. Firstly, management were given seminars on the severity of the existing problem and an early reporting system for injured nurses was introduced. Secondly, training sessions were increased providing information on the proper use of kinetic principles and the use of the shoulder lift when lifting patients. [Although Stubbs, et. al. (1983b) and Scholey (1983) disputed training reduced the risk to nurses.] 60
Thirdly, pre-employment health screening was introduced for all prospective nursing staff seeking positions with the Health Service. Those applicants for positions with a history of back pain were not employed in wards that required heavy lifting. Heap, (1987) suggested a multipronged approach to the problem of back injuries as being the most effective in reducing back injuries in nursing staff. However, Anderson, (1986) called pre-employment medical screening "a blunt instrument" and in light of the shortage of nurses it hardly seemed a solution to the problem.
Buckle, (1987) investigated epidemiological aspects of back pain experienced by the nursing profession. He reviewed a series of studies involving the investigation of nurses' back pain and the different methodologies that had been applied to these studies. A table (see Table 2.1) showing a number of studies that had been undertaken over the last 15 years was displayed in his article. The results revealed the rate per 1,000 nurses at risk at the time the reported surveys were implemented. Buckle suggested that it would not be unreasonable to "suppose that a figure of approximately 170 nurses per 1,000 at risk were experiencing back pain at the time of these surveys" (Buckle, 1987, 321). As Buckle, (1987) highlighted in his paper, the studies illustrated in Table 2.1 contained a variety of different methodologies in the approach used to study back pain, and although certain comparsions can be made (for example estimations of back pain risk) there is no reported reliability or vaHdity estimates associated with the questionnaires. The lack of these estimates question the reliability and validity of these particular measuring instruments. Although difficulties associated with comparing findings from back pain research has been raised by Stubbs and Buckle, (1984). They argued that it was "impossible" to directly compare results as most of the studies employed different populations and methods (Stubbs and Buckle,1984,935). 61
TABLE 2.1 NURSES' BACK PAIN PREVALENCE DATA Please see print copy for image
Reproduced from Buckle, P (1987) "Nurses' back pain prevalence data", International Journal Nursing Studies. 24(4) 320.
Stubbs, (1987) discussed the formation of a small team to research "patient handling and back pain within the nursing profession" (Stubbs, 1987, 285). The recommendations that evolved from their research indicated that in their opinion, ergonomic principles appeared to constitute the best approach to investigating the problem of back pain. To disseminate this information a seminar was organised by The Ergonomics Research Unit based at The University of Surrey and The Ergonomics Society. Stubbs defined ergonomics as "the practical and scientific study of people in relation to their working envhronment" (Stubbs, 1987,285). Several aspects regarding back pain were highlighted by Stubbs in the paper he presented at the conference. In particular, he expressed the 62 view that back pain as a symptom appeared to be a major problem for the nursing profession and that the aetiology of back pain was ill understood. During the five year period of research by the team, he reported diere appeared to be many mismatches "m die relationship between the nurses and the rest of the work system" often leading to unnecessary postural stt^ess (Stubbs 1987, 287). These mismatches he believed could be atttibuted to "interactions between the patient, equipment and the environment during the performance of everyday nursing tasks" (Stubbs, 1987, 287). Section 2.6.4 reports on the methodology used in ergonomic approaches to the study of back pain.
2.6.2 Australian Studies
In Australia numerous investigations into back injury have been carried out. Ferguson,
(1970) in a retrospective study carried out an investigation into strain injuries in hospital employees from injury registers maintained at three repatriation hospitals in Australia.
The size and nature of problems associated with manual handling in hospitals for a two
year period commencing from June, 30th, 1967 were analysed. A total of 4,189 hospital
employees were involved in the study with 2,008 employees from Concord Repatriation
Hospital in NSW, 1,363 participants from Heidelberg Hospital, Victoria and 818 participants from Greenslopes Hospital in Queensland. A variety of different staff designations were included; female staff participating consisted of 616 hospital
assistants, 270 nursing aides, 92 trainee nursing aides, 685 registered nurses, 329
student nurses, 182 clerical staff. 111 laundry staff and 250 "others", totalling 2,535 females. The male staff consisted of 492 orderlies, 271 male nurses, 182 clerical staff,
31 laundry staff, 145 kitchen staff, 70 store persons, 463 "others", totalling 1,654. The results showed that 570 strain injuries were reported over the two year period revealing
" a two year incidence of 14%" ( Ferguson, 1970, 376).
Employees from Concord Hospital demonstrated the highest percentage of recorded stt-ain injuries (16%) followed by employees from Heidelberg (12%) and Greenslopes
(11%). Female and male employees showed similar percentage levels for strain injuries with 14% of females and 13% of male employees. However these figures could be 63
subject to bias as the job designation of male staff differed to those female staff in the study, for example diere were only male orderlies and no female orderlies thus making it difficult to compare male and female categories.
The results from the study however did identify some major tt-ends, firstiy, of the total
570 sttrain injuries reported, 25% of employees were required to take between one to seven days off work, 13% of employees exceeded a week in time off, and 62% of employees did not take any time off work. Secondly, the most frequently mentioned agent cited by employees to be involved in the injury was the patient and walking surfaces. The third factor to emerge as an attribute was the type of accident and "about half of all strain injuries were incurred in hfting, and a quarter in falls" (Ferguson, 1970,
377). The part of the body most commonly affected was the trunk (54%), followed by the upper limb (33%) with less than a fifth of reported injuries affecting the lower limbs.
Although the researcher commented on the limitations of the study, for example the differences between institutions and groups in their reporting patterns, the study demonstrated a beginning step in exposing the Australian nursing professions' susceptibilty to occupational strain injuries.
Bruce and Mancy, (1982) investigated the problem of back injuries in nurses from five
Sydney schedule-2 public hospitals. Data were classified according to the Australian
Standard for Recording and Measuring of Work Injury Experience. One thousand, two hundred and fifty-nine trained nurses and 986 trainee nurses were involved in the study.
Injuries were classified into two categories, firstiy, the part of the body affected (for example the neck, spine, below the knee, and arm) and secondly, the nature of the injury, (for example sprain/strain etc.). Within the nature of the injury category there were sections to describe the type, and agency of the injury and a section for other unspecified injuries. The research showed a relatively low figure for reported injuries.
For the period 1981 to 1982 the total of reported injuries was 319. The researchers suggested several reasons as to why this low figure might have eventuated: 64
"the problem is not really as great as suspected. nurses are discouraged from reporting (ward too busy) nurses do not understand the importance of reporting nurses "recover" in their own time (for example, days off, hohdays/accepting injuries as "their lot") nurses sustaining injuries self-selecting out of the profession"
(Bruce and Mancy, 1982, 112.)
The researchers advised the management of the hospitals concemed to write a policy on manual handling and to involve nurses in consultative stages in the design of wards, manual handling problems and education programmes. A better approach may have been to introduce a system that ensured full reporting and then frame a policy on the basis of
those results.
Rice, (1986) investigated the occurrence of low back pain amongst community nurses.
She found many nurses experienced low back pain in the two groups of community
nurses she studied with 79% and 64% respectively in Group A (Service A "... nurses
had a high daily home nursing load" and Group B ("... A low daily home nursing load")
experiencing low back pain (Rice, 1986, 134). Compared to 43% found in the study by
Stubbs, Rivers, Hudson and Worringham (1981a), Rices' nursing groups showed high levels of low back pain.
Rice suggested further research was needed and believed policies should be determined and implemented to ensure that safe practices in nursing are instituted. Wright, (1981) and Daws, (1981) also stressed the need for cortect lifting techniques to be taught to nurses and training should be aimed at educating nurses how to protect their backs.
Arad and Ryan, (1986) investigated the incidence of low back pain in 829 subjects working in a large Sydney, NSW, Hospital. They found 53% of respondents to their questionnau-e experienced theu- first attack of back pain during nursing. The researchers revealed only 5.8% of subjects had received financial compensation for low back pain from all causes, and this included those injuries also sustained outside nursing (Arad and 65
Ryan, 1986). Exercise did not appear to influence the prevalence of low back pain and
interestingly those subjects who perceived their lives to be lonely or unsatisfactory had a
lower incidence of back pain. The researchers pinpointed the main problem as quite
simply that nurses lift weights that are too heavy for them and lift them too frequentiy.
They argued if the Act that was applied to factories and shops was applied to nursing
staff, hospitals would have been closed or had radical staffing changes long ago. They
recommended:
"For nurses in pairs it is reasonable to suggest that nurses under 165 cms should not lift patients weighing more than 50 Kg; that nurses over 165 cms may lift patients over 50 Kg but not exceeding 70 Kg and that patients over 70 Kg should be hfted by at least four persons"
(Arad and Ryan, 1986,48.)
Porter, (1987) in contrast to Arad and Ryan (1986), found that personality played an
important role in the way lower back pain was perceived. Porter reported that in
hospital and general practice surveys "increased anxiety, neurosis, depression and
heightened somatic awareness have been found in back pain populations" [Porter,
1987,78 in Buckle, (1987)]. However these particular findings related to patients
suffering from chronic disorders [see for example Fortcst and Wolkind, (1974)] rather
than nurses, and therefore it would be difficult to generalise Porters' results to
otherwise healthy nurses
Watt, (1986) investigated loads lifted by nurses and the frequency of lifting those loads
in a medical ward in a Victorian Base Hospital. She found during the two week trial
period the frequency of lifting or moving patients was:
"am shift (1700 to 1545 hours) - 34.5 times pm shift (1430 to 2300 hours ) - 23.7 times night shift (2230 to 0730 hours)- 7.4 times"
(Watt, 1986, 47.)
On the basis of one nurse providing nursing care for 5 to 6 patients the researcher 66
estimated one nurse would hft or move 1,440 kilogrammes, (based on 6 moves per shift
= 240 kg X 6 = 1,440 kg) (Watt, 1987, 47). As the researcher indicated, 1,440 kg is a
"staggering weight" for a nurse to lift (Watt, 1986, 47) and would no doubt lead to fatigue, however it would have been illuminating to discover just how much nurses were lifting when executing a single lift.
Griffin, (1987a) discussed the problem of nurses' back injuries in Queensland hospitals and argued nurses were disadvantaged and more at risk than their colleagues in other states due to the lack of occupational health and safety legislation. Accident and injury statistics collated from private nursing homes in Queensland supported this view. The figures collected from private hospitals showed a significantly higher rate than all other states (Griffin, 1987a).
Out of a total of 20 occupational groups in Queensland sustaining back injuries, nurses were shown to be in the seventh highest occupational risk category in the 1984/1985 figures or 1:43 compared to 1:60 in 1981/1982; they had previously been in the tenth highest occupational risk category. The ratio for nurses (1:43) when compared to bricklayers and other construction workers (1:90) indicated there appeared to be a higher risk factor for nurses. The ratio for labourers remained the highest (1.12).
In her investigations. Griffin, (1987a) revealed that contrary to unpubhshed data from the
Australian Bureau of Statistics for "time of day when Queensland nurses sustain over exertion injuries" which revealed 60.4% of these injuries occurted during the morning shift, most back injuries in her research occurred during the evening or night shift.
(Griffin, 1987a, 26). Griffin suggested this was due to lower numbers of staff on duty during evening and night shifts compared to comparatively higher numbers of staff on the morning shifts, and the "frenetic" pace required when working with geriatric patients.
The duration of temporary disability experienced by nurses was also investigated by 67
Griffin (1987a), who found:
"nearly one-third of all nurses' over-exertion injuries required longer than 15 days off work, 24 nurses had to be off work longer than 6 months, and three longer than six months, and three female nurses sustained permanent disabilities due to over-exertion injuries" (Griffin, 1987a, 26.)
The study does not report whether all nurses in her research claimed compensation, although the case studies resulting in legal action showed all plaintiffs received Workers' Compensation (Griffin, 1987b). Out of the nine case studies reported by Griffin, (1987b), five cases were settled out of court. For those cases that proceeded to court, nurses sued their employer for negligence.
The social cost of injury was large, both to the employer and employee, and total working days lost by nurses over the four year study increased by 18%. These data suggested nurses take off sick days rather than apply for compensation. Raistrick, (1981) supported this view in her study of 1,146 nurses who indicated they took sick leave and did not apply for compensation (Raistrick, 1981, 856).
2.6.3 Maximum Loads in Industry From an historical perspective various approaches have been instituted to prevent manual handling injuries. The most frequentiy used approach has been the appUcation of maximum weight lifting limits, which also apply to women and young people. These approaches have been integrated into legislation and regulations, however, both the legislation and weight limits have varied from state to state (see figure2.3) . The problem still remains in regard to agreement from state to state, and internationally, as what constitutes maximum weight lifting limits, and through what legislative avenues they should be implementated. In New South Wales, the statutory maximum load for manual lifting is 16 kilograms for males and females over the age of 18 years, and is outiined in the Factories, Shops and Industries Act, 1962. 68
Snook and Ciriello, (1974) compared a sample of industrial working men, industtial working women and housewives on lifting a variety of loads while performing different pushing, pulling, carrying, lifting, lowering and walking actions. They found significant differences in load handling capacities between men and women and, consistent with other studies, found significant statistical differences between the average weight handled by industrial men and women. They found that, "Women handled significantiy less weight than men, particularly when lifting, lowering and carrying" (Snook and Ciriello,
1974, 533). However, the researchers cautioned against these results being used for discriminatory purposes.
Discriminatory safety practices were levelled at women in NSW using weight hmits set down in Section 36 of The Factories, Shops and Industrial Act 1962 (NSW) which stated "... women employed in factories shall not be required to lift or carry by hand a loadof more than 16 kilograms" (Covell and Refshauge, 1986, 48).
Women working in the Wollongong NSW steelworks submitted complaints to the Equal
Opportunity Tribunal alleging sexual discrimination by the company in its "last-on-first- off principle" in retrenchments. It became clear the company was basing its legal argument on protective weight limit legislation. By 8th May, 1984, 34 complaints had been filed by women to the Equal Opportunity Tribunal claiming alleged sexual discrimination. An investigation by Refshauge, (1986) commissioned by The
Commissioner for Equal Opportunity, demonstt-ated the Company had used the weight limit as its major defence (Covell and Refshauge, 1986). The NSW Equal Opportunity
Tribunal rejected the defence of the Company based on Section 36 of the Act and supported the complaints of the women. Application of these load limits caused Prime
Minister Hawke to describe the "... weight limit as die most contentious of the range of resttictions on womens' employment (Covell and Refshauge, 1986, 49).
Snook and Ciriello, (1974) were obviously aware of the dangers of discriminatory practices against women attested to by what has become known as the "Wollongong
Case". There exists a real possibility in the nurses' workplace for discriminatory action to 69 be directed towards nurses given the nature of their work and their interactions with other ancillary workers. This issue wartants further investigation.
STATUTORY MAXIMUM LOADS FOR MANUAL LIFTING (in kilograms) Please see print copy for image
Figure 2.3 Showing "Statutory Maximum Loads for Manual Lifting" (National Occupational Health and Safety Commission, Safe Manual Handling, Discussion Paper and Draft Code of Practice, December, 1986, 14).
Some researchers have approached the investigation of measuring back stress in a different way. Davis, Stubbs and Ridd (1977) found that with the use of radio pills they could monitor back stress during manual materials handling. Eighteen subjects were requested to swallow a calibrated radio pill which was tracked by using a 7040 Rigel 70
receiver with output monitored by a portable recorder. Spinal posture was also monitored by using spinal markers which consisted of "rods projecting from flat plates adherent to the skin over the first and twelfth thoracic and first sacral spinous processes" (Davis et al., 1977, 211). Subjects were given five lifting tasks to execute during which time the intra-abdominal pressure was measured for each subject. Of the five lifting tasks the
"lateral full stoop" resulted in a peak pressure reading of 15.3 K Pa, the "straight full stoop" resulted in 12.6 K Pa and the "semi-stoop" 12.0 K Pa. A significantiy lower pressure (3.3 K Pa) was recorded for the "semi-flexed knee" lifting technique while lifting a 35 kg weight from the ground and the "straight full flexed knee" lift revealed an intra-abdominal pressure of 9.3 K Pa. These results demonstrated that flexing the knees and keeping the back erect resulted in the lowest intra-abdominal pressure level.
Unfortunately the authors reported results for only one subject and it would have been a better estimate of trends if the mean K pa was reported for the 18 subjects for each of the five lifting tasks. The researchers suggested the shortcomings of the method included the expense of the radio pills and the need for subjects to swallow the pill and then have to retrieve it, the latter an understandably unpleasant task.
2.6.4 Methodologies used to Investigate Low-back Pain
Methods used by researchers to investigate occupationally related low back pain has varied, with epidemiologically oriented approaches being a method favoured by many researchers. For example, Frymoyer, Pope, Costanza, Rosen, Goggin and Wilder,
(1980) used an epidemiological retrospective method to investigate low back pain in
2,068 subjects from a defined medical family practice. They found occupational factors were significantly related to low back pain and cited truck driving (p < 0.001) as an example. In using this method, the authors recognised the inherent difficulties associated with retrospective studies, and were developing a questionnaire to administer in a further 71
study which they hoped would improve their understanding of low back pain.
Buckle, Kember, Wood and Wood (1980) discussed the development of a statistical modelling approach in their retrospective pilot study which investigated back pain influences. Sixty-eight male patients between the ages of 18-58 were included in die
study. A variety of aims was outiined in the paper. These included
1) The assessment of each patient who was admitted to Park Hospital Rehabilitation Unit in die North Bedfordshire Healdi District, with a back problem.
2) Treattnent and assessment of each patient during their hospitalisation.
3) Recording of patients' history and onset of low-back pain with associated data
collection on work and home environment details.
4) Construction of a personality profile using the Cattell Questionnaire.
5) Recording of the effectiveness of treatment at a 12 week follow-up interview after
discharge from the unit.
An important aim of the pilot study was the development of a statistical model to; "1) isolate factors responsible for low-back pain, 2) identify the appropriate method of management, 3) predict probability of recurrent back pain, and 4) assist the clinician to evaluate alternative methods of treatment"
(Buckle, et al., 1980, 255.)
Other major aims of the study included ergonomic and clinical goals.
The statistical analysis applied to the data in the study was not fully reported, as the researchers stated frequencies in some cells were too low and therefore only trends were discussed. However, it was noted that probability levels were still reported, although it was not clear as to whether the probabilities were associated with the "one-way and two- way statistical analysis" (which in itself was not clear as to whether the statistic this statement referted to was a one variable chi-square statistic, or two way chi-square statistic or some other statistic). Unfortunately due to the preliminary nature of the study a full discussion of the model was not presented in the paper, although a diagram of the early stages of a systems model consisting of "input" "tt-ansformation" and "output" variables was presented. 72
The researchers revealed that of 37 patients who were able to relate the onset of back pain to a particular incident, 30% of patients attributed it to Hfting. Apparently only 42% of patients in the study whose occupations involved lifting had received some form of training in this area. The main contributing factors for the immediate cause of paininpatients was bending (17.6%), twisting (20.6%) and lifting (20.6%). The most frequently reported type of stt^ains experienced by subjects at work were due to bending and lifting. These results were statistically significant and "a significantly large (P < 0.001) number of patients attributed the onset of pain to a bending and twisting movement and also (P < 0.001) to a slipping and twisting movement". (Buckle, et al., 1980, 256).
The researchers concluded that, even though the sample was small, it was still representative of the population of low-back pain sufferers in the health district, and the sample was suitable for the modelling method envisaged. Unfortunately, diere was littie information about the questionnaire or the revised questionnah-e, only the results of the Cattell personality test were reported [which showed significant positive scores for factors G "Weaker ego strength", Q2 "Group-dependent", and significant negative scores for factors L "Trusting" (alaxia), N "Forthright, natural", and Q"Conservative"] (Buckle et al., 1980.) The researchers reported on the difficulty in not being able to use comparative British standardized norms due to non-existence of data for the Cattell and because of this compared results with standardized American norms.
Andersson, (1981) investigated epidemiological aspects of low back pain in subjects working in industry. He examined various studies from the literature and highlighted, that there were difficulties associated with classification, diagnosis and measurement of 73 back pain. He stressed the need for workers to be protected against "workplace" factors, and for future research efforts to be directed towards prevention (Andersson, 1981, 56).
A prospective epidemiological survey which included interview techniques and examination of subjects on return to work after back pain, was the method employed by Lloyd and Troup, (1983). They interviewed 9,036 subjects in an attempt to elucidate predictors of recurrent back pain. A follow-up postal questionnaire was mailed to each subject 12 months after return to work, with the questionnaire attracting a 86.3% response rate. They found clinical examination on return to work was useful prognostically, but suggested there was a need for more suitable screening methods to be developed
Biering-Sorensen and Hilden (1984) also used an epidemiological approach in their study of low back "trouble" in two populations, which consisted of 928 subjects, (479 women and 449 men) living in the municipality of Glostrup, Denmark, and 117 male hospital porters from Copenhagen. The methods included a general health survey, (which included "a thorough examination of the low back"), interview and objective measurement, (Biering-Sorensen and Hilden, 1984, 280). A follow-up questionnaire was mailed to each subject 12 months later which resulted in a 99% response rate. The study highlighted several methodological problems, of which inconsistencies of subjects' responses to the same, or similar questions was noted. In particular, hospital porters were inconsistent in their reporting of low back trouble and lumbar spinal x-ray. This was found to be so in 13 cases. The researchers believed that many of the inconsistent responses were due to subjects' "forgetfulness", particularly in under-reporting of low back pain. They argued caution needed to be exercised in the application of this particular methodological approach. 74
Stubbs and Buckle (1984) reported on various approaches that had been applied to the epidemiology of back pain in nurses and suggested that the best combination was
epidemiology and ergonomics.
Anderson, (1986) argued for more reliable "tools of measurement" in order for doctors
to be able to base their recommendations on preventive measures (Anderson, 1986, 90).
He also reported on the epidemiological aspects of back pain, and the development of a
measuring devise, which measured antero-postero and lateral flexion at T 12, antero-
postero flexion and sacrum, EMG of lumbar muscles and intra abdominal pressure. He
also highlighted the influence of environmental factors, such as proper posture, and
effort of low back, although the paper did not report on the actual use of the instrument.
A structured interview, and clinical examination, was the method employed by Hulttnan
(1987) to investigate healthy backs in 21 male subjects, aged 50-59. According to the
researcher, useful information was elicited by applying this particular method, and the
interview method revealed subjects exhibited positive attitudes to work, a low incidence
of smoking cigarettes (68% did not smoke), good general health level, low work
absenteeism and physical activity during leisure time. The clinical examination was also
effective in isolating flexibility in the back, and hamstrings, and isometric extensor
muscle strength was much higher than isometric flexion strength.
Gagnon, Chehade, Kemp and Lortie (1987) used three different measurement
techniques, (cinematography, force platforms and electt^omyography) to investigate 15
female nursing aides' lumbo-sacral loads, and selected muscle activity, while turning
patients in bed using a pique, (defined by the authors as "a water proof padded sheet placed under die patient", (Gagnon et al., 1987, 1013).
Analysis of variance (repeated measures design) was used to analyse " two repetitions of 75
six different variations in task execution" (Gagnon et al 1987, 1016). The subjects were evaluated for compression and shear force at L5/S1 joint and muscular activities in the trunk and shoulders. The results of research findings led the authors to recommend that when pulling and turning patients in bed, forces should be exerted in the vertical direction, with the patients' bed at the hip level of the lifters and the lift executed using rapid movements (that is, if the patients' conditions permits).
Several researchers found that certain postures appeared to pose risk factors in developing back pain. Lawrence (1955) found there was an association between back pain and stooping in coal miners and "men who had worked from 15-25 years in a stooping position" were more likely to experience back pain (Lawrence, 1955, 255). Partridge, Anderson, McCarthy and Duthie (1968) found prolonged stooping was associated with back pain in workers employed in iron foundries. Buckle (1983) also found bending or stooping to be risk factors associated with back pain.
Batty, Buckle and Stubbs (1986) investigated nurses' postural assessment during a shift using a questionnaire and direct measurement of stooped posture using an inclinometer. Forty-six subjects were involved in the study and were observed during "the full duration of a shift" (Batty et al., 1986, 285). The researchers found that the the combination of the two methods yielded good quality control over individual measurement techniques, although the researchers conceded that there were obvious flawsassociate d with using an inclinometer. For example the results from the inclinometer showed only a "superficial similarity" for stooping activity compared to those results from direct observation (Batty et al., 1986, 292). Other problems reported by the researchers as causing difficulties related to the securing of the inclinometer to die subject for the duration of the shift, as well as the recording of accurate angles and and trunk flexionreadings .
In a study by Batty and Stubbs (1987) a combination of different methodologies were used to investigate postural stress in geriatric nursing. Static and dynamic forces and 76
postures experienced by nurses during their working day were measured using "direct observation and an assessment of truncal stresses measuring intra-abdominal pressure
(lAP) " (Batty and Stubbs, 1987, 339). The participants in the study were geriattic nurses and were recruited from four health regions, (Wessex, South West Thames,
West Midland and Trent Regional Health Authorities). A total of 51 nurses took part in the study, comprising of 21 trained nurses, 24 auxiliaries and six learner nurses. The researchers compared the activities of stooping, standing, kneeling, pushing and pulling for nurses on 25 early shifts and 24 late shifts. The night shifts were excluded due to insufficient data. Intra-abdominal pressure was reported for 14 subjects.
The results showed that 98% of the total shift time for all nurses in the study was spent either, stooping, standing, walking or sitting down. There were "two peaks of stooping activity between 1500 and 1600 and between 1800 and 2000, corresponding with tea, supper and the patients' bedtime" (Batty and Stubbs,1987, 342). The researchers reported their concern on the increased load associated with moderately high postural levels that were being imposed on the nurse towards the end of the shift. Stooping, standing and walking activities increased in proportional terms from 0800-1000, and
90% of the two hour period between 0900 and 1100 was spent standing or walking with only 5% of the time spent sitting during these times.
The results concerning the LAP measurements for the high risk group readings (above 30 mm Hg) peaked 106 times per working day, and a mean number of 68 peaks greater than
40 mm Hg were also recorded. For the low risk group there were a mean number of 21 peaks over 30 mm Hg with seven peaks more than 40 mm Hg. The researchers suggested that geriattic nurses were probably more at risk of back pain resulting from the dynamic component of the job. Stooping was perceived as a high risk factor and the inabihty for nurses to take "spontaneous rest pauses" combined with the high work load during the early to mid-morning, where 90% of the time was spent standing, walking and in stooped postures which was seen as a particular problem. (Batty and Stubbs, 77
1987, 343). The researchers concluded that the problem of back pain and occupation appeared to be mulitvariate in nature and more attention was required in observance of ergonomic factors. The study did not report whether the same nurses completed the 25 early shifts and 24 late shifts, or whether different nurses were observed over the period of research. It was not reported whether nurses had "days off', during this period and if this was not the case then fatigue could be a confounding variable.
Few researchers have examined the problems of low back pain from a more comprehensive macro framework. Romer (1987) was one researcher who argued for a common conceptual framework, and methodology, to be applied to the study of back pain. Romer suggested there was a "strong need to include accident and injury epidemology in the curticulum of other types of health professionals' training" (Romer,1987, 187).
Dul and Hildebrandt (1987) in their review of the literature which investigated individuals and work-related factors of low back pain, called for ergonomic guidelmes to be established that applied specifically to low back pain. They also argued for the need for quantitative epidemiological data to be collected.
2.6.5 Summary
Nurses frequentiy experience low back pain (Magora, 1970; Cust, et al., 1972; Hoover, 1973; Stubbs, Rivers, Hudson and Worringham, 1981; Rice, 1986 and Watt,1987) and compared to other occupations nurses appear handle loads in excess of reasonable hmits, (DehUn and Lindberg, 1975; Owen and Damron, 1984 and Watt, 1986; Griffin, 1987a).
It would appear timely to investigate the extent of nurses' knowledge of weight restrictions and the loads they believe they can safely handle and to examine their 78
understanding and attitudes about lifting loads, back injuries and compensation for
injuries sustained at work.
Some of the methods used by researchers that have contributed useful information to
the literature have included interview techniques, (Hultman,1987) epidemiological
methods (Andersson, 1981) and questionnaries (Arad and Ryan,1986). Buckle et al.,
(1981) proposed the need for the development of a statistical model from which to
isolate low-back pain factors, identify satisfactory mediods of management and to make
predications about the recurrence of low-back pain. Romer (1987) highlighted the need
for a common conceptual framework, although limited this suggestion to low back pain.
2.7 Nosocomial Infections
In this section the occupational health risks (and their transmission modes) of hepatitis
B, AIDS and Legionnaires' disease in relation to nursing staff will be examined. These
infections currently represent major health risks prevalent in the working environment
of nursing personnel at the time of this study.
2.7.1 Needleprick Injury
Needleprick injuries have been recentiy recognised as an occupational risk for nursing
staff because of the risk of exposure to hepatitis B and AIDS (Temianka, 1979; DeRonde
and Mason, 1984; Neuberger, Harris, Kundin, Bischone, and Chin, 1984; Haas and
Beideman, 1986 and Solvas, Castillo, Vela, Espnar, and Vargas, 1987). In the
following sections (2.7.l.i and 2.7.1.ii), an examination of the curtent literature as to the risk of nurses contracting hepatitis B and AIDS by means of needleprick injury will be reviewed. 79
2.7.2 Hepatitis B Needleprick Injuries
Principal modes of hepatitis B virus transmission were studied by Maynard (1981) who believed the most probable frequent transmission mode was by; "Direct percutaneous inoculation by needle and contaminated serum or plasma or transfusion of infective blood or blood products" (Maynard, 1981, 441).
Reed, Anderson and Hodges (1980) investigated needleprick and puncture wounds in hospital personnel to study the epidemiological nature of the problem. Nursing staff were included in the high risk category (greater than 10 incidents/100 employee year worked), together with building management personnel, laboratory staff, medical students, supply, and surgical support personnel. They found personal carelessness was responsible for 55% of a total of 81 incidents and 35% of personnel were "innocent victims" (mainly domestic staff), with 10% of incidents unclassifiable. Employees sustaining needleprick injuries did not show positive hepatitis B surface antigen (HBsAg) and only two of the 45 subjects were hepatitis B surface antibody positive. Four employees were given immune globulin and 65 subjects did not receive any globuHn. The researchers found the risk of hepatitis B occurring from a needleprick or puncture wound was "minimal", aldiough evidence of subclinical hepatitis B or non-hepatitis B could not be excluded at the 6 month follow-up period. As a result of their findingsth e researchers instituted an in- service training programme for needleprick and puncture wound procedure.
McCormick and Maki (1981) discussed their epidemiological study of needleprick injuries in hospital personnel over a 47-month period from 1975 to 1979. Nursing personnel had the highest incidence of all needleprick injuries (60%). The only occupational injury amongst all hospital personnel to surpass needleprick injuries were musculoskeletal injuries.
The results showed that of all reported needleprick injuries "... 45.3 percent occurted in 80 registered nurses, 17.4 percent in housekeeping personnel, 14.9 percent in laboratory workers, 14.3 percent in nursing assistants and 8.2 percent in personnel in other positions" (McCormick and Maki, 1981, 929).
Needleprick injuries represented approximately one-third of all work-related accidents reported and even then the researchers suggested the figures were under-estimated. Staff members tended not to report injuries unless the patient was known to have a transmissible infection. Nurses experienced the greatest proportion of needleprick injuries in all occupational groups and sustained the majority of their injuries while administering parenteral medications or drawing up of blood. The findings prompted the hospital administration to purchase needle cutters to cut needles immediately after use and to implement formal guidelines for prevention and a protocol for management of needleprick injuries (McCormick and Maki, 1981, 932).
Dienstag and Ryan (1982) also argued the risk of hepatitis B virus infection was underestimated in hospital employees by clinical attack rates and suggested serologic marker studies were more accurate. They carried out a seroepidemiologic survey of 624 health workers and found the:
"...frequency of hepatitis B serologic markers increased as a function of contact with blood, previous hepatitis history, years in occupation and age but not as a function of contact with patients, years of education, previous needleprick, transfusion or globuhn injection" (Dienstag and Ryan, 1982, 26).
Under-reporting of needleprick injuries was identified as a problem in the study by Jacobson, Burke and Conti (1983). Nurses and laboratory personnel were found to make their own judgements as to whether the incident was worth reporting.
Hamory (1983) surveyed 1,429 university hospital employees to investigate the extent of needleprick injuries. Seven hundred and twenty-six subjects responded with 58.7% of respondents classified as employed in nursing service. Injuries were the highest in the 81 nursing service department (65%), followed by the laboratory department with 11%. Twenty-four percent of respondents were not aware that,"... a dependable method exists to prevent hepatitis following needleprick", although researchers did not define what department these responses came from (Hammory, 1983, 176).
The researchers argued many needleprick injuries were not reported by staff and they believed the data in their study supported there was an underestimation of the problem gauged by subjects' responses. For example, subjects reported they were reluctant to report injuries as "It was not worth it", it was "Too time consuming" and "Inconvenient"; these comments were provided "spontaneously" by the subjects involved in the study (Hammory, 1983, 176).
Neuberger, Harris, Kundin, Bischone and Chin (1984) carried out a retrospective study of needleprick injuries in hospital personnel from 1979 to 1981. During this period 256 needleprick injuries were recorded which represented an overall annual incidence of 48.8 per 1000 employees. The researchers stated most multiple needleprick injuries involved the nursing service department "Of the 286 incidents only 30 of the exposure sources were tested and of those tested 53% were HB sAg positive " (Neuberger et al., 1984, 175). This suggested subjects requested to be tested when they thought they were in danger of contracting hepatitis B. The researchers concluded that a comprehensive in- service reporting system was essential. They suggested in-service education and the provision of convenientiy placed impervious metal containers for needles were also necessary.
Osterholm and Garayalde (1985) reported on the results of a ten-year investigation into the incidence of hepatitis B in hospital personnel which was carried out in a Minnesota hospital. A total of 561 cases per 100,000 persons were identified between 1974 and 1983 with 412 cases of hepatitis B reported amongst hospital personnel. The authors stated studies showed hospital personnel at highest risk of acquiring viral hepatitis B 82 were those who had frequent blood contact. Nursing personnel experienced a decrease in the incidence of hepatitis B during the 10 year period but compared with other occupational health groups, they demonstrated the smallest decrease. In 1983 personnel in the haemodialysis service showed the highest rate per 100,000 personnel, of cases (N=392) compared with medical laboratory staff (N=0), physicians (N=25), nursing service (N=9) and other (N=2). The researchers did not define the occupational status of the haemodialysis service. The authors believed hepatitis B vaccine (HBV) was responsible for reducing the infection rates in 1983 and suggested because hepatitis B was an occupational health risk, staff in potential at risk areas should be vaccinated. Further data should be based on the frequency of"... asymptomatic HBV seroconversion or clinical illness, rather than HBV seroprevalence data" (Osterhohm and Garayalde, 1985, 3212).
Jackson, Dechairo and Gardner (1986) carried out a survey into the perceptions and beliefs of 1,473 nursing and medical personnel in two large teaching hospitals in California. They specifically investigated the subjects' beliefs about needleprick injuries and needle-handling practices. Four hundred and eighty-eight respondents replied and 164 (33.6%) of subjects reported receiving one or more needleprick injuries during 1983, with a large percentage of subjects not reporting their injury (40.4% at one hospital and 53% at the other). Carelessness was perceived to be the main cause for needleprick injuries with "lack of knowledge of proper disposal technique" ranking last for all groups (Jackson et al., 1986, 4).
Recapping needles accounted for between 15% and 24% all nurses' accidents, (Ruben, Norden, Rockwell and Hruska, 1983; Sumner, 1985 and Williams,1983). To investigate recapping needles procedure, Huber and Sumner (1987) carried out an experiment with seven different cap diameters measuring 0.7 cms to 2.0 cms. Subjects in the experiment consisted of 36 registered nurses and licensed vocational nurses. The subjects were given standardised instt^uctions to "(1) hold a syringe with a capped needle 83 attached, (2) remove the needle cap and set it down, (3) touch the needle tip to a small target and (4) replace the cap" (Huber and Sumner, 1987, 128).
A repeated measures analysis of variance compared the recapping task, number of sticks missed and time taken to complete the task. The results showed subjects were able to replace a cap 1.5 cms or larger significantly faster than the three smaller sizes. The researchers concluded accidental sticks could be reduced if larger cap diameters were used. They further claimed 80% to 90% of curtent accidents would be eliminated if a funnel-shaped shield of 1 to 2 cms diameter was used.
Wills (1986) investigated needleprick injuries amongst New Zealand registered and enrolled nurses. Fifty-four percent of respondents returned their questionnaire and of the nurses surveyed, 69% stated they had experienced a needleprick injury. The results also showed only 10% of the nurses surveyed were vaccinated against hepatitis B.
Krasinski, LaCouture and Holzman (1987) investigated ways of reducing needleprick injuries in hospital workers. A 27 month study was carried out by the researchers to compare needleprick injuries before and after the education programme. The experimental variable consisted of discouraging recapping and preventing bending or clipping of needles before discarding them. Impervious containers were provided for the used needles. An education programme was introduced simultaneously with the experimental sessions. The were three survey periods during the study. Nursing staff experienced the highest rate of all reported injuries (75% of a total of 315 incidents), and most injuries (20%) occurred while a patient was being medicated. The researchers were "surprised" the new needle-disposal system did not make any difference and suggested an attitudinal study to "... compare and contt-ast the attitudes of personnel who exhibit behaviour that is self-protective with the attitudes of those who do not" (Krasinski et al., 1987, 62). A similar experiment was carried out by Ribner, Landry, Gholson and Linden (1987) 84 who investigated employees' needleprick injuries before and after the introduction of a rigid, puncture resistant, needle disposal system. They found overall rates of needleprick injuries increased, from pre-test figures of 6.0 per 100 to post-test figures of 8.7 per 100 full time equivalent employees/year. Nurses represented the highest significant incident group (total pre-test 162, and post-test, 166). The next highest affected group was housekeeping with 11 pre-test, and 18 post-test. The incidence of hepatitis B has been shown to be increasing particularly in the last decade. Symington, (1987) stated this was probably due to the increase in HBV carrier rate in drug abusers: "One hospital, employing about 500 nurses, averaged one case a year, and three clinical cases a year were reported in "at risk" groups of hospital staff, with one fatal case in 1977" (Symington, 1987, 50).
Evidence appears to support the claim that nurses are at risk from transmission of infection due to the possibility of needleprick injury or incident with a known HBV patient or carrier. Symington argued for a comprehensive vaccination programme against HBV as a preventative measure against an occupational disease for nurses. Some health authorities in the past have been reluctant to immunise thek staff due to the high cost of the vaccine, [(one hundred sterling pounds per employee in the United Kingdom). (Omen and Morris, 1984; Symington, 1987, 51)].
Because of the risk of hepatitis B, among health service personnel immunisation against hepatitis B has been investigated by Morgan-Capner and Eddleston (1983). The vaccine became available in the United Kingdom in September, 1982 (and in the United States in June 1982; Chin, 1982) and recipients have been shown to induce antibodies to the antigen (anti-HBj) in 90% of cases. The course consists of three immunisations over a three month period.
The researchers discussed the concern that"... the hepatitis B carriers used as a source 85
of plasma for preparation for the vaccine may well belong to groups in whom the acquired immunodeficiency syndrome (AIDS) occurs" (Morgan-Capner and Eddleston,
1983, 221). The researchers also stated AIDS had been identified in vaccine recipients however the incidence was the same as in a similar unimmunised group.
James, Solnick, Habel and Agee (1985) surveyed hepatitis B vaccination programmes for hospital employees. Questionnaires were sent to 207 general care hospitals in
California. One hundred and ten (66.3%) hospitals responded. Hospital staff were asked to respond to the existence or absence of a hepatitis B policy, immunisation policy, screening tests used and payment source for screening tests. Thirty-seven hospitals possessed a policy to immunise employees, ten had a policy not to immunise and three did not nominate either way. Screening tests varied, with the antibody test for HBV susceptibility the most common. Payment source policies also varied. However most hospitals paid the cost of immunisation for those employees exposed to risk situations.
The researchers concluded that further studies should be carried out on immunisation policies.
Windsor, Arbuckle, Spencer, Sebastian, Ginwala, Jinahai, Matjila, Naidoo, O'Dowd and Ramiah (1984) carried out two seroepidemiologic surveys of 423 nurses and 141 domestic staff working in a Durban, South African Hospital. Results showed that;
"The prevalence of antibodies to HBV was 14.9 percent in 101 white nurses, 52.2 percent in 322 African nurses and 51.8 percent in 141 African domestics. This represents a greater than eight times increase for white nurses and a fifty percent increase for African nurses and domestics over that seen in the equivalent blood donor groups (p < 0.(X)1 in each case)"
(Windsor et al., 1984, 81).
The researchers recommended HBV marker screening prior to vaccination as being economically sound for indigenous staff working in high HBV endemicity. They supported staff vaccination, and argued it was essential for the protection of both patients and staff.
Hadler, Doto, Maynard, Smith, Clark, Mosley, Eickhoff, Himmelsback and Cole (1985) 86
examined the risk of occupationally acquired hepatitis B from blood and or needleprick exposure in 5,697 hospital workers. Two groups of nurses were shown to be at risk; firstly, a group representing nurse anaesdietists, registered nurses and licensed practical nurses (probability <.001) and, secondly, nurses' aides and orderlies (probability <.02).
The risk of HBV infection did not correlate with the degree of patient contact but rather with the degree of blood contact and frequency of needleprick injuries. The researchers exposed a need for divising hepatitis B vaccine programmes for hospital personnel and warned of the danger of underestimating the prevalence of HBV as evidenced by chnical hepatitis. Silent infections also needed to be diagnosed as only 15% of infections in their study were clinical according Martin, Jannausch, and Skendzel (1986) who recommended hepatitis B vaccine for high-risk health care workers. In their study of 422 employees in six small Michigan rural hospitals they found the prevalence of hepatitis B surface and core antibody to be 5.5% in " ... general nursing, intensive care nursing, recovery room IV therapy, laboratory and respiratory therapy" (Martin et al., 1986, 64).
This study highlighted the risk nurses encountered in these particular clinical areas.
Klotz, Norman and Silberman (1986), in a study of seroconversion to hepatitis of 236 subjects only 53% or 124 subjects, showed protective levels of antibody to hepatitis B surface antigen. The researchers indicated a need to provide a booster injection to subjects for full protection and continued antibody surveillance.
A serological study was carried out by Smith (1987) to find evidence of hepatitis markers using HBsAg, anti-HBc, in 561 hospital personnel. The three groups tested were nurses, dental and junior medical staff. Subjects involved in the study had not previously received hepatitis B immunoglobulin. The results showed of the 419 nurses not vaccinated in the study, 3.8% were positive for at least one marker. Sixty-nine dental practitioners demonstrated a prevalence rate of 1.1% and of the 52 junior medical staff,
9.6% were positive for at least one marker.
Smith (1987) concluded the results reflected only a "... relative risk of occupational 87 exposure" (Smith, 1987, 39). Nurses were at twice the risk of the general population and he argued against the widespread vaccination of health employees until a "... cheaper genetically engineered vaccine becomes available" (Smith, 1987,42).
Tong, Howard, Schatz, Kane, Roskamp, and Boone (1987) tested 1,745 employees for hepatitis B virus antibodies prior to carrying out a hepatitis B immunisation programme in a 565 bed hospital in California. Fourteen point five percent (14.5%) of subjects showed evidence of antibodies and a significantly higher prevalence was found in those subjects who had a previous history to needles, hepatitis and blood transfusions. A vaccination programme was offered to all members of staff free of cost to prevent potential complaints of discrimination against the administration. Fifty percent of employees were vaccinated with only "... 54% of susceptible nurses and 18% of susceptible physicians" electing to be inoculated with the hepatitis B vaccine (Tong et al., 1987, 107). A large proportion of subjects (33%) refused to be immunised because of safety reasons. Non-participating subjects were concemed about the risk of contracting AIDS from the vaccine. Tong, et al., (1987) stated "... the hepatitis B vaccine was pooled plasma of chronic HBsAg positive carriers, most of whom were gay males" (Tong, et al., 1987, 107).
Shanson (1986) elicited a similar response from theatre and intensive care staff in a London Hospital after an outbreak of hepatitis B. None of the staff in these chnical areas accepted vaccination as they feared contracting AIDS from the vaccine, although an education campaign was carried out to assure staff the risk was "... virtually non existent" (Shanson, 1986, 131).
In Belgium, the increase in compensation claims by health care staff due to occupationally acquired hepatitis B caused the Belgium Insurance Fund for Occupational diseases to provide hepatitis B vaccination for those at risk (Lahaye, Baleux, Strauss and VanGanse, 1987). In 1981, the vaccination was offered to all hospital personnel 88
(including nursing and medical students). Some nurses refused the offer but the researchers did not explain the reason for this refusal. The cases of hepatitis B infection decreased and in 1985 HBV infections consisted of only 28% of the 1980 total. This compares with the prevalence of HBV in France (57% of the 1980 total) and 51% in Austria for the corresponding year.
Lahaye, et al., (1987) considered the economic investment in the hepatitis B vaccination programme as being "priceless", because temporary incapacity to work generally meant a minimum of four months off duty. The risks of other factors, for example cirrhosis of the liver and "death" compensation also provided economic as well as social savings (Lahaye, et. al., 1987, 442).
The study by Lewy (1987) of United States health care personnel showed only 28% of at risk health employees were immunised against hepatitis B. Lewy supported the need for immunisation particularly as 6% to 10% of those infected with hepatitis B became carriers and carriers with an attendant higher risk (12 to 300 times) of "... developing primary liver cancer" (Lewy, 1987, 435). Twenty-five percent of carriers also develop chronic active hepatitis. Lewy (1987) reported on the development of a genetically prepared vaccine that became available in 1987. The incidence of adverse side effects of this form of vaccine was reported as "low" (Lewy, 1987, 435).
2.7.3 Needleprick Injuries and Acquired Immunodeficiency Syndrome (AIDS) Studies
Wormser, Johne, Duncanson, and Cunningham-Rundles (1984) reported on needleprick injuries during the care of patients with AIDS at a New York Medical College. From "... twenty-seven parenteral exposures to the blood of patients with AIDS", 24 were caused by needleprick in 25 hospital employees (Wormser et al., 1984, 1461). The occupational groupings of subjects were nurses (11), house officers (9), medical 89 students (3), attending physician (1) and one phlebotomist. Compared to a control group of 30, 12 subjects tested did not demonstt-ate any significant differences in white cell count, total lymphocytes, T lymphocytes, and T-cell subsets six months after exposure to AIDS. Surveillance of the subjects' blood counts was to be continued, as the researchers considered "... the incubation period for AIDS may be prolonged" (Wormser, 1984 p. 1461). The researchers concluded needles should not be recapped but rather convenient needle disposal units be available.
In 1984 The Lancet published a report of a nurse who received a needleprick injury from a patient diagnosed with HTLV-EI. The nurse was resheathing a hypodermic needle in a syringe which contained fresh blood from the patient's arterial line. The nurse's serum was tested on the 27th day after the injury and on the 49th and 57th the titres were respectively 12 and 24, indicating the presence of HTLV-IE (The Editor, The Lancet, 1984, 1377).
The report warned against self inoculation with blood and blood products from patients with HTLV-III and urged utmost care during the nursing of these clients. Epidemiological evidence presented in the report suggested AIDS in Central Africa differed epidemiologically to that in the US of America and also it appeared to be spread heterosexually.
HTLV-III infection among health care workers was discussed by Weiss, Saxinger, Rechtman, Grieco, Nadler, Holman, Ginzburg, Groopman, Goedert, Markham, Gallo, Blattner, and Landesman (1985). They reported three case studies involving health care workers and AIDS transmission. The first case study involved health care worker "A" who sustained two needleprick injuries to her hand in late 1983 and early 1984 while drawing blood from two AIDS patients. In November 1984 all serum samples collected from the subject were found to be positive for HTLV-III antibodies until June 1985 when they were found to be negative (Weiss, et al., 1984, 2091). The subject declined to be 90 interviewed by health authorities because of the issue of confidentiality.
The second case study involved subject "B" who had her finger punctured with a forcep which had just removed a biopsy from a patient with AIDS. The incident occurred early in 1983 and in May 1985 her serum samples were HTLV-in positive as well as positive for hepatitis B surface antigen, although she was never immunised against hepatitis B. Other possible avenues for infection were discounted after interviews with her sexual partner. The researchers stated epidemiologic investigations were still proceeding.
The third case study was "... a healthy 21 year-old unmarried male "whose serum was tested and found to be HTLV-III positive when he volunteered as a contt-ol subject for an experiment (Weiss, et al., 1985, 2091). He recalled two occasions when he cut his hand. The first was late in 1983, "... while handling blood from a transfused leukemic patient", and the second in mid-1984 when "... he accidentiy jammed a capillary tube, which contained pooled platelets from 16 donors, into his palm" (Weiss, et al., 1985, 2091). During the interview he denied any other possible transmission routes.
The researchers commented on the evidence from the case studies and they argued the fu-st case study was consistent with occupational exposure to HTLV-III. The second case study involving subject B was considered ambiguous, because serum for testing was not available from her sexual partner early in the course of the infection. Subject C in the third case study, was considered to be probably due to occupational transmission. They highlighted the potential risk of needles as a route of AIDS exposure for health care personnel and suggested needles should not be recapped and there should be "... scrupulous attention of blood-drawing" (Weiss, et al., 1985, 2092). In concluding, they emphasised the importance of teaching nursing, medical and laboratory staff,"... proper techniques of phlebotomy and other high risk procedures" (Weiss, et al., 1985, 2093). Hirsch, Wormser, Schooley, Ho, Felsentstein, Hopkins, Joline, Duncanson, 91
Samgadharan, Saxinger, and Gallo (1985) investigated the risk of nosocomial acquired infection with human T-cell lymphotropic virus III in 85 employees. The employees were those who had experienced needleprick injuries from patients with AIDS and those who had been exposed to specimens from AIDS patients. The results showed a negative HTLV-III antibody finding in all specimens taken from the subjects. The researchers suggested the case of nosocomial acquired AIDS was not clearly established and as the numbers of cases had been small continued long-term surveillance was considered necessary.
Gerberding, Hopewell, Kaminsky, and Sande (1985) discussed a case of an operating room staff member who sustained a needleprick injury during a bronchoscopy being carried out on a 31 year old homosexual client. The male subject's serum tested positive for HBsAg. Fifteen weeks after the exposure and again at one year and fifteen weeks after the exposure, the subject's antibody to AIDS associated retrovirus was negative. The researchers suggested the case did not "preclude" transmission of AIDS by needleprick, as it was possible viral titres could have been higher in patients before the development of the full-blown disease. Further they suggested the titres may have subsequently fallen with the reduction in T helper-cell function as the infection progressed.
Oksenhendler, Harzic, LeRoux, Rabian, and Clauvel (1986) discussed the case of a nurse who was infected with HTLV-III with seroconversion after a superficial needleprick injury to her finger. She received it while recapping a needle after a thoracentesis of a patient diagnosed with, "... generalised lymphadenopathy, pleural effusion, seropositivity for HTLV, and hepatitis B surface antigen" (Oksenhendler, et al., 1986, 582). Specific immunoglobulins and hepatitis B vaccine were given immediately after the injury. Fifty-three days later she developed acute anicteric hepatitis and her serum was HTLV positive on days 68, 82 and 151. She was epidemiologically investigated for risk factors for HTLV infection. Her husband was tested was found to 92
be HTLV negative 110 days after the injury. The researchers emphasised the need for careful handling of needles and body fluids of HTLV patients.
Soicof and Morse (1986) discussed the investigation of a female healdi care worker who received an AIDS contaminated needleprick injury from a large-bore needle during an emergency procedure. She was screened and 14 days later she developed chills, fever, myalgias, and arthralgias. At 15 days post-injury she had a temperature of 40.3^0., enlarged right auxiliary lymph nodes and her while cell count was rising (1700 with 26 percent lymphocytes). She lost nine kgs in weight over the next month and on days 184 and 239 her blood sample antibodies for HTLV-III were positive. Her husband was investigated and an epidemiologic study showed he did not demonstrate any risk factors for AIDS. The researchers called for the strict adherence to infection control procedures, particularly during emergency procedures when they claimed there was a higher risk for accident occurrence.
AIDS seroconversion was reported by Neisson-Vemant, Afri, Mathez, Leibowitch, and
Monplarsir, (1986) in a 24-year old nursing student who in July, 1985 sustained a needleprick penetration with a needle used to take blood from an AIDS patient. In
January, 1986 the nurse was found to be seropositive, with a normal T helper count although the helper/suppressor ratio was increased, [(0.78 and Ig G (1830 mg/dl) and
IgM (471 mg/dl)]. On testing, her husband showed negative counts and investigations demonstrated she was not at risk from other possible sources. The researchers attributed the episode to an acute HIV infection caused by the puncmre wound she sustained.
A nationwide surveillance was carried out by McCray (1986) in Atianta, USA, for health care workers who had been exposed to AIDS via parenteral or mucous-membrane exposure. Seventy-six percent of the exposures were caused by needleprick injuries or sharp penetrations. Nine- hundred and thirty-eight subjects were followed up, (28 subjects were unavailable for the study). The subjects in the study were to be evaluated at six monthly intervals for a period of three years. At each interview their history was recorded, a physical examination took place and blood was collected for a white-cell 93 count, phenotypic T-cell subset analysis. A confidential questionnaire was completed by the subject on non-occupational AIDS risk factors.
Results showed 61% of subjects were nurses, 17% were physicians or medical students, 10% laboratory workers, 6% phlebotomists, 4% respiratory therapists and 2% were defined generally as "health care workers". Immunologic testing on 341 subjects showed 96% had normal T helper/T suppressor cell ratios. Twelve subjects showed low ratios and of seven who had follow-up tests three subjects showed persistent low ratios. Of the three subjects, one subject would not consent to HTLV-III testing, one subject was seronegative and the third subject was seropositive. The researchers suggested the literature and dieu- findings revealed a very low incidence of documented tt^ansmission of HTLV-III antibodies. However, they argued that health care workers should familiarize themselves with and follow recommended precautions.
A study was carried out at St. Stephen's Hospital, London, by Shanson (1986) into a variety of blood inoculation injuries and association with known ABsAg or HTLV-III antibody donors during the period January, 1982 to July, 1985. It was found that"... Only 1 of 151 different staff tested has been positive for HTLV-III antibody and he was found to be an active homosexual" (Shanson, 1986, 131).
Shanson suggested the infection in the staff member arose from personal risk factors rather than working in the hospital. During the study eight staff members had needleprick injuries and injuries from "... dirty sharp needles" and to the time of publication none of the injured had seroconverted to HTLV-III (Shanson, 1986, 131). Some researchers have argued the risk of occupationally acquired HTLV-III is low. Wills (1986) reported the problem of needleprick injuries and HTLV-III was an occupationally transmissible infection, but acknowledged the risk of HTLV-III appeared low. He added, however, that the risk still existed and caution needed to be observed with needleprick injuries. 94
Garibaldi (1986) suggested the "... possibility of transmitting HTLV-in in hospitals is quite low" and "... only blood exposures, such as needles, are likely to put health care workers at increased risk for nosocomically acquired infection" (Garibaldi, 1986, 133).
Mitchell (1986) also discussed the potential for Q-ansmission of HTLV-III by needleprick and also stated the transmission rate was low. He warned that pregnant health care workers ran the risk of transmitting HTLV-III to the fetus because many AIDS patients also carried teratogenic cytomegalovirus. This infection could also be transmitted to the pregnant women and her unborn child, (Mitchell, 1986, 855).
Valenti (1986) also raised the question of pregnant health care workers caring for AIDS patients and in a somewhat ambiguous statement suggested they:
"... are not at increased risk of HTLV-III infection because of pregnancy. While the guidelines do not say that pregnant workers may safely care for patients with AIDS, they do not recommend restriction either" and "their guidehnes do not restrict pregnant women for nursing patients with cytomegalovirus as well." (Valenti, 1986, 429)
Valenti and Anarella (1986) investigated the understanding of the acquired immunodeficiency syndrome among 741 hospital personnel. Two hundred an sixty-six surveys were returned, representing a 36% response rate. There were 64 nurses in the population sample. Subjects were asked a series of questions about isolation precautions, infection control procedures and their attitude towards AIDS patients. The findings showed subjects who stated they had no concern about caring for patients with
AIDS (22%), were more likely to show a higher level of understanding of the infection.
The results highlighted that 88% of subjects in fact indicated they had "concerns", demonstrating die fear health care workers had in caring for clients with AIDS.
Crossley and the Morbidity and Mortality Weekly Report (MMWR), (1987), discussed health care workers with AIDS. A total of 1,875 (5.8%) of 32,395 subjects diagnosed as 95
infected with AIDS were found to be health care workers. Eighty-seven health care workers were categorised as not having an identifiable risk although information was incomplete for "... 16 (18%) due to death or refusal to be interviewed; 38 (44%) are still being investigated" (Crossley and MMWR, 1987, 1293).
The 33 remaining health care workers were followed-up; 3% were nurses and 9% were nursing assistants. Fifteen of these 33 health care workers had reported needleprick injuries and or parenteral exposure from patients in the ten years prior to AIDS diagnosis but none of the "... exposures involved a patient with AIDS or known HIV infection"
(Crossley and MMWR, 1987, 1293).
The Report urged all health care workers to prevent needleprick injuries/ sharp injuries by following correct guidelines. The Report suggested, for example, uncapping needles and placing all sharps in a puncture-resistant container.
Adequate compensation for health care workers who contract occupationally acquired
HTLV-III was discussed by Brennan (1987). He stated accidents leading to HIV infection should be easily identifiable and defined the latency period as "... three to five or more years", therefore discounting the need for "probabilistic reasoning about causation "... as is the case for some occupationally acquired diseases (Brennan, 1987,
582).
Kuhls and Cherry (1987) discussed the probabihty of acquiring HIV infection following an AIDS patient-associated needleprick injury and stated the risk was "... 1% or less"
(Kuhls and Cherry, 1987, 211). They postulated the risk of acquiring AIDS in this way was considerably less than contt-acting hepatitis B, although they did not dispute the probability of needleprick transmission accidentiy occurring. They outlined a procedure that should be followed after needleprick injuries with biological exposure to AIDS (see
Figure 2.3). 96 Please see print copy for image
Figure 2.4 Showing "Protocol for the follow-up of accidental needleprick exposures to biological specimens of HIV seropositive individuals" (Kuhls and Cherry, 1987, 213).
In a study outlining the legal implications of AIDS involving employees and employers
Dimond, (1987) reported on an incident at the Royal College of Nursing conference at
Glasgow. He related an incident of " ... a nurse who suffered a needle injury when treating an AIDS patient. While waiting for results of an AIDS test, the nurse manager provided her with a marked plate and cup for the canteen" (Dknond, 1987, 29).
The researcher stated that the behaviour of the employer and manager constituted harassment, and indicated that they could be found liable and acting in fundamental breach of contract. Furdier, Dimond (1987) argued that if a professional nurse refused to care for a patient with AIDS, there could be legal grounds for acting unreasonably. The employer had an obligation to provide "... adequate protective clothing, gloves and other equipment necessary to prevent her from being cross-infected" (Dimond, 1987, 29). If the nurse was found to be acting in an unreasonable manner then it was possible that the 97 employer could legitimately dismiss the employee.
Litigation cases have also been reported in the hterature by Burda (1987), who discussed two cases which resulted in litigation. One case involved an operating room technician who sued St. Joseph's Medical Centt-e, Joliet because she was suspended after she refused to care of a patient with AIDS. The second case involved a male nurse who sued the Terte-bonne General Medical Centre, LA, because he was fired after the administration of the hospital in which he was employed discovered his roommate had died of AIDS.
Burda (1987) also reported in the literature about a compensation claim that had been filed by an employee, who developed a stress related disorder after nursing patients with AIDS. The nurse working at San Francisco General Hospital developed ulcers while caring for an AIDS patient. She was awarded $5,000 in compensation.
Attitudes towards AIDS have been explored by Wertz, Sorenson, Leibling, Kessler, and Heerein (1987) who discovered after the implementation of an education programme about AIDS "... sizeable percentages of health care providers continued to believe after the programme that AIDS could be transmitted by casual contact, such as sharing coffee cups" (Wertz et al., 1987, 248).
Attitudes towards the risk of registered nurses acquiring AIDS in an Australian 85 bed community hospital was investigated by Neilsen (1988). Seventy-nine percent of the registered nurse population responded to a survey which was divided into three parts. Part one was based on Valentis' study and was designed to elicit subjects' understanding of AIDS. The results showed 44% of subjects possessed some cortect information concerning the disease. Part two of the instrument was designed to elicit sources of information from nurses about AIDS and issues concerning carriers of the infection. The 98 results for this part of the survey revealed 71% of subjects obtained information via the media and 29% gained their information from professional journals and seminars. The concerns subjects expressed about acquiring the disease from patients, included 47% of subjects. Forty-one percent of nurses were concerned about both acquiring the disease from a patient as well as transmitting the disease to a patient.
Part three of the survey examined subjects specific at-risk situations including needleprick injuries. Fifty-three percent of subjects indicated they sustained a needleprick injury annually or less and 29 subjects sustaining one monthly, ten percent monthly and two percent weekly. Skin contact with blood or blood excretions was a concern expressed by 62% of nurses who nominated this occurred "frequently", and 32% of nurses nominated this action took place "occasionally".
The preparedness for subjects to wear gloves each time the subject had contact with blood or body fluids containing blood, showed 49% of subjects believed they would wear gloves 25-50% of the time. Only 17% of subjects believed they would wear gloves 100% of the time. The results highlight the lack of factual information possessed by the subjects in the study.
2.7.4 Summary
The evidence suggests the risk of transmission of AIDS by needleprick is low, compared to hepatitis B (Lifson, Castt-o, McCray, Jaffe, 1986). It is evident there is a great degree of fear associated with possible AIDS contamination, [via, for example, immunisation against hepatitis B (Shanson, 1986)] and lack of understanding about the disease, (Neislon, 1988). It appears timely to investigate nurses' attitudes towards both hepatitis B and AIDS and current hepatitis B immunisation patterns within the defined research sample population of nurses. 99
2.7.5 Legionnaires' Disease as an Occupational Risk
"Legionnaires' disease is a pneumonic illness with systemic manifestations that is caused by legionella pneumophila" (Meyer, 1983, 258). The disease was named due to the first out-break which occurted in Philadelphia at a state convention of die American Legion, in July 1976 (Eraser, Tsai, Orensteiin, Parkin, Beecham, Sharrar, Hartis, MalHson, Martin, McDade, Shepard and Brachman, 1977; Tsai, Finn, PUkaytis, McCauley, Stanley, Martin, and Eraser, 1979).
Meyer (1983) discussed the nosocomial aspects of Legionnaires' disease and reported that the highest incidence of nosocomial acquired Legionnaires' disease occurred at Pittsburg Veterans Administration Medical Center. Legionnaires' disease has been commonly noted in hospitals as a nosocomical infection, (Marks, Tsai, Martone, Baron, Kennicott, Holtzhauer, Baird, Fay, Feeley, Mallison, Eraser and Halpin, 1979; Helms, Massanari, Zeitler, Streed, Gilchrist, Hall, Hausler, Sywassink, Johnson, Wintermeyer and Hierholzer, 1983 and Johnston, Latham, Meier, Green, Boshard, Mooney, and Edelstein, 1987). Legionnaries' disease has more commonly affected patients, rather than health personnel employed in hospitals. Therefore the following discussion of the effect of legionnaires' disease on nursing staff will be brief due to the lack of studies in the literature.
Saravolatz, Arking, Wentworth, and Quinn (1979) investigated the levels of immunity to Legionnaires' disease in two matched groups of health personnel. Group one comprised, 215 hospital staff who had been in contact with patients' diagnosed with the infection and group two comprised, 269 staff who had not been in contact with patients diagnosed with the disease. Both groups consisted of approximately equal numbers of "... physicians, nurses, respiratory therapists, medical technicians, unit clerks and housekeeping personnel" (Saravolatz, et al., 1979, 601). 100
Results from the survey showed group one had significantly higher antibody titre, [less or equal to 128 "... using the hemagglutination technique, (Saravolatz, et al., 1979,
601)] compared to group two. There was no cortelation between the prevalence of high titres, (less than or equal to 128) and degree of contact with the patients. The researchers stated further studies needed to be carried out to investigate the risk to hospital staff exposed to patients with Legionnaires' disease and transmission modes needed to be studied further.
Haley, Cohen, Halter, and Meyer (1979) discussed nosocomial Legionnaires' disease involving 49 subjects at Wadsworth Medical Center. Forty-nine patients were diagnosed
as having Legionnaires' disease during the period from May, 1977 to July, 1978. Three of the subjects were employees of the hospital (Kirby, Snyder, Meyer and Finegold,
1980). A serologic survey was carried out on employees working in three selected areas of the hospital and 12 groundskeepers (who worked in the grounds of the hospital) were
also tested. The researchers did not define the occupational status of the hospital employees. The indu-ect FA method for antibodies to the LD bacterium demonstrated out of a possible 119 volunteer employees, 20 (17%) had titres 128 or higher for
Legionnaires disease compared with only "... 4% (five out of 116) of the regional office employees ( p < .0004, Fisher's exact test": Haley, et al., 1979, 585). The results of the test showed subjects' exposure to the disease resulted in some employees serum levels being affected.
Dondero, Rendtorff, Mallison, Weeks, Levy, Wong, and Schaffner (1980) reported on an outbreak of Legionnaires' disease in 44 cases involving employees, visitors and passersby. The risk to the subjects correlated with the proximity to a temporary auxiliary water tower. The water tower had not been decontaminated and possessed levels of L. pneumophila.
Twelve cases of Legionnaires' disease were reported by Fisher-Hoch, Tobin, Nelson, 101
Smith, Talbot, Bartlett, Gillett, Pritchard, Swann and Thomas (1981) that occurted in
Kingston Hospital, Surtey. The 12 patients included eight who were admitted for a variety of diseases other than pneumonia and developed pneumonia after admission (2-10 days later). One patient was admitted two days after returning from Spain with pneumonia. Of the three remaining cases who were admitted with pneumonia one was a visitor and 2 were employees at the hospital. The occupations of the two employees were a cleaner and a porter. The researchers stated 11 of the patients probably acquired
Legionnaires' disease by nosocomial infection and the source was later found to be "... the plumbing system and possibly also the air-conditioning cooling tower exhaust in the new building of the hospital" (Fisher-Hoch et al, 1981, 932).
A Legionnaires' disease outbreak occurred in Wollongong on March, 1987 and at the end of the epidemic " ... 97 atypical pneumonia cases had been investigated, 38 legionnaires' cases were proved, with seven deaths" (The Sydney Morning Herald, Friday, June 12,
1987, 4).
The epidemic caused the secretary of the NSW Nurses' Association to voice concern regarding the welfare of union members working at the Wollongong Hospital (Haupt and
O'Neil, 1987, 4). At the end of the epidemic the causative organism was found to be present in a water cooling tower in a chemist shop in the local shopping district and "... legionella was found in water samples taken from Wollongong Hospital on April 3 and the hospital's water tower had been cleaned on April 6, April 24 and April 26" (Simpson,
1988). There was one reported case of a hospital employee (whose designated occupation is a driver), being affected by the disease and he was recentiy awarded a workers' compensation case against the hospital administration for loss of wages and medical bills (Simpson, 1988).
Martie, George, Macdonald, and Haase (1986) in their investigation of 500 health 102
workers in a Canadian Hospital during an outbreak of Legionnaires' disease the researchers concluded the risk of infection to employees was low, 2.4% or less.
Glasgow Hospital experienced an outbreak of legionella in a new building in the hospital. Brodie (1987) reported 15 patients and one staff member (the occupation of the staff member was not stated) being infected with a mortality rate of five patients.During the epidemic 100 staff members were screened with seven percent of staff members showing a positive antibody to legionella pneumophila. Two staff members demonstrated titres of 64 or above. The researcher stated the essential factors in containing and controlling the outbreak were due to good communications, team work and good working relationships (Brodie 1987, 131).
2.7.6 Summary Legionnaires' disease has been established as a disease which poses an occupational health risk factor for nurses. Although the majority of cases have involved non nursing staff where outbreaks have occurred, littie is known about the attitudes of nurses to Legionnaires' disease and whether they view it as a risk factor. It would appear timely to investigate nurses' attitudes to the disease given the outbreak of Legionnaires' disease in the Wollongong area.
2.8 Assault as an Occupational Risk Factor
Nurses are often placed in at-risk situations in their working environment and "... a nurse may find herself losing a fightwit h a drunk in casualty, a violent psychiatric patient, or a terrified patient who starts hitting out at anything and everything" (Denning, 1985, 14).
Assault appears to be an occupational hazard for the nursing profession. It has been 103
historically recognised as a particular hazard for psychiatric nurses (Levy and
Hartocollis, 1976). The literature in this area has revealed few studies have been carried out in the general nursing area. The few studies researched in the general nursing area have shown assault is higher than generally believed (Lanza, 1984; Holden, 1985).
Lion, Snyder, and Mertill (1981) investigated the incidence of assault in a large state hospital in USA, consisting of 800 nursing staff and 1,000 patients. For the year 1977 they discovered there were 302 cases of assault which involved nursing staff, and they ranged from bruising, broken dentures to one staff member who required sutures to facial lacerations.
The researchers were prompted to carry out an analysis of daily ward reports during the months of April, August and November, 1977. Their investigations revealed there were distinct differences between those assault incidents formally reported and those noted in the daily ward reports. There were 40 assaults formally reported and 237 assaults which were noted in the daily ward reports and were not formally reported. Seventy-two percent of assault incidents occurred in admission units. The researchers argued the study contained methodological problems and were concemed that the hospital where the study took place had no guidelines for reporting assaults. The results of the study prompted the implementation of staff workshops to encourage staff to report incidents of assault.
Lanza (1984) carried out a study to gain insight into nurses' reaction to assault. Ninety- nine registered nurses (93 women and 6 men) participated in the study. The subjects were presented with a standardised situational vignette to read in which the victim was sometimes male and sometimes female. Subjects completed a questionnaire which was designed to elicit their attitudes as to who was to blame for the assault and how the victim would feel. Fifteen percent of the subjects blamed the nurse-victim, 72% of the subjects blamed die patient and 2% held society in general to blame. Lanza (1984) concluded that the study only represented a beginning documentation of assault and that many nurses 104
beUeved it was unprofessional to express their feehngs about the subject.
Lewis (1985) in a similar study, investigated the frequency of assault in six male and 93 female registered nurses working on day, evening and night duty and in three clinical
locations, (psychiatric, medical and nursing care units).She reported that "About one-
fifth of the sample had never been assaulted by a patient, anodier fifth had been assaulted
more than three times, and the remainder had been assaulted from one to three times"
(Lewis, 1985, p.9). The researcher did not state in which chnical setting the assault took place.
Registered nurses' attitudes to being assaulted were also investigated with the aid of a
vignette which showed a nurse being hit by a patient. A high level of subjects (71%)
expected the victim to experience "fairly severe" to "very severe" emotional responses to
the assault; subjects however rated their own responses as "less severe" than those of the
victim. Interestingly 45% of subjects believed that the victim would not receive any
support from co-workers or hospital administrators. In concluding, Lewis (1985) stated
there was a need to make the clinical environment safe for nurses (particularly as there
was a critical shortage of nurses) and for victims to receive support to enable them to
cope with their responses.
Holden (1985) studied the causes and effects of aggressive behaviour towards nursing staff in general hospitals and comunity health agencies in Victoria. Six hundred questionnau-es were distributed to 35 health agencies; of these 17 metropohtan hospitals,
3 community agencies and 4 country hospitals responded. Three hundred and ten questionnaires were returned representing a response rate of 53%.
Results showed aggression against nurses by patients was experienced by 85.8% of the total number of subjects involved in the study. In 41.9% of nurses in the study, visitors were the source of aggression. The sex distribution of the aggressors for 260 nurses 105
were male agressors and for 162 nurses the aggressors were female (or 52.3%). The
emotional responses of the nurses towards patient's aggressive acts revealed a high level
of anger by charge nurses (73.4%) and helplessness (45.3%). Student nurses were the
most anxious (66.6%) and registered nurses demonstrated the most resentment (33.0%).
The location where the most frequent assaults occurred were medical wards (N=71),
surgical wards (N=70) and accident and emergency wards (N=61). Geriatric wards
numbered 49 and the lowest frequency occurred equally in the operating room and the
paediatric ward with six in both cases.
Subjects in the study experienced high levels of physical and verbal abuse. With 63.2%
of subjects experiencing physical abuse and verbal abuse was found in 72.5% of nurses.
The researcher concluded that existing levels of aggression directed towards nursing staff
were unacceptable and a series of recommendations were made. Some of those
recommendations included increased staff/patient ratios in wards in high risk areas, the
introduction of courses in the management of aggression and provision of a counselling
service for nursing staff within the hospital system.
Cust (1986) reported on the assault of two male nurses by a violent patient admitted to a
psychiatric hospital for assessment. Both nurses requked physiotherapy for four months
after the assault took place. The patient was returned to court to stand trial with a
document stating he was not psychiatrically disturbed and was fit to stand trial.
Four months after the assault took place the nurses filed an assault charge against the ex-
patient. A preliminary hearing ruled there was sufficient evidence to proceed with the
case in court. At the trial, the defense argued on two points, firstly, on the basis of
consent and secondly, intention. Consent was present because the subjects freely chose
to work in a psychiatric hospital therefore knowing assault was likely in such an
institution and intention because the defendant did not mean to assault the nurses. The defendant was found not guilty. The researcher warned that consideration should be 106 given by nurses in future to the amount of support expected by hospital staff, and victims should give due consideration to this fact before proceeding to lay charges against a patient.
In contt-ast to the finding reported by Cust (1987), an eartier study by Schwartz and Greenfield (1978), showed a male nurse successfully won a court case against a female patient who resided in a short-term psychiatric unit. The incident of assault occurred after the male nurse had suggested to the patient that "... It must seem terrible that no one likes you" (Schwartz and Greenfield, 1978, 198). The patient responded by forcefully striking the nurse on the the side of the head which resulted in the nurse sustaining a perforated eardrum.
The judge, after hearing the evidence decided in favour of the nurse. There were four main points the judge based the decision on and he:
"... accepted the prosecution argument that the patient was legally capable and that the setting was irrelevant. He rejected the defense argument that the nurse had given permission to be assaulted by virtue of working in a psychiattic setting. He questioned the appropriateness of the wording the nurse had used and wondered if a more neutral statement could have been addressed to the patient. However, provocation itself, it it were indeed present could not affect his finding that the patient was in fact guilty of assault" (Schwartz and Greenfield, 1978, 198).
These two cases show the inconsistencies in the legal decisions by the courts and make the position difficult for the nurse, particularly the psychiatric nurse.
An investigation into the incidence of assault was carried out by Wills (1987). In a questionnaire mailed to 500 New Zealand nurses, which resulted in a 54% response rate. Wills found 31% of nurses in the survey indicated violence by patients was a significant problem and 20% of respondents had experienced assault resulting in an injury. Twenty-six percent of subjects had been assaulted by a patient within the last 107 twelve months and 60% of subjects had been assaulted by a patient during their nursing career. The most interesting aspect of the study was 62% of subjects indicated the assault occurted in a general hospital as opposed to 23% of subjects, who nominated the assault occurted in a psychiatric hospital. The researcher reported most injuries involved confused patients and Wills (1987) stated "... Presumably, it (assault) is accepted as part of the job, especially in some settings" (Wills, 1987, 9).
Leiser (1987) reported on the increasing problem of violence against hospital staff in the United Kingdom. High rates of assault have been reported in accident and emergency departments according to Leiser (1987). The problem of assault according to Leiser, appeared to be more widespread throughout other departments rather than just being confined to the accident and emergency department.
Morton (1987) suggested nursing staff could be taught effective nursing interventions to prevent the escalation of violent situations. Further she argued in situations where weapons were involved, staff responsibilities "... can be operationalised, taught, and practised by nursing staff (Morton, 1987, 280).
2.8.1. Summary
At the present time after a thorough investigation into the literature, it would appear that very littie research has been carried out into this area. Specific to New South Wales hospitals, the literature is extremely limited. The extent of assault as an occupational risk and the attitudes of nurses towards assault need to be investigated. 108
2.9 Anaesthetic Gases as an Occupational Risk Factor
The risk anaesthetic gases pose for nurses has represented a controversial area, for example "... We must conclude by stating that, despite the lack of evidence that waste anesthetic gases are hazardous, it also cannot be proven that exposure to the gases is safe" (Mazze, 1985, 228).
Anaesthetic risks for nurses working in operating rooms has been investigated, and a cause-effect relationship has not been established, (Cohen, Bellville and Brown, 1971 and Cohen, Brown, Bruce, Cascorbi, Corbett, Jones, Whitcher, 1974). Scavenging systems introduced into operating rooms in the 1970's helped reduce the levels of anaesthetic gases, (Yeakel, 1970; Whitcher, Cohen, and Trudell, 1971). There has been some controversy over the use of scavenging systems alone and effective ventilation systems have been recommended to be used as well (Nikki, Pfaffli, Ahlman, and Ralli, 1972).
Investigations into the effects of anaesthetic gases on reproductive function of nurses, mainly working in operating rooms has been investigated.
Rosenberg and Kirves (1973) in their study of miscarriages in 300 married Finnish operating room, casualty, scrub and intensive care personnel found an increased rate of spontaneous abortions. The highest rate was evidenced among scrub nurses with 21.5% of pregnancies ending in spontaneous abortion, a 16.7% rate in intensive care nurses, 15% rate in anaesthetic nurses and 8.3% in casualty nurses.
The researchers concluded from their study they beheved it was due to stress caused by excessive workloads rather than anaesthetic gases causing the increased rate of abortions. Further, they argued that the low incidence of malformations and fetal deaths ruled 109
against the teratogenic effects of anaesthetic vapours. Before positive conclusions could
be established the researchers suggested all abortuses of nurses in operating room would
need to be cytogenically examined.
Corbett, Comell, Entires, and Lieding (1974) carried out a survey of 621 female nurse-
anaesthetists in Michigan to investigate the incidence of birth defects. The authors
compared the total number of births of those mothers who practised anaesthesia at some
time during their pregnancy, and those mothers who did not practise during their
pregnancy. Those mothers who practised during their pregancy consisted of 434
subjects which represented 62.4% of the population. Those mothers who did not
practise during their pregnancy consisted of 261 subjects or 37.7% of the population.
The findings showed that in the 434 offspring in the mothers who practised 71 subjects
(or 16.4%) had birth defects. In the 261 offspring of those mothers who did not
practise, 15 or 5.7% of the population had birth defects. The results between the two
groups showed a statistical significance at the probability <.005. The authors suggested
"... exposure to low concentrations of anaesthetic gases, transmissible viruses and
radiation" could be implicated as causes of birth defects and increased incidences of
abortion in female operating room staff (Corbett et al., 1974). Although the study only
involved a small sample the authors suggested practicing female anaesthetist's offspring
risked bu-th defects.
Cohen, Brown, Bruce, Cascorbi, Jones, and Whitcher (1974) in a national survey of
occupational disease among operating room personnel (in the United States) investigated
the effects of anaesthetic exposure. Two groups were used in the survey; 49,585 subjects
who were exposed to anaesthetic gases and 23,911 subjects who were not exposed. The researchers found statistical evidence to support the hypothesis that those women
working in operating rooms experienced significantly higher rates of spontaneous no abortions than comparable subjects not working in operating rooms.
Ericson and Kallen (1979) investigated all infants born during the period 1973 to 1975 involving Swedish women working in operating rooms during their pregancies. They surveyed 494 subjects, 37 of whom were working for half of their pregnancy, and ten working for less than half their pregnancy. They found no significant differences between a reference group and the study group for incidence of threatened abortion, birth weight, perinatal death rate or congenital malformations. The researchers concluded that there were " ... possibly more gestations lasting less than 37 weeks" (Ericson and Kallen, 1979, 302). They argued their findings were based on unbaised register data and that was the reason for the negative findings in their study. Further the deleterious reproductive hazards caused by anaesthetics reported in previous studies were due to "... biased data collection" (Ericson and Kallen, 1979, 305).
Brodsky (1983) disagreed with Ericson and Kallens' (1979) conclusions and the stance Walts (1983) postulated. Walts (1983) argued there was no evidence to support that chronic exposure to anaesthetic gases caused adverse effects on reproduction or health. Brodsky (1983) stated the Ericson and Kallen (1979) study did not compare "... the incidence of spontaneous abortions between the exposed and non-exposed women" and further he believed exposure to anaesthetic gases was a major risk for spontaneous abortion (Brodsky, 1983, 134).
Brodsky (1983), to support his case, cited a study involving dentists' and "chairside dentists'" exposure to nitrous oxide. The study revealed greater increases of liver and renal damage and spontaneous abortions in dentists' wives as well as congentital abnormalities in the offspring of dentists in the study (see Cohen et al., 1980). Ill
Lauwerys, Siddons, Misson, Boriee, Bouckaert, Lechat, and De Temmerman (1981) investigated the effects of anaesthetic gases on the health of two groups of operating room personnel and a control group, (namely nurses and anaesthetists). A total of 2,839 individuals were sent a questionnaire resulting in a total response of 1,027 respondents or 57% of the population. The results showed there were no statistically significant effects on pregnancy due to working in operating rooms. Exposure to volatile anaesthetic gases was studied in 944 of the subjects and there was no difference between the control group and the experimental groups for miscarriages, congenital malformations, stillbirths or premature births. The only difference found was the frequency of headaches which was more prevalent in anaesthetists and nurses than in the controls. The researchers concluded that more research was required into the effects of volatile anaesthetics.
Axelsson and Rylander (1982) investigated the relationship between exposure to anaesthetic gases and increased rates of miscarriages in Swedish nursing personnel.
Two questionnaires were constructed to elicit, firstly, general information about pregnancies and outcome and, secondly, to gather specific information from those subjects who had experienced a miscarriage.The first questionnaire was mailed to subjects who were born during 1930 or later, and who had worked in areas where they might have been exposed to anaesthetic gases during the period 1st January, 1970 to
30th June, 1979. The contt-ol group consisted of non-exposed subjects selected from medical wards where "regular" exposure to anaesthetic gases did not occur. Categories of staff in the survey consisted of anaesthetic nurses, theatre nurses and nurse assistants. 112
Eighty-five percent of exposed subjects and 84% of non-exposed subjects responded to the first questionnaire. Due to the poor response to the second questionnake a telephone follow-up was instituted and the final reponse consisted of 92% of exposed subjects and
90% of non-exposed subjects.The differences between exposed subjects (12.4%) and non-exposed subjects (9.1%) were not statistically significant ( x2 = 0.23, p > 0.6). The researchers commented on the response bias in the study and were dissatisfied with the questionnaire mailing methodology employed. They concluded, although there were no significant differences between the two groups, the results of the study should not be interpreted in such a way to mean exposure to anaesthetic gases did not increase the miscarriage risk.
In a similar investigation Hemminki, Kyronen and Lindbohm (1985) studied 217 nurses who had been pregnant in the years spanning from 1973 to 1979, and whose pregnancies had resulted in a spontaneous abortion.Subjects in the study worked in anaesthesia, surgery, intensive care, operating rooms and internal medicine in Finnish general hospitals.
The researchers found there were no significant increases in the risk of spontaneous abortion or malformations due to the exposure of anaesthetic gases. They recommended however that there should be further studies carried out on the influence of cytostatic agents which they perceived as presenting possible risk factors.
Risk factors involving halothane and nitrous oxide exposure was discussed by Letts and
Wilkinson (1985). They argued that these particular gases were the most commonly used gases and stated exposure was caused by improper techniques used by anaethetists. 113
unscavenged or leaky anaesthetic delivery systems. This they suggested allowed gases to escape into the work environment of operating room staff. The researchers stated a causal relationship had not been determined but sufficient data existed to warrant a concern. They warned of the potential teratogenic and mutagenic effects of these gases and the possible increased susceptibility to infections and cancer (see Green, 1981).
Nitrous oxide exposure was investigated by Swedish researchers Sonander, Stenquist and Nilsson (1985) in 25 female and five male nurses anaesthetists and two female and four male anaesthetists. Two methods were used to measure the levels of gases and they were compared for reliability. Namely, a technical exposure measurement technique (pump-bag sampling equipment) and biologic exposure from urine samples.
Different anaesthetic conditions were used and the efficiency of general air-conditioning and close scavenging methods were investigated. The results showed exposure to nitrous oxide varied greatly. The two measurement methods correlated very well, (r = .97). The different anaesthetic conditions showed general, orthopaedic, unrology, thoracic and gynaecological anaesthesia compared favourably with the Swedish control limit, ["...100 ppm for 8 h time-weighted average (TWA)"; Sonander, 1985, 203]. Exposure in paediattic anaesthesia showed out of a total of 98 exposure periods, 16 out of the 18 recorded exposure periods above 100 ppm were in this area of speciality. The high figures were believed to be due to the leakage of anaesthetic gases around uncuffed endottacheal tubes used in paediatric anaesdiesia. 114
Tannenbaum and Goldberg (1985) reviewed the epidemological hterature of exposure to anaesthetic gases and reproductive outcome. After an extensive review, involving studies of anaesthesiologists (Vaisman, 1967Lancet, 1972; Knill-Jones, Moir and Rodriquez,1972; Knill-Jones, Newman, and Spence, 1975; Tomlin, 1979; Halsey, 1981), dentists, (for example,Cohen, Brown and Bruce, 1975; Cohen, Brown, Wu, Whitcher, Brodsky, Gift, Greenfiled, Jones and Driscoll, 1980) nitrous oxide, (Amess, Burman, Rees, Nancekievill, and MolHn, 1978; Layzer, Fishman and Schafer, 1978) and health care personnel, (for example, Rosenberg and Vanhinen, 1978 and Ericson and Kallen, 1979) concluded that the major epidemiological studies that had been conducted in this area had utilised significant flaws in their methodology. Therefore there was insufficient evidence to draw useful conclusions from the studies.
In her review of the literature Rogers (1986) postulated exposure to waste anaesthetic gases as a threat to 200,000 health care workers in the United States of America. She stated there had been an "... increased rate of spontaneous abortion, congenital anomalies, hepatic and renal disease as well as reduced psychomotor performance" (Rogers, 1986, 574). These findings appear to support the argument that, anaesthetic gases posed an occupational risk for health care workers. She emphaised the need for envu-onmental and health monitoring, particularly employee surveillance screening when waste anaesthetic gases are present.
The literature shows difficulties in establishing cause and effect between anaesthetic gases and reproductive complications (Tannenbaum and Goldberg, 1985). Methodogical 115
problems have been highlighted in the literature (Walts, 1983; Tannenbaum and Goldberg, 1985). The attitudes of nurses towards the effects of anaesthetics has not been investigated. In this intended research nurse's attitudes towards anaesthetic gases will be explored.
The literature shows difficulties in establishing cause and effect between anaesthetic gases and reproductive complications (Tannenbaum and Goldberg, 1985). Methodogical problems have been highlighted in the literature (Walts, 1983; Tannenbaum and Goldberg, 1985). The attitudes of nurses towards the effects of anaesthetics has not been investigated. In this intended research nurse's attitudes towards anaesthetic gases will be explored.
2.9.1. Summary The literature shows difficulties in establishing cause and effect between anaesthetic gases and reproductive complications (Tannenbaum and Goldberg, 1985). Methodogical problems have been highlighted in the literature (Walts, 1983; Tannenbaum and Goldberg, 1985). The attitudes of nurses towards the effects of anaesthetics has not been investigated. In this intended research nurse's attitudes towards anaesthetic gases will be explored.
2.10 Dermatitis as an Occupational Health Risk
Although skin disease is reported as the most frequent occupational illness representing 46% of all reported occupational illnesses in the US few studies relating to nursing have been carried out in this area (Shmunes, 1983). Shmunes, (1983) stated occupational skin disease accounted for 83% of all compensated industrial diseases in South Carohna, US. 116
After a careful search of the Australian nursing literature, little has been revealed suggesting dermatitis has been investigated as an occupational risk for nurses. An examination of the international literature have revealed three studies involving nurses.
Van Der Meeren and Van Erp (1980) reported on a male nurse's anaphylactoid reaction to glove powder. An extreme reaction was experienced by the subject after wearing surgical gloves. In the reported case, tests failed to reveal the causative agent and the researchers warned of possible sensitivity to both lubricant and glove powder.
Surgical gloves have been reported in the literature as causing contact dermatitis in surgeons (Henderson, Melville-Jones, Barr and Griffiths, 1975; Forstrom, 1980). As nursing staff wear surgical gloves in operating rooms and other areas it would be expected nurses would have similar occupational risk factors.
Kassis, Vedel, and Darre (1984) reported on two nurses who sustained contact dermatitis from methyl methacrylate used in bone cement during hip operations. The two subjects in the study revealed subject one was required to take two months sick leave from the operating rooms and the other subject resigned from her position. The latter subject was able to return to work when it was found the wearing of butyl rubber gloves instead of latex gloves prevented the occurrence of dermatitis.
Mossovitch, Mossovitch, and Alkan (1986) discussed nosocomially acquired dermatophytosis by nurses working in a newborn unit. Thirty nurses working in the unit were investigated when a lesion was noticed on the left forearm of two nurses in the unit. Tests showed seven out of 30 nurses and and one newborn exhibited lesions.
Treatment for the nurses infected with the organism consisted of griseofulvin 500 mg/day for fourteen days, and nurses were also instructed to wear long sleeves while working in 117
the unit and while nursing the newborns. The newborn was treated with a course of local tolnaftate. The researchers believed the outbreak was connected in some way to infant feeding, and it was thought the pathogen may have been transmitted by one of the nurses who had a prior history of skin disease.
2.10.1. Summary
Nurse's attitudes towards dermatitis as an occupational risk factor will be investigated in this intended research. After a careful search of the literature there does not appear to be recorded evidence to suggest similar studies have been investigated.
2.11. The Risk of Ionising Radiation to Nurses
The nursing literature revealed very few studies have been carried out into the risk of isonising radiation and its effects on nursing personnel. However, the effect on patients has been investigated ( Renter, 1978; Harrison, Clayton, Day, Owen, and York, 1983;
Boles, Boussert, Manens, Le Cam, Bellet and Garre, 1987; Grazer, Meislin,
Westerman, Griss and Tucson, 1987) and also on physicians (Wiatrowski, 1980; Braun and Skiendzielewski, 1982).
It is well recognised nurses come into daily contact with ionising radiation, especially X- ray procedures and radioactive substances (Carrier and Martel, 1985). The literature that is available on radiation has predominantly advised nurses on how to avoid ionising risks. (Nurses Action Group, 1981; Carrier and Martel, 1985).
Fenlon (1985) revealed there was widespread practice of Queensland nurses required to take X-rays without possessing a licence to do so. In doing this nurses risk exposure to radiation and risk prosecution by patients if patients are harmed in the process. 118
Gregory (1985) reported that nurses were at risk from diagnostic radiation and particularly from those patients who had implants in place. She warned nurses who were pregnant "... will exceed 3/10 of the pro rata annual dose equivalent limit (50 rems)" (Gregory, 1985, 13).
Gregory (1985) expressed concern over the possible biological ramifications for nurses from exposure from radiation, irrespective of the exposure limits. She was critical of government policies that she believed were merely cost-benefit analyses reflecting only a judgement of acceptable risk.
2.11.1 Summary
The nursing literature does not appear to reveal studies exploring nurses' awareness to the risk of ionising radiation. In this study nurses' attitudes towards the risks of ionising radiation will be investigated.
2.12 Repetitive Strain Iniurv (RSI) as an Occupational Health Risk to Nurses
Burry and Stoke (1985) have defined repetitive strain injury (RSI) in the following terms: "The collective name given to groups of muscular and tendon injuries whose common cause is the continous use of hand, leg or body movements required for repetitive or continous work. It is also used to describe pain in the neck; shoulder and arm due to postural stt-ain" (Bun-y and Stoke, 1985, 610).
Although RSI represents "a major growth area in personal injuries litigation in NSW", the nursing literature is bereft of studies (Punch, 1985, 140). Women are reported to be amongst the most commonly affected group of RSI sufferers. In 1985, RSI represented 19.4% of new male compensation cases compared to 82.7% of new female 119
compensation cases (Meekosha and Jakubowicz, 1986).
Although the Hterature is replete with studies about workers who suffer from RSI, for example video display unit operators, (Smith, 1981; McPhee, 1982; Dainoff, 1983) controversy appears to exist between proponents as to the cause. Some in fact would argue that RSI is non existent as a disorder and merely a ruse for acquiring money for a compensable disorder (Awerbuch, 1985; Mackey, 1985). Meekosha et al., (1986) argued, some groups believed it was a disorder merely caused by "conversion hysterics". They suggested that"... there may be pain, but is there indeed any injury and is there a clinical entity to which RSI refers" (Meekosha, 1986, 395). They stated five other current etiological explanations, ("Is there an injury at all?"..."Occupational neurosis", "Ergonomic/work practices", "... the Australian factor", and "... the Labour process" (Meekosha, 1986, 345).
2.12.1 Summary
In this intended research RSI will be investigated with a view to determining whether or not it constitutes an occupational problem that concerns nurses.
2.13 Overview
The nursing literature has revealed extensive studies have been carried out into nurse's back injury problems, yet little is known about nurse's attitudes towards biomechanics of lifting and the loads nurses believe they can safety lift. As compensation is inextricably linked to back injuries (and indeed occupationally acquired injuries generally), it also appears to be an area requiring investigation. Whether nurses in the workplace have been afforded the opportunity of in-service training in lifting and back care and 120
occupational health and safety areas generally, has also been an area not fully investigated and warrants investigation.
Needleprick injuries represent an occupational health risk to nurses and the literamre has shown although possible contamination with AIDS via needleprick penetration is low
(Kuhls and Cherry, 1987), possible transmission of hepatitis B constitutes a risk
(Symington, 1987). It appears necessary to investigate nurse's attitudes towards the comparative risk of these two diseases and whether nurses in this intended research are immunised against hepatitis B. In-service training opportunites for registered nurses also needs investigation, and given the relatively new appearance of AIDS as an occupational health risk it would appear necessary to include it as an area for study. Knowledge about and representation on occupational health safety committees also requires investigation.
Legionnaires' disease has been established as a nosocomially transmitted disease,
(Brodie, 1987) and although the risk for nurses appears to be low, it warrants futher investigation, particularly as an outbreak of the disease has occurred in the geographical area of the intended sample population.
The nursing literature has revealed few studies have been carried out in the area of physical and verbal assault (Lanza, 1984), the effects of anaesthetic gases (Rogers,
1986), occupationally acquired dermatitis, radiation as an occupational health risk and attitudes towards RSI as an occupationally acquired disorder. Therefore, a beginning investigation into these areas appears deskable.
2.14 Recommendations for Research Investigations
The evidence in the nursing literature clearly demonstrates there is a need to investigate nurses attitudes and awareness towards those areas that represent occupational risk factors to nurses. It would appear timely to investigate the attitudes of both neophyte 121
nurses, and nurses who have been in the workforce. Because the first students from tertiary institutions will be completing their nursing course at the end of 1987, a unique opportunity is afforded to investigate their attitudes before attitudinal change occurs in the workplace.
The literature shows there are no available instruments for the measurement of attitudes and awareness towards occupational health and safety in nursing. Therefore in this intended research it will be necessary to design an appropriate instrument and to test its validity and rehabihty as a data -gathering instrument.
An occupational health and safety nursing model requires development to provide a framework for the study and explicitation of occupational health and safety within the nursing context.
Finally, because (of the nature of) nursing (as espoused by the author) is a fundamentally humanistic profession that engenders a holistic approach to nursing practice, both quantitative and qualitative research paradigms will be adopted. This was the decision taken for the development of an occupational health and safety nursing model. CHAPTER THREE 122
PILOT STUDY
.3.1 Introduction
Certain elements of Roys' (1980) and Johnsons' (1980) systems models were utiUsed as structural components for formulating an approach to developing a nursing accident causation model for this study. The models in the occupational health and safety literature show that while a causative theoretical explanation is acceptable, it has limitations because of its lack of applicability in the nursing miUeu.
Because this study is a broad issues based investigation, the first step is to carefully observe, describe and provide respondents with opportunities to talk about their views on issues in occupational health and safety within a nursing environment. To achieve this aim a pilot study was conducted by the investigator based on a series of open-ended interviews about accident and injury experiences with volunteer registered nurses and nursing students. The second stage of the pilot study consisted of constructing an instrument to investigate possible causes of accidents and injuries in order to set up a testable occupational health and nursing safety model and to formulate hypotheses. These steps will be described in the next section.
11 Development of the Pilot Studv
The pilot study consisted of two main developments; firstly, the development of the instrument and secondly, the actual pilot study using the devised instrument. In this section these two developments will be discussed. 123
3.2.1 Development of the Instt-ument
The first stage consisted of a series of interviews on accidents and injury experiences with nursing students and registered nurses. Nursing students were requested to give their views on occupational health and safety issues. A notice to this effect was left on the noticeboard at the hospitals involved in the research project and the University's department of nursing studies where the nursing students attended lectures. OrUy a small number of students responded to this appeal. Their views were franscribed in shorthand by the researcher. An open-ended interview technique as suggested by Kerlinger, (1979) as being appropriate in the developmental stages of the research as "... an exploratory device to help identify variables and relations, to suggest hypotheses and to guide other phases of the research" (Kerlinger, 1979, 480).
Interviews with nursing students were conducted at the University and the registered nurses were interviewed in their clinical setting at a time and date suitable to the subject.
Registered nurses were recruited by the investigator by first gaining permission from the nurses in their clinical setting as there were no responses from registered nurses to the notice-board request. A cross-section of registered nurses curtently working in different clinical settings was sought.
Those registered nurses who were interviewed worked in a variety of chnical settings; for example, operating room, intensive care, medical and surgical wards and maternity units.
The second stage involved a content-analysis of statements generated from the interviews.
"Content analysis is a method of studying and analysing communications in a systematic, objective, and quantitative manner to measure variables."
(Keriinger, 1979, 525) 124
The content-analysis technique consisted of listing occupational health and safety
statements. These statements were subsequentiy grouped into discrete categories,
numbered according to how many times they were mentioned by the subjects interviewed
(Appendix C). Thirty-eight attitudinal statements were generated from the content-
analysis and statements from the subjects were also included in a section on descriptive
information in the proposed form.
The third stage consisted of content validation of the first stage of the Instrument. Five
clinical experts from a variety of clinical specialities currently practising in nursing were
asked to rate statements from a two-point scale of "agree" or "disagree" on the
Occupational Health and Safety Form (see Appendix D). Space was provided for the
chnical nursing experts to provide any additional comments.
3.2.2 Pilot of the Instrument in the Clinical Area
A pilot study was carried out to test the reliability and validity of the Instrument. The
hospital chosen for the research contained a cross-section of chnical environments; for
example, medical, surgical, accident and emergency, maternity, operating rooms,
extended care, and paediatric wards. The hospital also provided clinical experience for
the students from the tertiary institution and provided a teaching environment for nursing
students.
Permission was gained from the Director of Nursing to conduct the research and the
researcher visited each ward in the nominated Hospital P and explained to registered
nurses the purpose of the study and instructions regarding filling in the instrument. The
instrument was left in a sealed envelope in each ward addressed to each subject to ensure
the subject received the instrument. The sample was achieved by selecting every second registered nurse on each ward roster to achieve a random sample. The sealed envelope carried tiie registered nurses' name on the outside of the envelope to ensure the correct 125
person received the instrument, a procedure agreed to by the subjects. Their name did not appear anywhere on the instrument, only a number, and confidentiality was strictiy maintained. A large envelope was placed on each ward which the researcher collected at weekly intervals for the month the pilot study was conducted.
Nursing students were also involved in the pilot procedure and a similar sampling procedure utilised. Students were involved in their clinical experience at the same hospital during this period and a similar procedure was followed for nursing students as for the registered nurses involved in the pilot study.
Demographic and descriptive data were included in the study as some personal characteristics had been previously investigated by other researchers in an attempt to identify discriminating variables that cause back pain (Rice, 1986; Owen and Damron, 1984). This step is important in order to link the findings to particular contexts and categories of respondents.
3.3 Results from the Pilot Studv The results from the pilot study are reported in the following section.
3.3.1 Demographic Data: Registered Nurses
A total of 21 registered nurses were involved in the study. Table 3.1 shows the position in the chnical setting of the registered nurses who participated, and Table 3.2 indicates the nursing certificates held by the respondents. 126
TABLE 3.1 POSITION IN THE CLINICAL SETTING: REGISTERED NURSES.
Designation Number of subjects
Education 1 Nurse Unit Manager 3 Registered nurse 1-5 years 12 Registered nurse 6-10 years 6 Registered nurse 15-19 years 1
Total 23*
* = more than one response possible
TABLE 3.2 NURSING CERTIFICATES: REGISTERED NURSES
Type of certificate Number of subjects
General 18 Midwifery 3 Odier 3
Total 24 * * = more than one response possible
The area of work speciality of the registered nurses is depicted in Table 3.3.
TABLE 3.3 AREA OF WORK SPECIALITY: REGISTERED NURSES
Area of work speciality Number of subjects
General nursing 7 Midwifery 4 Operating Theatt-e 3 Recovery 1 Palliative Care 4 Accident and Emergency 2
Total 21 127
The level of secondary education completed by the subjects in the pdot study showed ten subjects held a School Certificate and 11 subjects indicated they had completed a Higher School Certificate. The highest tertiary qualification possessed by the subjects revealed that none of the nurses had completed tertiary qualifications.
3.3.2. Demographic Data: Nursing Students
Twelve nursing students participated in the pilot study. They were present at the pilot hospital for their clinical practicum while data were collected from the registered nurses.
The nursing student sample consisted of six first-year students, five second-year students and one third-year student. This was considered a random sample of nursing students who were present in the pilot study hospital.
Three nursing students indicated they had prior nursing experience and nine had not. The nature of the experience showed one subject had been employed as a ward assistant, one subject had been in the army reserve, (nursing section), and one had completed one year of general training.
3.3.3. Descriptive Data: Registered Nurses
Table 3.4 shows the age range for the registered nurses in the pilot study with the highest proportion of subjects represented in the 20 to 25 year (33%) and 25 to 30 year (33%) age group. The age ranges illustrated in the following tables were constructed to include 20 years, 0 days to 24 years 362 days and for each of the age categories this principle was observed, or 20 < age < 25. Conventional mathematical notation is used for this categorisation in tabular listing: [20-25). This principle was followed for the categories shown in Tables 3.4, 3.5, 3.6, 3.8, 3.9 and 3.10 as well as the Tables 4.4, 4.5, 4.11, 4.16 and 4.17 illustrated in Chapter 4. 128
TABLE 3.4 AGE RANGES :REGISTERED NURSES
Age ranges in years Number %
[50-54) years 1 4% [45-50) years 2 10% [40-45) years 0 0 [35-40) years 2 10% [30-35) years 2 10% [25-30) years 7 33% [20-25) years 7 33% 21 100%
The gender of the registered nurses indicated only one male and 20 females were included in the pilot study
The registered nurses' weight ranges are shown in Table 3.5 and are included in this study as they have been shown to be worthwhile personal characteristics to be investigated by other researchers (Owen and Damron, 1984).
TABLE 3.5 WEIGHT RANGES: REGISTERED NURSES
Weight ranges in kg N %
>70kg 1 4% [65-70) kg 2 10% [60-65) kg 2 10% [55-60) kg 5 24% [50-55) kg 4 19% [45-50) kg 3 14%
17 100%
Table 3.6 highlights the height ranges for the registered nurses in this pilot study. Rice (1986) included height ranges in her study of low back pain in community nurses. Although no clear trends were discernible from her analysis, it was included in the study due to the importance of physical variables (Owen and Damron, 1984, p. 311). 129
TABLE 3.6 HEIGHT RANGES:REGISTERED NURSES Height in cm N % [170-175) cm 4 19% [165-170) cm 6 29% [160-165) cm 2 10% [155-160) cm 4 19% [150-155) cm 5 23% 21 100%
The marital status of the registered nurses is shown in Table 3.7.
TABLE 3.7 MARITAL STATUS : REGISTERED NURSES Marital status N %
Mamed 10 48% Never married 9 46% Divorced 2 6% 21 100%
3.3.4 Descriptive Data: Nursing Students Nursing students' age ranges are shown in Table 3.8.
TABLE 3.8 AGE RANGES : NURSING STUDENTS
Age ranges N % [30-35) years 2 16% [25-30) years 2 16% [20-25) years 4 34% [17-20) years 4 34% ~ 12 100%
The gender of the nursing students showed nine subjects were female and three subjects were male. 130
The nursing students weight ranges are depicted in Table 3.9 with the highest proportion
of subjects in the 50 to 55 Kg weight range.
TABLE 3.9 WEIGHT RANGES :NURSING STUDENTS
Weight ranges in kg N %
>70kg 2 16% [65-70) kg 1 9% [60-65) kg 2 16% [55-60) kg 1 9% [50-55) kg 4 34% [45-50) kg 2 16%
12 100%
The height ranges show an even distribution of nursing students in each of the height
ranges shown in Table 3.10.
TABLE 3.10 HEIGHT RANGES: NURSING STUDENTS
Height ranges in cm N %
[170-175) cm 3 25% [165-170) cm 3 25% [160-165) cm 3 25% [155-160) cm 3 25%
12 100%
The marital status of the nursing students is shown in Table 3.11. 131
TABLE 3.11 MARITAL STATUS : NURSING STUDENTS
Status N %
Married 2 17% Never married 7 59% Divorced 1 8% De-facto 1 8% Separated 1 8%to
12 100%
3.3.5 Accident and Iniurv Descriptive Information
This section discusses the findings for accident and injury data for questions 15 to 39 in the nursing instrument. Registered nurses and nursing students were asked whether or not they had previously filled out personal accident/ injury forms.
The results showed 13 registered nurses and no nursing students indicated they had filled out personal accident/injury forms and eight registered nurses and 12 nursing students stated they had not filled out such a form.The responses from registered nurses who had answered in the affirmative mode, showed that three had filled out a form within the last year and ten had filled one out "over one year" ago. These results required further investigation with a larger population of nurses particularly, nursing students, as the population was too small to generalise about trends for either group.
Both groups were asked to specify the types of accident they had experienced in the "last week", "the last month", "the last year" and "over one year ago". Only one nursing student had been involved in an accident; and that was within the last year and it consisted of "slipping over in the bathroom - but not reported". Three registered nurses indicated they had been involved in an accident/injury in the "last year" and they consisted of "damaged glasses", "stabbed by a sharp" and "needleprick" injuries. Ten 132
subjects indicated they had sustained an accident/injury "over one year" ago and they were as follows: four subjects sustained back injuries, three subjects sustained needleprick injuries and one subject was kicked in the groin. One subject reported having sustained four injuries which consisted of" needleprick", "bum to hand", "back strain", and "medication spuit to eyes". One other subject reported having sustamed two injuries "patient fell on me and injured my shoulder and arm", and "needleprick" injury. When asked if they had formally reported the above stated accidents, one subject who sustained an injury in the last year affirmed she had and of those who had sustained an injury "over one year": three indicated they had done so.
Information to elicit information on regarding physical injury by a patient showed eight registered nurses and no nursing students indicated they had suffered such an injury. The completion of an accident/injury form was reported by 18 registered nurses and no nursing students had done so.
Very few subjects had lost days due to accidents/injuries. In fact there were no nursing students who had lost work and/or studies and only three registered nurses had lost days. All subjects reported that the days off had occurred "over one year" ago and two subjects had missed three days and one subject had missed diree to four days.
Question 24 asked if subjects had "ever claimed compensation" for injuries sustained. Only two registered nurses had claimed compensation; one was for a motor vehicle accident and the second for "pulled neck and shoulder muscles while lifting a patient". When asked if subjects had been entitled to claim compensation and have not done so, four registered nurses indicated they had. The reasons where listed as; "not encouraged" to do so, (two subjects), "did not feel injury was serious enough" (one subject), and one subject asked "How can you claim compensation for spinal manipulation due to vertebrae being pulled out by hfting a patient?" 133
Question 28 investigated registered nurses' training experiences in occupational health and safety issues since graduation. Seven subjects had attended such sessions and 14 subjects had not attended workshops. In those workshops that had been attended, the sessions consisted of sessions as varied as: "AIDS and hepatitis B", Lifting techniques", "hospital fires and patient evacuation", and "fire drill".
Registered nurses and nursing students were asked to nominate the prescribed load for safe lifting (16 Kg) Table 3.12 highlights the responses.
TABLE 3.12 OPINION FOR PRESCRIBED SAFE LOAD FOR LIFTING: REGISTERED NURSES AND NURSING STUDENTS
Response Registered Nursing Nurses Students
100 Kgs 2 0 80 Kgs 1 0 45 Kgs 0 1 25 Kgs 1 0 15 Kgs 2 0 10 Kgs 0 1 Don't know 9 4 Depends 1 0 "If you have to hold your breath its too heavy" 0 1 "It depends if its' a dead weight" 1 0 "Depends on the height of die nurse" 0 1 No answer 4 4
Total 21 12
The varied responses from these answers indicates a need for further investigation with a larger population and more specific questions. Curtent immunisation for hepatitis B showed only three out of the 21 registered nurses were immunised. Interestingly, six subjects did not have current protection against tetanus and tuberculosis. Eight subjects did not have current protection against typhoid. 134
Questions pertaining to occupational health and safety units within the hospital showed five subjects believed there was such a unit, three stated there was no such a unit and 13 subjects indicated "don't know". All nursing students (12) indicated a "don't know" response. The responses for the occupational health and safety committees showed 14 registered nurses and zero nursing student nominated "yes" for this question. Three registered nurses and no nursing students nominated "no" and four registered nurses and 12 nursing students indicated "don't know". When questioned on whether they were aware of nursing representation on the committee, ten registered nurses and no nursing students nominated "yes", one registered nurse indicated "no", and six registered nurses and 12 nursing students nominated "don't know".
The responses to question 35 to 37 were confusing as the majority of subjects responded to all alternatives listed in the question rather than make a choice. However, this was probably due to the poor question construction and it was subsequentiy decided not to include them in the main study as they did not directiy relate to the model.
Question 28 investigated the availability of wardsmen/orderlies to help registered nurses and nursing students lift heavy patients. Eleven registered nurses and seven nursing students indicated they knew of their availability, one nursing student only nominated "no" indicating she was aware of their existence. Ten registered nurses nominated "other" and suggested wardsmen were not available at night and not always readily available. When asked if they had performed nursing care with back pain, 19 registered nurses and five nursing students nominated "yes" they had and, two registered nurses and seven nursing students nominated "no" they had not. It was felt by the investigator this particular question needed further explanations as to why this might be so, and would be further explored in the main study. 135
3-3.6 Attitudinal and Open-Ended Responses Section 3 contained a four-point Likert scale consisting of "strongly agree", "agree", "disagree", and "strongly disagree". Subjects were asked to respond to attitudinal statements in four sub-sections of the instrument (sub-sections A,B,C, and D). Each sub section was followed by an area for subjects to make additional comments if they so desired.
Difficulties arose with the scale when many of the nursing students were unable to make a choice, since, in some of the statements, they felt they genuinely could only respond that they "did not know". Therefore it was not possible to make statistical comparisons for this part of the research, and the Likert scale was changed from a four-point scale to a five-point scale to provide for a "don't know" response. A reliability function was performed on two questions within the scale for a split half reliability co-efficient for registered nurses (r = .868) and nursing students (r = .878).
Comments from sub-section A of the instrument are presented in Table 3.13.
TABLE 3.13 OPEN-ENDED COMMENTS FROM SUB-SECTION A: REGISTERED NURSES "There are not enough in-service educational programmes for safety measures or any other topic. This is probably due to lack of staffing and as usual money." "Unless it is serious most nurses, (me included) won't report accidents to themselves." "The threat of litigation is the only reason patient injuries are reported - but they have to be significant injuries and the patient has to be "complaining." "Many nurses are too busy to report accidents because we are too busy at the time of the accident." "Nurses take sick leave in preference to workers' compensation because: 1. less problems with administtation staff (and they are a problem) 2. less paper work 3. you don't have to wait ten weeks for your pay." 136
From these comments it appears there is a perception by nurses that there are insufficient in-service programmes for safety and "any other topic". The results from an exploration of the type of in-service programmes offered to nurses in the work-place appeared to support these comments (see responses to question 28). There also appeared to be a reluctance to claim compensation.
The responses from the nursing students are presented in Table 3.14.
TABLE 3.14 OPEN-ENDED RESPONSES FROM SUB-SECTION A: NURSING STUDENTS
"A few of these questions were a bit hard in view of the fact I haven't been in the system very long so I use my own observations." "Some of these questions I don't know." "You may feel the accident is too trivial to bodier filhng out a form."
The responses from the students support the need to include a category that allows them to state they do not know.
The open-ended responses from registered nurses for sub-section B are presented in Table 3.15. 137
TABLE 3.15 OPEN-ENDED RESPONSES TO SUB-SECTION B: REGISTERED NURSES
"There is not enough equipment or staff or wardsmen/orderlies for lifting patients." "Nurses are always lifting heavy patients without the help of wardsmen-mainly because there is a waiting time involved." "No time to think of yourself when lifting a patient, you just lift." "The type of lifting varies from hospital to hospital." "In six years of nursing I have seen mechanical devices used to lift heavy patients once and diis occurted in a spinal unit." "Wardsman is discriminating it is wardsperson."
The responses suggest nurses do not use mechanical devices to help with lifting patients and this area needs further investigation.
Nursing students' comments are displayed in Table 3.16.
TABLE 3.16 OPEN-ENDED RESPONSES TO SUB-SECTION B: NURSING STUDENTS
"Sometimes I have found that orderlies/wardsmen are not used to help lift patients because of time, (that is waiting for them to come)." "Little regard is taken for the set weight lifting limits and nurses rarely obey diem or are encouraged to follow them." "Often the hospital hasn't got any mechanical devices for lifting patients."
Students have highlighted the problems they perceive that are associated with lifting heavy weights. Firstiy, wardsmen are not readily accessible; secondly, some nursing students appear to lift weights that are too heavy for them and thirdly, nurses do not appear to have lifting equipment readily accessible to help lift heavy patients.
Registered nurses' open-ended comments for sub-section C are recorded in Table 3.17. 138
TABLE 3.17 OPEN-ENDED COMMENTS FOR SUB-SECTION C: REGISTERED NURSES
"There is not enough knowledge about the hazards of chemicals etc."
"I think the AIDS scare will cause more needleprick injuries to be reported" (two subjects commented on this). "I think midwives are at risk of both AIDS and hep B and I think doctors should screen diek patients ante-natally."
The responses from registered nurses highlighted a concern about the risk of AIDS and hepatitis B being acquired. Only one nursing student responded to this part of the questionnaire noting that: "dermatitis is a common problem for many nurses against
which there is not protection provided".
Registered nurses' open-ended comments from sub-section D are shown in Table 3.18.
TABLE 3.18 OPEN-ENDED RESPONSES FROM SUB-SECTION D: REGISTERED NURSES
"More safety measures should be incorporated in nursing jobs."
"Non-slip surfaces would be a bonus instead of "shiny floors."
"If I cross a violent patient I don't go near them."
"Bemg abused physically and verbally may be a fact of life for nurses, but it hurts and is very upsetting."
"A lot of nurses resent being assaulted."
"Generally nurses are dedicated to their job and suffer in silence or discuss it with a colleague. I have known nurses to be ignored by their seniors when reporting injuries with the attitude " I had to put up with it; its your turn now".
Comments from the registered nurses in Table 3.18 show a concern about assault, both physical and verbal, and it appears to be an occupational hazard for nurses. Further exploration is required to investigate the extent of the problem. Although very few students appended comments for this section one student commented, "Physical assault 139 shouldn't be a fact". Also highlighted in this section is the registered nurses' perceptions of a negative attitude from administrative staff towards reporting accidents/injuries and further consideration needs to given to this variable and how it affects nurses.
3.3.7 Summarv
The results from the pilot study showed Section 1 of the questionnaire (Nursing background) required littie alteration. There were indications that some of the questions in Section 2 required modification and questions 15,16,17 and 24 were redesigned in order to allow subjects the opportunity of indicating that they did not know, if it was appropriate. Section 3 contained rank-order questions and the attitudinal questions were transferted to a new section, (section4).
The scale in Section 4 was redesigned from a four- scale choice ("Strongly Agree", "Agree", "Disagree", and "Stt-ongly Disagree") to a five-scalechoice , ("Strongly Agree", "Agree", "Don't Know" (or "Undecided"), "Disagree", and "Stt-ongly Disagree". The reason for this was that nursing students wrote on the scale "Don't Know". As this was a relevant factor in the research, that is determining at what stage of then- development as a nursing student do they become aware of occupational health and safety issues, a five- point Likert scale was considered to be more appropriate. The sub-sections in Section 4 were re-organised with sub-section "a" and "d" interchanged as it was considered sub section "a" a more difficult section to answer first. Some statements were modified on the basis of the responses of the comments from subjects in the open-ended sections of the instrument.
The tide wardsman was changed to wardsperson due to comments from one subject on the use of the discriminatory term wardsman. 140
Raw data from the pilot study are appended in Appendix G. Reliability split-half co efficients for questions 58 and 59 are appended in Appendix H (r = .868 for registered nurses) and in Appendix I for nursing students (r = .878). The revised Occupational
Health and Safety Nursing Instrument (OH&SNI) is appended in Appendix J.
The sampling method for the main study was changed to one of surveying the total subject population in the four participating hospitals. The decision for this change was made to ensure a sufficient population was available for the main study.
3.3.8 Recommendations
The results from the pilot study led the investigator to develop a concept analysis for the nursing model. Chinn and Jacobs (1983) argued that:
"concept analysis is essentially an empiric-scientific approach, but it also offers the opportunity to integrate esthetic, ethical, and personal knowing in relation to empirics. As an empiric-scientific techniques, concept analysis is designed to objectify reality, using language as a primary tool".
(Chinn and Jacobs, 1983, 89)
In developing a concept analysis for this study the investigator used personal observations and experiences based on 26 years of nursing, ten of which involved teaching nursing students. The concept analysis approach utilised in this research is a system theory approach, based on Roy's (1980) and Johnson's (1980) models of inputs, processes and outputs.
Empirical data was subsequently utilised in the main study to test the model's applicability and this was achieved through an enquiry into registered nurses' and nursing students' opinions as to the cause(s) of accidents/ injuries in their professional practice area. Empirical data generated by subjects was investigated for causation of accidents/injuries. An example of this application would be in responding to the question: "Do nurses believe accidents/injuries are caused by more than one cause?" (see
Chapter 1, Section 1.5.3). 141
Testing of causative theoretical relationships will be achieved by evaluating correspondence to experience, (see Chinn and Jacobs, 1983). This experience will be investigated, firstiy by, empirical data using open-ended questionnaire methods, secondly, by validating statements by testing specific hypotheses articulated in the methodology chapter (Chapter 4) thirdly, by the development of an occupational health and safety nursing model and fourthly to test the rigor of the model by comparing injured nurses' responses to those factors stated in the model. CHAPTER FOUR 142
METHODOLOGY: MAIN STUDY
4.1 Introduction
A variety of research methods was employed to gather data for this investigation. The interview technique employed to determine the attitudes of registered nurses and nursing students towards occupational health and safety issues was discussed in Chapter 3, Section 3.2.1. The survey instrument constructed from the resultant interviews was also discussed in Chapter 3, (see Section 3.2.1). This chapter will outline the main investigation using the Occupational Health and Safety Nursing Instt-ument (OH&SNI), to investigate attitudes of registered nurses and nursing students. This aspect of the research constituted the main part of the study.
4.2 Research Design The variables for investigation included: Dependent variables: The following variables were measured by the OH&SNI. i. Physical injury by a patient. ii. Experience in filling out accident forms for patients. iii. Loss of work/studies due to accident/injuries in the workplace. iv. Entitiementto claim compensation. V. Attendance at training on health and safety issues since graduation as a registered nurse, vi. Nature of training experience, vii. Opinion as to the prescribed load for safe hfting. viii. Curtent immunization for hepatitis B. ix. Awareness of employer/institution Occupational Health and Safety Committee. X. Awareness of nursing personnel representation on Occupational Health and Safety Committee. 143
xi. Awareness of employer/institution Occupational Health and Safety Unit for
staff/students, xii. Incidence of performing nursing care whilst experiencing back pain, xiii. Attitudinal responses to variables in section 4 of the OH &SNI.
Independent Variables:
The independent variable was the registered nurse and nursing student category.
4.3 Selection of Subjects
In this section the selection of subjects for the main research study will be discussed, and
the location of the study stated, the registered nurse and nursing student population
described.
4.3.1 Subjects
The subjects were generated from two nursing populations: a registered nurse population
and a nursing student population. The registered nurse population constituted full time
registered nursing staff and excluded part-time nursing staff, the latter often only
working two days each fortnight. The nursing student population represented the total
nursing student population at the tertiary institution.
4.3.2 Registered Nurse Population
The registered nurse population was representative of four hospitals within the Illawarta
Health Area Service, excluding the staff at the hospital involved in the pilot study. The hospitals chosen for the study represented the four main public hospitals associated with the tertiary nursing clinical teaching programme. A total of 267 registered nurses participated in the study. Sixty-one subjects were surveyed from hospital A, with a response from 55 subjects, (or 90% of Hospital A's full time registered nurse 144 population). Twenty-six subjects out of a total of 38 registered nurses from hospital B responded, (or 68% of Hospital B's full time registered nurse population). Sixty-one subjects out of 73 from hospital C responded, (or 85% of Hospital C's full time registered nurse population) and 125 subjects out of 150 from hospital D, (or 83% of the full time registered nurse population), participated in the research. Approval for the study was granted by the Acting Chief Executive Officer of the Illawarta Area Healdi Service.
Table 4.1 illustrates that a large proportion of the subjects from hospital A (24%) and hospital B (19%) were represented in the 30 to 35 year age group. The majority of subjects from hospital C were represented in the 25-30 year age group (34%). Hospital D demonstt-ated that the majority of subjects were disttibuted evenly between the 35-40 year age group (20%) and the 25-30 year age group (20%).
TABLE 4.1 AGE RANGE: REGISTERED NURSES Years Hospital A Hospital B Hospital C Hospital D N % N% N% N%
>55 years 2 (4%) 0 0 6 (5%) [50-55) years 2 (4%) 1(3%) O(-) 8 (6%) [45-50) years 3 (6%) 4(16%) 2(3%) 11(8%) [40-45) years 9(16%) 7(27%) 5(8%) 16(13%) [35-40) years 9(16%) 4(16%) 9(15%) 25(20%) [30-35) years 13(24%) 5(27%) 14(24%) 22(18%) [25-30) years 10(18%) 4(16%) 21(34%) 25(20%) [20-25) years 7(12%) 1(3%) 10(16%) 11(9%) Unspecified O(-) O(-) O(-) 1(1%) Total number 55 26 61 125
Table 4.2 shows the gender distribution in hospitals A, B, C and D. Ninety-three percent of subjects were female and seven percent male from hospital A, 85% were female and 12% were male from hospital B (for one subject gender was not stated), with 97% female and 3% of male subjects from hospital C and 95% female and 4% male subjects from hospital D (one subject from hospital D did not state their gender). 145
TABLE 4.2 GENDER: REGISTERED NURSES
Gender Hospital A Hospital B Hospital C Hospital D N % N % N % N %
Female 51(93%) 22(85%) 59(97%) 118(95%) Male 4 (7%) 3(12%) 2(3%) 6(4%) Unspecified O(-) 1(3%) O(-) 1 (1%)
Total number 55 26 61 125
The marital status of the registered nurse population depicted in Table 4.3 shows the majority of the registered nurses were married, with 64% being married and 16% single from hospital A, 73% married and 19% single from hospital B, 72% married and 20% single from hospital C and 69% married and 23% single from hospital D.
TABLE 4.3 MARITAL STATUS: REGISTERED NURSES
Marital status Hospital A Hospital B Hospital C Hospital D N % N % N % N % Married 35(64%) 19(73%) 44(72%) 86(69%) Single 9(16%) 5(19%) 12(20%) 29(23%) Divorced 7(13%) O(-) 3(5%) 5(4%) Widowed 1(1%) O(-) O(-) O(-) Separated 3(6%) O(-) O(-) 2(1%) De-facto O(-) O(-) 2(3%) 3(3%) Unspecified O(-) 2(8%) O(-) O(-) Total 55 26 61 125
Table 4.4 shows the majority of registered nurses from hospital A were in the >70 Kg (24%) and 50-55 Kg (24%) weight range, from hospital B the majority were in die 60-65 Kg(35%), from Hospital C they were in the 55-60 Kg(25%) and in hospital D the majority were in the 55-60 Kg (30%) weight range. 146
TABLE 4.4 WEIGHT RANGES: REGISTERED NURSES Weight ranges Hospital A Hospital B Hospital C Hospital D in kg N % N % N % N %
>70kg 13(24%) 5(20%) 12(20%) 27(22%) [65-70) kg 6(12%) 5(20%) 12(20%) 18(14%) [60-65) kg 12(23%) 9(35%) 8(14%) 23(18%) [55-60) kg 7(13%) 4(15%) 15(25%) 38(30%) [50-55) kg 13(24%) 1(2%) 5(8%) 12(10%) [45-50) kg 3(3%) 2(8%) 5(7%) 5(4%) <45kg O(-) O(-) 3(5%) 1(1%) Unspecified 1(1%) O(-) 2(1%) 1(1%)
Total 55 26 62 125
Observation of Table 4.5 shows that the largest proportion of registered nurses from hospital A were in the 160-165 cm range (27%). In hospital B the majority were in the 170-175 cm range (30%), in hospital C the majority were in the 165-170 cm range (31%) and in hospital D the largest proportion was in the 165-170 cm range (24%), although the latter was only marginally so, with 33% of registered nurses nominating their height ranges to be within the 160-165 cm category.
TABLE 4.5 HEIGHT RANGES: REGISTERED NURSES
Height ranges Hospital A Hospital B Hospital C Hospital D in cm N % N % N % N % [170-175) cm 13(24%) 8(30%) 16(26%) 22(18%) [165-170) cm 9(16%) 7(27%) 19(31%) 30(24%) [160-165) cm 15(27%) 4(15%) 11(19%) 28(23%) [155-160) cm 18(33%) 4(15%) 12(20%) 42(34%) [150-155) cm O(-) 3(13%) 3(4%) 3(1%)
Table 4.6 shows the positions of the registered nurses in their curtent clinical position, with the majority of subjects placed in two categories. Thirty-three percent of subjects nominated the registered nurse 1-5 year classification and 28 percent of subjects were represented in the registered nurse 6-10 year category. 147
TABLE 4.6 POSITION IN THE CLINICAL SETTING: REGISTERED NURSES
Position Hospital A Hospital B Hospital C Hospital D
Administration 10 2 10 0 Education 0 1 0 2 Supervisor 1 0 1 0 Nurse Unit Manager 2 1 2 10 Registered Nurse 1-5 Yrs. 22 7 22 38 Registered Nurse 6-10 Yrs. 15 8 15 37 Registered Nurse 11-14 Yrs. 4 3 4 17 Registered Nurse 15-19 Yrs. 7 2 7 11 Registered Nurse 20-24 Yrs. 3 2 3 6 Registered Nurse 25> 2 1 2 10
Total *66 *27 *66 *130
Key * = Some registered nurses are in more than one category.
The nursing certificates held by registered nurses are tabled in Table 4.7.
TABLE 4.7 NURSING CERTIFICATES HELD BY REGISTERED NURSES
Type of Nursing Hospital A Hospital B Hospital C Hospital D Certificate*
General 52 26 60 119 Psychiatric 1 1 0 3 Midwifery 11 14 14 77 1 1 3 8 Mothercraft 16 7 21 19 "Odier"
Key * = More than one nursing certificate held by some subjects The area of work speciality of the registered nurse population is shown in Table 4.8. It can be seen a general nursing certificate was held by almost the entire population of registered nurses with a few exceptions of subjects from Hospital D. It is interesting to note that a large number of subjects also held midwifery certificates. 148
TABLE 4.8: AREA OF WORK SPECIALITY: REGISTERED NURSES
Work Speciality Hospital A Hospital B Hospital C Hospital D
General 32(58%) 14(54%) 35(58%) 38(30%) Midwifery 1(1.5%) 5(20%) 10(10%) 47(38%) Community 1(1.5%) O(-) O(-) O(-) Mothercraft 2(4%) O(-) O(-) 1(1%) Operatmg rooms 6(11%) 2(6%) 7(13%) 25(20%) Odier 13(24%) 5(20%) 8(4%) 13(10%) Unspecified O(-) O(-) 1(5%) 1(1%)
Total 55 26 61 125
The figures in Table 4.8 highlight the large number of subjects working in the general area of the hospital, with 58% working in this area from hospital A, 54% from hospital
B, 58% from hospital C and 30% from hospital D. The largest percentage of subjects from hospital D(38%) work in the midwifery area.
The highest secondary education level achieved by registered nurses is illustt-ated in Table
4.9 .
TABLE 4.9 THE HIGHEST SECONDARY EDUCATION LEVEL ACHIEVED BY REGISTERED NURSES
Educational Hospital A Hospital B Hospital C Hospital D Qualification
School Certificate 33(60%) 13(50%) 21(34%) 50(40%) Higher School Certificate 13(23%) 6(23%) 31(50%) 50(40%) Odier 8(15%) 7(27%) 8(14%) 23(18%) Unspecified 1(2%) O(-) 1(2%) 2(2%)
Total 55 26 61 125
It can be deduced from the data in Table 4.9 that the highest number of subjects held a
School Certificate (44%) with 37 percent of subjects possessing a Higher School
Certificate. 149
It is clear from the data presented in Table 4.10 that very few of the subjects held tertiary qualifications.
TABLE 4.10 THE HIGHEST TERTIARY QUALMCATION HELD BY REGISTERED NURSES
Tertiary Hospital A Hospital B Hospital C Hospital D Qualification
Diploma 3 3 4 5 Degree 0 1 1 4 Post-graduate Diploma 0 0 0 1 Masters' Degree 0 0 0 1 Ph.D. 0 0 0 0 None of the above 51 21 54 109 Unspecified 1 1 2 5
Total 55 26 61 125
4.3.3 Nursing Student Population
The nursing student population represented 82% of the total intake of a Diploma of Nursing course with students drawn from the first, second and third years of the course. There were 196 students, (including the 12 students involved in the pilot study) who participated in the study out of a total population of 240. In the main study there were 81 students from first year, 52 students from second year and 51 students from third year. The 12 students who participated in the Pilot study were excluded from the main study.
The age ranges of the students illustrated in Table 4.11 show the majority of subjects were represented in the 20 to 24 years and 17 to 19 age groups. 150
TABLE 4.11 AGE RANGES: NURSING STUDENTS
Age range First year Second year Third year [45-50) years 1(2%) 2(4%) 1(2%) [40-45) years 3(3%) 2(4%) 3(6%) [35-40) years 2(2%) 1(2%) 4(7%) [30-25) years 1(2%) 1(2%) 3(6%) [25-30) years 6(7%) 1(2%) 6(12%) [20-25) years 9(11%) 25(48%) 34(67%) [17-20) years 59(73%) 20(38%) O(-)
81 52 51
The gender of the nursing students in the study shows the population consisted of 70% females and 30% males in first year, 73% females and 27% males in second year and % females and 20% males in third year (see Table 4.12).
TABLE 4.12 GENDER: NURSING STUDENTS
Gender First year Second year Third year
Female 57(70%) 38(73%) 41(80%) Male 24(30%) 14(27%) 10(20%)
81 52 51
It is clear from the information presented in Table 4.13 that the majority of first year, second year and third year nursing students in this study were single (84%, 79% and 72% respectively). However 11% of first year nursing students, 8% of second year nursing students and 14% of third year nursing students were married. 151
TABLE 4.13 MARITAL STATUS: NURSING STUDENTS
Status First year Second year Thkd year Married 9(11%) 4(8%) 7(14%) Single 68(84%) 41(79%) 37(72%) Divorced 2(3%) 3(5%) 1(2%) Widowed O(-) 1(2%) 1(2%) Separated 1(1%) 1(2%) 4(5%) De-facto 1(1%) 2(4%) 1(2%) 81 52 51
Figure 4.14 shows the previous nursing experience of the nursing students in the study. The majority of subjects in this study did not have any prior nursing experience.
TABLE 4.14 PRIOR NURSING EXPERIENCE : NURSING STUDENTS
Experience First year Second year Third year
Yes 21(26%) 8(15%) 14(28%) No 58(71%) 44(85%) 37(72%) Unspecified 2(3%) O(-) O(-)
81 52 51
Table 4.15 shows the nature of previous nursing experience consisted of mainly "other" health-related experience. "Other" classification included those subjects who had commenced general nursing in the apprenticeship system and not completed the course.
TABLE 4.15 PREVIOUS NURSING EXPERIENCE : NURSING STUDENTS Nature First year Second year Third year Enrolled nurse 9(11%) 1(2%) 7(14%) Ward assistant 1(2%) 1(2%) 5(10%) Nil 57(70%) 44(85%) 36(70%) Odier 14(17%) 6(11%) 3(6%) 81 "^2 "51 152
Table 4.16 shows the distribution of weight ranges for nursing students. It can be seen die majority of students lie in the 55 to 60 Kgs range, that is 25% in first year, 25% in second year and 29% in third year.
TABLE 4.16 WEIGHT RANGES: NURSING STUDENTS
Weight ranges First year Second year Third year
>70Kg 14(17%) 10(19%) 9(18%) [65-70) Kg 10(12%) 11(20%) 4(8%) [60-65) Kg 17(21%) 4(7%) 10(20%) [55-60) Kg 20(25%) 13(25%) 15(29%) [50-55) Kg 13(16%) 9(18%) 4(8%) [45-50) Kg 5(7%) 5(10%) 7(14%) <45Kg 1(1%) O(-) 2(3%) Unspecified 1(1%) O(-) O(-) 81 52 51
In Table 4.17 the height distributions of the nursing subjects is shown. In first year 25% of students are distributed equally in the 165-170 cms range and 155-160 cms range, with the majority of second students(37%) in the 165-170 cms range and in third year the majority (31%) in the 150-155 cms range.
TABLE 4.17 HEIGHT RANGES: NURSING STUDENTS
Range First year Second year Thu-d year [170-175) cm 25(31%) 15(29%) 14(27%) [165-170) cm 20(25%) 19(37%) 6(14%) [160-165) cm 16(19%) 9(17%) 14(27%) [155-160) cm 20(25%) 9(17%) 16(31%) [150-155) cm O(-) O(-) 1(1%) 81 52 51 153
4.4. Research Instrument
The research instrument designed for the study was trialled for its suitabihty, rehability and validity.
The final instrument consisted of four sections, namely:
Section lA which contained questions investigating registered nurses' demographic background. It elicited descriptive information concerning nursing position, nursing certificates, work setting, and secondary and tertiary educational background.
Section IB consisted of descriptive information designed to elicit information from
Diploma of Nursing students in a tertiary setting. Specific information sought included the year of the course in which they were currentiy enrolled, previous nursing experience and, if applicable the nattire of the nursing experience.
Section 2 consisted of 20 questions for both registered nurses and student nurses. The information sought was social/demographic data on age, gender, weight, height and marital status. Aspects of occupational health and safety information were also sought; for example, physical injury by a patient, experience in completing accident/injuries forms, compensation claims, training in health and safety issues and the type of training, the safe load for lifting, and curtent immunisation status.
Three questions pursued subjects' knowledge of Occupational Health and Safety
Committees and representation on that committee, and the existence of an Occupational
Health and Safety unit in their working environment. Question twenty-seven investigated the presence or absence of back pain while performing nursing duties.
Question twenty-eight was an open-ended question designed to investigate the reasons 154
"why" subjects might perform nursing care while experiencing back pain. Question
twenty-nine investigated the subjects' opinions as to the cause(s) of accidents/injuries.
This question was designed to support or reject a causative theory of accidents/injuries
and a systems Occupational Health and Safety Nursing Model.
Section 3 contained five questions which consisted a series of statements asking the
subjects to rank in order of importance, or frequency. Section 4 contained attitudinal
questions in four sub-sections requu-ing the subject to respond to a five-point Likert scale
consisting of "strongly agree", "agree", "don't know", "disagree", and "strongly
disagree". The subject was provided with a set of explanations about the scale and was
asked to respond to the point on the scale that most closely matched their own opinion.
They were requested to avoid the middle point unless they really did not know. Subjects
were asked to record any additional comments in the space provided at the end of each
sub-section.
Section 4A contained 14 questions on hazardous infections (namely hepatitis B, AIDS,
and general trauma risks from sterilisers). Section 4B consisted of six questions on
assault/aggression and environmental factors. Section 4C involved ten questions relating
to lifting, back injuries/pain and biomechanics of lifting. Section 4D consisted of 16
questions designed to elicit information concerning attitudes towards the organisational
hierarchy and role of nursing administrators in the procedures reporting for accidents/
injuries.
Statement groupings were chosen according to allocation under the following categories;
nursing hazards, physical injuries, nursing practice and biomechanics of lifting and
administrative procedures for registered nurses and nursing students. The results will be
grouped according to general research question and the hypotheses namely, the need for
educational inputs, the influence of environmental inputs, management inputs, social
aspects, organisational processes, patient/client centred processes and nurses centred processes (see Section 4.8). 155
4..^ Data Collection and Recording
4.5.1 Method: Registered Nurses
The OH&SNI was administered to 267 registered nurses in four public hospitals associated with providing clinical experience for The University of Wollongong's
Diploma of Applied Science (Nursing) students. The instrument was delivered by the experimenter to each of the wards in the four hospitals. A letter of explanation accompanied the instrument and the experimenter explained the procedure to the subjects at the time of distribution (see Section 4.5.4). Forms were collected by the experimenter at one week intervals for a month after the time of distribution.
4.5.2. Method : Nursing Students
The research instrument was administered to a total of 184 nursing students. The instrument was delivered to first, second and third year nursing students in lecmre rooms at The University where the students attended. An explanation was provided to the subjects by the investigator and subjects were given a choice as to whether or not they wished to participate. Participating students filled in the survey form in the lecture room and the investigator collected it before the students left the lecture venue. At no time was there an attempt by the investigator to coerce the student body into participating in the survey. Students were given every opportunity to leave the lecture venue without criticism or fear of retribution, and a short period of time was observed by the investigator to ensure students were give every opportunity to leave if they wished. 156
4.5.3 Method of Scoring
The Occupational Healtii and Safety Nursing InsttTiment is discussed in Section 4.4. The mediod of scoring for the fu-st two sections of the insttnment consisted of computing raw scores and converting them into frequencies. Section 3 of the insttiiment contained data used for part of the statistical analysis.
Section 3 of the instt-ument contained the data used for the statistical analyses. Raw data were computed for each item (questions 35 to 80) regarding the attitude of registered nurses and nursing student to each question. A score of 1 to 4 was allocated to each of the positive and negative ratings, and an overall score was computed for each item. A raw score was computed from the registered nurses' responses and the nursing students' responses separately. Ratings used were as follows: 4 for "strongly disagree", 3 for "disagree", 2 for "agree", and 1 for "strongly agree". The "don't know" point on the scale was eliminated from the analysis and was not scored. Missing values were also eUminated from the analyses.
4.5.4 Training Sessions The conceptual framework of the form and the scoring instructions were explained to registered nurses and nursing students prior to the implementation of the OH&SNI. Training sessions were provided by the experimenter firstiy to nurse unit managers at artanged meetings and subsequently in clinical ward settings in each of the participating hospitals. Students were provided with a training session prior to distribution of the form (see Section 4.5.1).
4.5.5 Content Validitv of the OH & SNI The method used to investigate content validity is discussed in Chapter 3, Section 3.2.1. Five chnical specialists were asked to judge the validity of die statements contained in the insttument. Clinical nursing experts were chosen on the basis of their designation as a 157 clinical nurse specialist. A raw score was computed for each of the statements to investigate the level of agreement between the judges (see Appendix E).Two categories were provided; namely "agree" or "disagree" forjudges to choose from.
4.5.6 Reliabilitv Estimates In order to estimate the reliability of the responses to the OH&SNI, Cronbach's alpha using split-half co-efficients was applied to both groups. The groups consisted of the registered nurses from the four hospitals involved in the research and the first, second and third year nursing students in the research, (Nie, Fry, Hull, Arendt, Jenkins, Walaszek, Sours, Morrison, Beadle, and Gruen 1983, 720).
4.6 Statistical Analvses
In this section, the statistical analyses used to interpret the data will be outlined. All computing was carried out at the University of Wollongong, using The Statistical Package for the Social Science X (SPSS-X, Nie et al., 1983).
Many proponents of grounded theory (Benner, 1984; Chenitz and Swanson, 1986; Morse, 1989) advance a view that statistical analyses are not relevant to studies such as this. Whilst not following this extreme view, no attempt is made in this thesis to fit parametric statistical models since point estimates and associated confidence intervals for parameters which represent, for example differences between categories of nurses and students are not of any direct interest. The statistical analyses which have been carried out are du-ected towards potentially providing support for hypotheses such as Hypothesis 3, [namely. Nurses' attitudes towards occupational health and safety training, hepatitis B immunisation, provision of in-service by management and ward staffing show that management inputs conttibute towards accident/injury causation]. 158
Frequencies for all statements were computed. The chi-squared statistic was used to investigate differences between the four registered nurse groups and the three nursing student groups for the responses to the attitudinal statements (namely questions 15 to 27 and 30 to 76). The expected frequencies in many cells were less than five which is the accepted minimum for the chi-squared statistic (Lumsden, 1974). Many of the significant differences appeared to be due to differences in degree of agreement for example, "strongly agree" and "agree". For these two reasons, the responses of registered nurses and nursing students were reduced to a two by two contingency table to check differences in acceptance ("strongly agree/agree") and rejection ("disagree/strongly disagree"). Where the differences appeared to be between groups of registered nurses, the data for registered nurses were collapsed into a two by two contingency table to check whether the difference was still apparent on an accept or reject basis. This collapsing was done in a manner that highghted only apparent differences, for example 2 hospitals versus 2 hospitals or 1 hospital versus 3 hospitals, depending on the responses in an individual question.
The most important factor in each question is whether or not the respondents accepted the statement based on the model. This was checked by collapsing all responses into simply accept or reject categories and the level of acceptance was reported in simple percentage terms and was checked in each case by the chi-squared goodness of fit statistic.
The strict validity of the calculated significance level of the test may be in doubt because of small numbers in some cells, but the general interpretation of the data should remain valid. Significant differences largely attributable to particular cells are commented on in the analyses. Discriminant function analysis was used to investigate possible association between personal characteristic data (questions 10 to 14) and accidents sustained by subjects (question 30). The level of significance for all statistical procedures was set at alpha = 0.05. 159
4.7 Statistical Significance Level and Limitations
4.7.1 Significance Level
The choice of significance level was set at the conventional alpha = 0.05. The rationale for accepting alpha = 0.05 for the hypothesis testing was to:
i. prevent Type 1 errors. [The probability of a Type 1 error is uicreased by setting alpha too high, for example alpha = 0.10. Thus a null hypothesis will too frequentiy be rejected when it is true.] and ii. prevent Type 2 errors. [The probability of committing a type 2 error is increased by setting alpha too low.]
4.7.2 Power of the Test The power of a statistical test of a null hypothesis is discussed by Woods and Cantanzano (1988, 114) "as the probability that the test will lead to the rejection of the null hypothesis". Essentially the power of the test rests in its ability to tease out
differences or associations. "Statistical power refers to the value of 1-b where b is the probability of type II error , the probability of failing to reject the null hypothesis when the effect really exists" (Woods in Woods and Cantanzano, 1988, 114). An important
aspect of the power of the test is it is inversely related to the p value and expanding the sample size allows for a more acute detection of overall effects and to reject the null hypothesis when it is false. (Woods in Woods and Cantanzano, 1988, 114).
The power also is a function of the specific alternative hypothesis. In the context of this thesis, the usual concern is with general alternatives [for example some association between registered nurses and nursing students]. There is no specific alternative, nor paramedic family of alternatives for which the power is of any particular interest. 160
4.7.3 Resttictions on the use of the Chi-square Statistic The following resttictions should be observed when applying the chi-square statistic to the analysis of certain data.
1. Chi-square requires to be calculated from frequencies according to Lumsden, (1974, 137)" it must never be calculated from proportions, percentages or scores."
2. Chi-square should not be employed when any expected frequency is less than five.
3. "The classifications which produce the frequencies for the X2 test must be independent of one another" (Lumsden, 1974, 137).
4.7.4 Sampling Problems and Non-responders
Sampling is defined by Woods in Woods and Cantanzano, (1988,97) as "the process of selecting a subset of a population in order to obtain information regarding a phenomenon in a way that represents the entire population". In this study the accessible population, that is "that aggregate that meets the criteria for inclusion in the study and that is available to the investigator," (Woods in Woods and Cantanzano, 1988, 97), revealed some problems. The population of registered nurses employed full time was low (N=254) and the choice of a sub-population for sampling would further reduce this figure. For this reason it was decided that the entire population of registered nurses should be surveyed. Evidence from earlier surveys suggested that a response rate of 40 -50% should be expected and this was also seen as a critical factor. Response rates appear to be variable according to the method employed to administer the survey, for example, Stubbs et al., (1986) had a return of 46.1% of dieir questionnaire from nurses in their study. The response rates for this studv were relatively high. The registered nurse sample 161
(which consisted of 90% of hospital A's full time registered nurse population, 68% of hosptial B's full time registered nurses, 85% of hospital C's full time registered nurses, and 83% of hospital D's full time registered nurse population) consisted of 83% of the population of registered nurses. One of the reasons this situation occurred was that during the interview and pilot collection stage, discussions with registered nurses revealed their desire for anonymity. The investigator, to ensure a non-threatening survey situation and complete anonymity observed the strictest principles for ensuring that individuals would not in any way be identified. Although the subjects' name was written on the outside of the survey form there was no way of identifying the subject as their name was not appended to the returned survey form. Because the subjects in the study were assured of complete anonymity and did not feel threatened it is possible that this could be one reason why the response rate was so high.
There is a need to ensure as much as possible that the responses are representative. Some methods can be used to investigate for the presence of response bias, these include;
"i)..."can compare the characteristics of the sample with other known values for the population of interest" ii). ..."to collect data from those individuals who chose not to respond to the sttidy" iii)..."the investigator could ask those individuals who chose not to participate to complete an abbreviated interview or questionnaire describing demographic characteristics or other information of particular interest to the investigator" Woods in Woods and Cantanzano (1988, 112).
Raisttick (1981) also discussed the problem of non-responders and cited the findingso f Cust et al., (1969) and the method they used to investigate non-responders. Although Raistt-ick (1981) cites Cust et al., (1969) in her article in regard to non- responders, on inspection of the literature and attempts to locate the article, Cust et al, (1969), were in vain, and the information she quoted was found in Cust et al., (1972,170-171) who stated; 162
"The prevalence and incidence rates in the teachers are based on die repHes of 949 (65.1%) of the 1,458 teachers employed in the city. Again a better response was obtained in the smaller schools. To test that the prevalence of LBP was no different in non-responders to the questionnaire, all non- responders (49) to the questionnakes in the 3 randomly selected schools were interviewed." and "In the nursing population, 13 (40.6%) of the 32 non- responders interviewed gave a history of LBP. Of the 49 non-responders interviewed from the teachers, 15 (30.6%) reported LBP. These rates are not statistically different from the rates in the main survey."..."Thus, the samples responding to the main questionnau-e were representative of the populations of nurses and teachers."
In this study, because data were not available from the Area Health Service nor from the
NSW Nurses Registration Board due to nurses' rights to confidentiality, it was not
possible to implement point i) as outhned by Woods in Woods and Cantanzano (1988).
Points ii) and in) nominated by Woods in Woods and Cantanzano (1988) were not
followed due to the registered nurses request for anonymity.
The procedure by Stubbs, et al., (1986) was adopted with some minor modifications.
An analysis to investigate for the possibility of response bias followed the procedure
reported by Stubbs, Buckle, Hudson, Rivers and Baty, (1986). They compared the
differences between high and low response districts in their study into nurse wastage
associated with back pain for the following variables; " grade, speciahty and sex"
(Stubbs el at., 1986, 328.)
The high and low response categories for the registered nurses group were from
Hospital A (90% of Hospital A registered nurses responded) and Hospital B ( 68% of
Hospital B registered nurses responded). The variables chosen for comparison were,
gender, age range and area of work speciality.
The gender percentage of registered nurses from both hospitals were similar with a 163
slightiy higher proportion of female registered nurses in Hospital A (93%) than Hospital
B (85%). The Hospital B percentage can be adjusted to 88% after one subject did not specify a gender.
There were "close" similarities in the age distributions for registered nurses from both these hospitals. For example 18% of Hospital A registered nurses and 16% of registered nurses from Hospital B were found in the [25-30) year age range, in the [30-35) age range there were 24% of Hospital A registered nurses and 27% registered nurses from
Hospital B, and in the [35-40) age range there were 16% of registered nurses from both hospitals.
The area of work speciality (see Table 4.8) was also found to be similar for both groups of nurses, 58% of Hospital A nurses' work speciality was in the "general" area and 54% of Hospital B registered nurses also nominated general nursing as their work speciality.
The proportion of nurses who nominated general nursing as their area of work speciality was similar (Hospital A: 58%, Hospital B: 54%) but there were some dissimilarities among the other specialties, e.g. midwifery for which there is no longer a unit at Hospital
A. Thus there are differences between the two hospitals which can be explained without appeal to response bias.
A similar method was also adopted for the nursing students but difficulties were found with collecting characteristics of the total population of nursing students as the method of enrolment changed with the entry of nurses into the tertiary sector. Selected data were available from University enrolment records. However, these records included students who had withdrawn, and as the data for this study were collected towards the end of the year the original student enrolment records were not able to be used for comparative purposes.
Therefore, the gender and prior nursing experience were compared for first and third 164 year nursing students. Age categorisations (see Table 4.11) are not sufficientiy narrow to be used "for this puipose" as third year students are over 20 year of age because students in NSW do not sit for the Higher School Certificate until they are 18 years of age.
Genders of the nursing students were recorded in Table 4.12. (There were 70% and 80% of female nursing students in the first and third year groups respectively. There were 30% and 20% of male students in the first and third year student groups respectively, reveating a higher percentage of male students in the first year group when compared to the third year group.)
Prior nursing experience is shown in Table 4.14 and it can be seen that there are similar estimates recorded. For example, 26% of first year nursing students and 28% of third year nursing students indicated that they had prior nursing experience.
These comparisons show many similarities between the groups and indicate that for both the registered nurse groups and nursing student groups the sample was similar in most respects.
The method used to investigate response bias however does possess an inherent weakness. In comparing the low and high response groups in the research it shows only that these groups are self-consistent and does not exclude the possibility of a self- consistent group not responding. However this method does provide some confidence about the responders.
In this study because of the anonymity of the method employed and the absence of an identification system to identify individual subjects it was not possible to analyse the characteristics of the non-responders. However it is highly likely that the guarantee of 165
anonymity resulted in the high response rate.
4.7.5 Limitations As only one tertiary nursing population was used in the study, any generalisations to odier populations would need to be considered with caution. Registered nurses from only one Area Health Service were included in the study, and dierefore generalisations to odier populations of registered nurses would also need to be considered with caution. Cortoborative studies would need to be undertaken in other settings to support any findings that may be identified in the survey.
4.8 The General Research Que.stion and Hypotheses
The general research question addressed in this study is, whether an occupational health and safety systems model will explain the genesis of accident/injury causation with multicausal factors contributing towards nurses' accident occurrence.
In answering this question it was decided to look at the following general hypotheses; Hypothesis 1 Nurses' attitudes towards loads lifted, lifting patients, back care, and availability of in- service education will show a need for educational inputs to avoid accidents/injuries.
Hypothesis 2 Nurses' attitudes towards nosocomial infections, poor equipment and equipment maintenance will show that environmental inputs contribute towards accident/injury causation. 166
Hypothesis 3
Nurses' attitudes towards occupational health and safety training, hepatitis B immunisation, provision of in-service by management and ward staffing will show that management inputs conttibute towards accident/injury causation.
Hypothesis 4
Nurses' attitudes towards their own performance and social expectations will show that social inputs contt-ibute towards accident/injury causation.
Hypothesis 5
Nurses' attitudes towards availability/co-operation of ancillary staff and ergonomic design will show that organisational processes contribute towards accident/injury causation.
Hypothesis 6
Nurses' attitudes towards physical injury, verbal and physical abuse, infectious diseases will show patient/client centred processes contribute towards accident/injury causation.
Hypothesis 7
Nurses' attitudes towards days missed from work, compensation claims and work motivation will show nurse centred processes contribute towards accident/injury causation. CHAPTER FIVE 167
RESULTS
5.1 Introduction
A study was untaken to identify, describe and provide a theoretical analysis and framework for accident causation within the context of a clinical nursing environment, (see Chapter 1, Section 1.6.5,). Concomitantiy, nurses' attitudes to accident causation, plus selected personal characteristics were sought to categorise groups.
Data from interviews, questionnaires administered to a representative sample of nurses and a follow-up interview schedule with selected injured nurses, were analysed by appropriate statistical methods and qualitative gathering procedures. The rehabihty co efficients computed for registered nurses' and nursing students' responses to the OH&SNI and the content validity of the research instrument are stated. The results of this study are reported in relation to the hypotheses posed in Chapter 4, Section 4.8.
5.2 Analvsis of Participants' Responses
In the following section registered nurses' and nursing students' responses will be reported, providing evidence to support an occupational health and safety systems model, which will explain the genesis of accident/injury causation with multicausal factors contributing towards nurses' accident/injury occurrence.
The results from registered nurses' and nursing students' responses towards reasons for accident/injury causation are presented in the following section. Tables 5.1 and 5.2 display the results for registered nurses and nursing students respectively.
Comments are grouped under seven main headings, namely; educational, environmental, management, and social inputs; client/patient centred, organisational(hospital), and nurse centred processes. 168
Comments appended under the educational inputs demonstrate the lack of educational inputs that appear to conttibute towards accident causation according to registered nurses and nursing students in this study. Registered nurses nominated four such factors, namely; "incortect procedures", "no education on OH&S", "lifting unassisted" and "lack of clinical instruction"(see Table 5.1), compared to nursing students who nominated two factors (see Table 5.2) "going beyond your capabiHties" and "lack of education in lifting". Environmental inputs showed that five factors where nominated by registered nurses and two factors by nursing students. The five factors nominated by registered nurses consisted of "cords dangling in operating rooms", "poor faulty equipment", "inadequate lifting aids", "gases making you sick" and "wet/slippery floors" (see Table 5.1). Nursing students mentioned "busy wards" and "radiation from x-rays" (see Table 5.2).
Management inputs highlighted by registered nurses consisted of three factors, which were; "administration discouraging you from reporting and intimidation", "heavy workload" and "inadequate numbers of support staff" (see Table 5.1).Nursing students nominated "no support from administt-ation" and "staff shortages"(see Table 5.2).
Social inputs consisted of two determinants, namely macro-social and micro-social factors. Macro-social inputs were tested by the OH&SNI and were the attitudes, perceptions and habits that impinge upon nurses in the workplace. Micro-social inputs where also tested by the survey form and reflect the immediate social situation demands/responses to the demands of the" job". The following statements to investigate nurses' attitudes to "have you performed nursing care when you have had back pain?", "I always report patients' ttivial accidents/injuries however trivial", "I often neglect to report my own accidents/injuries", "I know some registered nurses are disinclined to report patients' trivial injuries", "nurses do not like to claim compensation for accidents/injuries", and "nurses who take time off for accidents/injuries are thought to be malingerers". 169
Client/patient centred determinants nominated by registered nurses consisted of four factors. These factors were; "assault from aggressive/violent patients", "lack of co operation from confused patients", "in contact with drug users, risk of AIDS, hepatitis B" and "in contact with patients' body fluids". Nursing students responded in a similar manner suggesting "angry/distt-essed patients hitting you" and "uncontrollable patients" as two such factors.
Organisational (hospital) processes mentioned by registered nurses consisted of four factors, namely "staff shortages", staff freeze", "untrained staff" and "wardsmen not available/refusing to help; against union rules to lift heavy patients". A high proportion of registered nurses mentioned "staff shortages" (105). Only one factor was nominated by nursing students; "to avoid getting dismissed staff were being asked to leave their part- time jobs if claiming compensation".
Nurse centred processes were the most numerous and eight factors were recorded by registered nurses, namely; "burns from steriHser", "lifting heavy patients", "lifting incorrectly", "needleprick, sharps", "overworked", "reluctance of medical staff to help lift in operating room" and "tiredness". Nursing students nominated five factors, namely "inexperience in lifting", "left alone to hft", "negligence", "short cuts" and "tiredness".
A number of subjects did not respond to this particular question, with 32 registered nurses and 15 nursing student opting not to comment. 170
TABLE 5.1 RESULTS OF ACCIDENT/INJURY CAUSATION: REGISTERED NURSES
Comments Hospital Hospital Hospital Hospital Total A B C D
Fdncational inouts
"incortect procedures" 8 5 7 7 27 "No education on 0.H.& S." 6 2 3 4 15 "Lifting unassisted" 0 3 3 1 7 "Lack of chnical insttuction" 8 2 2 5 17
Environmental inputs
"Cords dangling in operating rooms" 0 0 3 2 5 "Poor faulty equipment" 1 0 2 4 7 "Inadequate lifting aids" 6 0 0 2 8 "Gases making you sick" 0 0 2 3 5 "Wet/slippery floors" 9 2 2 17 30 Management inputs
"administt-ation discouraging you from reporting and intimidation" 3 1 3 3 10 "heavy workload" 4 3 2 25 34 "Inadequate numbers of support staff" 0 2 2 5 9
Social inputs Macro: These are the attitudes, perceptions, habits that impinge upon nurses in the workplace, for example disregard for their own safety (these attitudes are tested by the OH&SNI). Micro: This is the immediate social situation demands/responses to the demands of the "job", for example the nurse having to lift a patient by her/himself(these attittides are also tested by the OH&SNI). 171
TABLE 5.1 RESULTS (CONTINUED) OF ACCIDENT/INJURY CAUSATION: REGISTERED NURSES
Comments Hospital Hospital Hospital Hospital Total A B C D
Client/patient centt-ed "Assault from aggressive/violent patients" 2 3 10 14 29 "Lack of co-operation from confused patients" 6 1 2 10 19 "In contact with drug users. risk of AIDS, Hep. B" 0 5 3 8 16 "In contact with patients' body fluids" 1 5 3 10 19
Organisational fHospitaD processes "Staff shortages" 33 11 18 43 105 "staff freeze" 0 0 0 14 14 "unfi-ained staff 3 2 1 2 8 "Wardsmen not available/ refusing to help: against union rules to lift heavy patients" 2 0 3 8 13
Nurse centred processes "Burns from steriliser" 2 1 2 5 10 "Carelessness" 6 3 0 14 23 "Lifting heavy patients" 7 1 7 10 25 "Lifting incortectiy" 8 5 7 6 26 "Needleprick, sharps" 5 3 2 14 24 "Overworked" 0 0 4 11 16 "Reluctance of medical staff to help lift in operating room" 2 0 0 3 5 "Tiredness" 11 1 3 4 19
No comment 10 14 32 172
TABLE 5.2 RESULTS OF ACCIDENT/INJURY CAUSATION: NURSING STUDENTS
Comments First year Second year Third year Total
Educational innuts
"Going beyond your capabilities" 1 4 7 12 "Lack of education in hfting" 0 2 0 2
Envu-onmental inputs
"Busy wards" 1 1 2 4 "Radiation from X-rays" 1 0 2 3
Management inputs
"No support from administration" 0 1 2 3 "Staff shortages" 7 9 5 21 Client/patient centred processes
"Angry/distt-essed patients hitting you" 2 6 2 10 "UnconttroUable patients" 1 3 7 11
Organisational (hospital) processes
"To avoid getting dismissed staff were being asked to leave thek part-time jobs if claiming workers' compensation" 1 0 0 1
Nurse centred processes
"Inexperience in lifting" 3 2 0 5 "Left alone to lift" 5 4 2 11 "NegUgence" 1 0 0 1 "Shortcuts" 0 1 2 3 "Tiredness" 2 0 3 5
No comment 7 2 6 15 173
The results support the notion of an occupational health and safety systems model with multicausal factors contributing towards accident occurtence in the nurses' working environment. A concept analysis of the model will be presented in Chapter 6.
5.3 The Need for Educational Inputs to Avoid Accidents/Injuries.
The following questions concerning loads lifted, lifting patients, back care, and availability of in-service education address the need for educational inputs to avoid accidents/injuries.
TABLE 5.3 OPINIONS FOR PRESCRIBED SAFE LOAD FOR LIFTING: REGISTERED NURSES
Weight m Hospital Hospital Hospital Hospital Kilograms A BCD
>61 16(26%) 6(23%) 13(34%) 20(16%) 41-61 8(13%) O(-) 8(14%) 14(11%) 31-40 3(5%) O(-) 3(6%) 8(7%) 21-30 10(16%) 9(35%) 5(9%) 17(14%) 10-20 17(28%) 6(23%) 18(33%) 45(36%) <10Kgs 5(8%) 1(4%) 2(4%) 13(10%) Don't Know 2(3%) 4(15%) 6(10%) 8(6%) Missing 1(1%) O(-) O(-) O(-)
Total 61 26 55 125
Table 5.3 demonstrates registered nurses' opinions as to the prescribed legal load for lifting. The results clearly show that the majority of registered nurses believed the load was higher than it is, (that is 16 kg). A third of the registered nurse population from hospitals C and D were aware of the cortect prescribed (legal) safe load for lifting. 174 compared to approximately one fifth of registered nurses from hospital A and B nominating the correct range.
TABLE 5.4 OPINIONS FOR PRESCRIBED SAFE LOAD FOR LIFTING: NURSING STUDENTS Weight in First Second Third kilograms Year Year Year
61> 9(11%) 9(17%) O(-)
41-60 21(26%) 12(23%) 9(18%)
31-40 17(21%) 8(15%) 11(22%)
21-30 8(10%) 10(19%) 12(23%) 10-20 15(18%) 12(23%) 11(21%)
<10 2 (2%) 1 (3%) 4 (8%)
Don't know 9 (12%) O(-) 4 (8%)
81 52 51
Compared to the registered nurses, the nursing students demonstt-ated a better awareness of the cortect load for lifting, particularly as they became more senior. This trend became more evident with the third year students; not one of the third year students nominated a category in the 61 kilogram range and over. Greater numbers of second and third year students were closer to the correct load than first year students, [(the correct load is defined as 16 kgs according to the Factories, Shops and Industries Act 1962, see Chapter 2, Section 2.6.3) (see Table 5.4)]. It appears the more senior students responses' resembled the registered nurses, particularly those registered nurses from hospitals A and B. Clearly, the third year students responses when compared to all nurses, demonstrated a better understanding of what constituted a reasonable weight to lift. 175
TABLE 5.5 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "NURSES OFTEN WORK WHEN THEY HAVE BACK PAIN"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A t23(45.1%) 28(54.9%) O(-) O(-) 51 * 14.6 34.9 1.1 0.4
Hospital B 11(42.3%) 14 (53.8%) O(-) 1(3.8%) 26 7.4 17.8 0.6 0.2
Hospital C 22(36.1%) 37 (60.7%) 2 (3.3%) O(-) 61 17.5 41.8 1.3 0.4
Hospital D 36 (30.3%) 81 (68.1%) 2 (1.7%) O(-) 119 34.1 81.5 2.6 0.9
Fkst year 7 (10.9%) 52(81.3%) 3 (4.7%) 2 (3.1%) 64 18.3 43.8 1.4 0.5
Second year 9 (17.6%) 42 (82.4%) O(-) 0 (-) 51 14.6 34.9 1.1 0.4
Third year 12 (25.5%) 33 (70.2%) 2 (4.3%) O(-) 47 13.5 32.2 1 0.3 Column Total 120 287 9 3 419
£Chi-Square 40.1, d.f 18; p < 0.005]
t observed frequency and percentage of row total. * expected frequency (under the hypothesis of no interaction between registered nurse/student category).
First year nurses are the least inclined to stt-ongly agree that nurses often have to work when they have back pain, with the majority of first year students (81.3%) showing that they agreed. The third year nurses show a pattern of reponses that are beginning to resemble registered nurses' responses, and, it is clear that the majority of registered nurses believe that nurses often work when they have back pain ( see Table 5.5). The cell responsible for the significant value for the chi-square was the contribution by the first year nurses' responses to "strongly agree" widi an observed frequency of seven and a higher expected frequency (18.3). The significant difference was largely due to differences between the "strongly agree" and "agree" point on the scale. When groups were reduced to registered nurses and nursing students, a two by two contingency table revealed no significant difference. 176
The responses were collapsed into two categories "agree/strongly agree" and "disagree/strongly disagree". These data resulted in 94% of registered nurses and 95% of nursing students supporting the statement. These results supported hypodiesis one.
TABLE 5.6 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "MECHANICAL DEVICES ARE AVAILABLE TO HELP LIFT HEAVY PATIENTS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) 15 (30%) 16(32%) 19 (38%) 50 2.9 26.9 12.4 7.8
Hospital B O(-) 14 (56%) 8 (32%) 3 (12%) 25 1.4 13.5 6.2 3.9
Hospital C 1 (1.8%) 23 (41.1%) 20 (35.7%) 12 (21.4%) 56 3.2 30.1 13.9 8.7
Hospital D 1(0 .9%) 42 (37.5%) 40 (35.7%) 29 (25.9%) 112 6.4 60.3 27.9 17.4
First year 15 (19.5%) 60 (77.9%) 2 (2.6%) O(-) 77 4.4 41.4 19.2 12.0
Second year 2 (4.1%) 36 (73.5%) 10 (20.4%) 1 (2%) 49 2.8 26.4 12.2 7.6
Thu-d year 5 (10.2%) 35 (71.4%) 8 (16.3%) 1 (2%) 49 2.8 26.4 12.2 7.6
Column Total 24 225 104 65 418 [ Chi-Square 140.3, d.f. 18; p < 0.0001]
Table 5.6 shows that the majority of registered nurses disagreed, or strongly disagreed, that mechanical devices were available to help lift heavy patients. Responses from registered nurses from hospital A, C and D were similar for the "agree" point on the scale, showing a contrast with the responses of registered nurses from hospital B. Hospital B registered nurses were more hkely to choose "agree", than registered nurses from the other hospitals. In contrast hospital B and the majority of nursing students agreed with the statement. There were similarities between the second and third year students for their responses to "disagree", with 20.4% of second year students and 16.3% of third year students compared to only 2.6% of first year nursing students who 177 responded to the "disagree" point on the scale. For these results the chi-square statistic highlighted differences between hospitals and between nursing student groups, and the first year students responses to "stt-ongly agree" revealed a low expected frequency (4.4) compared to a higher obtained frequency (15) which partially explained the significant value for chi-square. A two by two contingency table comparing registered nurses and nursing students responses demonstrated a significant difference (p < 0.001) The responses were collapsed into two categories "agree/strongly agree" and "disagree/stt-ongly disagree". These data resulted in 60% of registered nurses and 13% of nursing students who believed that mechanical devices were not available to help lift heavy patients. TABLE 5.7 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "MECHANICAL DEVICES ARE ALWAYS USED IF THE PATIENT IS TOO HEAVY TO LIFT".
Category Stt-ongly Agree Disagree Stt"ongly Row Agree Disagree Total
Hospital A O(-) 1 (2.0%) 22 (44%) 27 (54%) 50 0.7 3.3 30.1 15.9
Hospital B O(-) O(-) 19 (73.1%) 7 (26.9%) 26 0.4 1.7 15.7 8.3
Hospital C O(-) 2 (3.4%) 36(61%) 21(35.6%) 59 0.8 3.9 35.5 18.7
Hospital D 1 (0.8%) 3 (2.5%) 70 (58.8%) 45(37.8%) 119 1.7 7.8 71.7 37.8
First year 4 (5.7%) 11(15.7%) 49 (70%) 6 (8.6%) 70 1 4.6 42.2 22.2
Second year O(-) 6(12%) 30 (60%) 14(28%) 50 0.7 3.3 30.1 15.9
Third year 1 (2%) 5 (9.8%) 30 (58.8%) 15 (29.4%) 51 0.7 3.4 30.7 16.2
Column Total 6 28 256 135 425 [Chi-Square 57.1, d.f. 18; p< 0.001]
Inspection of Table 5.7 shows that the majority of registered nurses disagreed that they 178 used mechanical devices if the patient was too heavy to lift. On examination of the data, the pattern of responses of hospital B registered nurses, show differences when compared to the responses of the registered nurses from the other three hospitals, with greater numbers of hospital B nurses choosing "disagree". There were some similarities between registered nurses and nursing students for this variable, however, it can be seen that the second and third year nursing students' responses more closely resembled the registered nurses' responses, than the first year nursing students.
The chi-squared statistic revealed differences between registered nurses and between nursing students groups. The first year nursing students' responses for the "agree" point on the scale revealed a lower expected frequency (4.6) than obtained frequency (11) and a higher expected frequency (22.2) than obtained frequency (6) for the "strongly disagree" point on the scale, which contributed to the significant value. When registered nurses' and student nurses' responses were observed in a two by two contingency table a significant difference was demonsQ-ated.
The responses for this statement when collapsed into two categories either accepting ("agree/stt-ongly agree") or rejecting ("disagree/strongly disagree"), revealed 97% of registered nurses and 84% of nursing students "disagreed/strongly disagreed" that mechanical devices were always used if the patient was too heavy to lift. 179
TABLE 5.8 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "NURSES OFTEN LIFT MORE THAN THE PRESCRIBED LOAD"
Category Strongly Agree Disagree Stt-ongly Row Agree Disagree Total
Hospital A 28(57.1%) 20(40.8%) 1(2%) O(-) 49 22.1 26.1 0.8
Hospital B 14(53.8%) 12(46.2%) 0 (-) O(-) 26 11.7 13.8 0.4
Hospital C 34(55.7%) 25(41%) 2(3.3%) O(-) 61 27.6 32.5 1.0 Hospital D 69 (55.2%) 55 (44%) 1 (0.8%) O(-) 125 56.5 66.5 2
Fkstyear 11 (15.1%) 60 (82.2%) 2(2.7%) O(-) 73 33 38.8 1.2
Second year 21 (41.2%) 30 (58.8%) 0 (-) O(-) 51 23 27.1 0.8
Thu-d year 20(39.2%) 30(58.8%) 1(2%) O(-) 51 23 27.1 0.8 Column Total 197 232 7 0 436
[Chi-Square 42.5, d.f.l8; p< 0.0001]
The responses from registered nurses and nursing students shown in Table 5.8 for the statement, "Nurses often lift more than the prescribed load", showed accord between all groups of nurses.
The chi-square statistic showed a significant difference, this can be attributed to the responses of the first year students who nominated "strongly agree" in lesser numbers compared to other groups. For this cell the results revealed a low obtained frequency
(11) compared to a relatively higher expected frequency (33), as opposed to all the other groups whose responses were equally divided between the "agree" and "stt-ongly agree" points on the scale. Nurses agreed they believed that they lift more than the prescribed load, however it is also clear from the evidence (see Tables 5.3 and 5.4) they are unsure of the correct load. When the chi-square statistic was applied to a two by two 180 contingency table for registered nurses and nursing students responses there was no significant difference.
When the responses were collapsed into two categories either accepting ("agree/strongly agree") or rejecting ("disagree/strongly disagree"), 98% of registered nurses and 98% of nursing students accepted the statement.
TABLE 5.9 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "NURSES ALWAYS THINK FIRST ABOUT THE MECHANICS OF LIFTING BEFORE THEY LIFT A PATIENT"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 4 (8%) 14 (28%) 22 (44%) 10 (20%) 50 1.9 12.9 27.7 7.5
Hospital B 1 (4%) 7 (28%) 14 (56%) 3 (12%) 25 0.9 6.5 13.9 3.7
Hospital C 1 (1.8%) 10 (17.9%) 34 (60.7%) 11(19.6%) 56 2.1 14.5 31.1 8.4
Hospital D 8 (6.7%) 45 (37.8%) 58 (48.7%) 8 (6.7%) 119 4.5 30.7 66.0 17.8
First year 1 (1.4%) 18 (25.4%) 46 (64.8%) 6 (8.5%) 71 2.7 18.3 39.4 10.6
Second year O(-) 10 (19.6%) 32 (62.7%) 9 (17.6%) 51 1.9 13.2 28.3 7.6
Third year 1 (2%) 5(10%) 28 (56%) 16 (32%) 50 1.9 12.9 27.7 7.5
Column Total 16 109 234 63 422 IChi-Square 46.0, d.f. 18; p < 0.001]
Table 5.9 shows the responses from registered nurses and nursing students for the statement, "Nurses always think first about the mechanics of lifting before they lift a patient". It can be seen that the majority of all nurses "disagreed" with the statement. Similar response patterns to the "agree" point on the scale, were elicited from registered nurses from each of the four hospitals and the nursing students. Compared to all other groups third year nursing students were less likely to nominate "agree" (10%). The chi- 181 square statistic was significant, principally due to the conttibution of the "agree" cell for third year nurses which revealed an obtained frequency of five compared to a high expected frequency (12.9) . There was a significant difference (p < 0.001) between registered nurses and nursing students responses for a two by two contingency table. These results revealed in the opinion of the majority of nurses in this study that most nurses do not think about the mechanics of lifting before they lift a patient. When the responses for this statement were collapsed into two categories either accepting ("agree/strongly agree") or rejecting ("disagree/strongly disagree"), results revealed 64% of registered nurses and 79% of nursing students rejected die statement
5.10 RESPONSES OF REGISTERED NURSES TOWARDS "ATTENDANCE AT TRAINING SESSIONS ON OCCUPATIONAL HEALTH AND SAFETY ISSUES SINCE GRADUATION"
Category Yes No
Hospital A 48 6 (88.9%) (11.1%) Hospital B 16 9 (64%) (36%) Hospital C 58 2 (96.7%) (3.3%) Hospital D 122 3 (97.6%) (2.4%)
Data were secured from registered nurses to investigate whether they had attended any kind of training in health and safety since graduation as a nurse (see Table 5.10). The results showed that the majority of registered nurses had attended in-service tt-aining. The attendance rates varied from hospital to hospital with registered nurses from hospital C and D demonstt-ating that more than 95% of registered nurses had attended. Registered nurses from hospital B showed the lowest attendance rates (64%), with almost 90% of attendance levels shown by registered nurses from hospital A. 182
5.11 REGISTERED NURSES RESPONSES TOWARDS:" THE TYPE OF IN- SERVICE ATTENDED"
Type of in-service Hospital A Hospital B Hospital C Hospital D
/UDS Yes 26(44%) 7(27%) 21(38%) 49(39%) No 33(56%) 19(73%) 34(62%) 76(61%)
Hepatitis B Yes 27(46%) 6(23%) 12(22%) 46(37%) No 33(54%) 20(77%) 43(78%) 79(61%) Liftmg techniques Yes 42(70%) 12(46%) 29(53%) 74(59%) No 18(30%) 14(54%) 26(47%) 51(41%)
Back care Yes 21(35%) 5(19%) 24(44%) 47(38%) No 35(59%) 21(81%) 31(56%) 78(62%)
Fire drill Yes 55(91%) 13(50%) 37(67%) 113(90%) No 5(9%) 13(50%) 18(33%) 12(10%)
Hospital fires Yes 50(84%) 14(54%) 39(71%) 96(77%) No 10(16%) 12(46%) 16(29%) 29(23%)
When the data is analysed further to investigate the nature of the tt-aining,i t can be seen from the results depicted in Table 5.11, that the major type of training provided was in the area of "fire drill". It is evident that over 90% of registered nurses had attended this type of training from Hospitals A and D, however, the attendance levels were noticeably lower for hospital C registered nurses, and hospital B registered nurses, who showed the lowest percentage of attendance rates, (50%).
The results for attendance at "hospital fires" showed a similar pattern of attendance to "fire drill" training, although, with comparatively reduced attendance levels. Approximately 80% of hospital A registered nurses had nominated they attended "hospital fires" training, with again hospital B nurses showing lower attendance patterns, 183
(54%). Registered nurses from hospitals C and D showed that just over 70% of nurses had attended such sessions.
In other critical areas, the provision of in -service training appeared to be very low, with AIDS in-service showing that less than half the hospital A nurses attended such courses. The hospital B registered nurses again showed the lowest percentage of attendance, (27%).
Provision of training by management for in-service on hepatitis B also showed few nurses having attended such courses, particularly those from hospital B and C, (23% and 22% respectively), but with proportionally more registered nurses from hospital A and D indicating attendance, (46% and 37% respectively).
Registered nurses attending "back care" in-service from hospital A and hospital B (35% and 19% respectively) showed comparatively lower percentages of attendance than registered nurses from hospital C and D, (44% and 38% respectively). Registered nurses from all hospitals were more likely to have attended "lifting techniques", than "back care" in-service, and in one case, 70% of registered nurses indicated they had attended, (hospital A nurses). The attendance rates for the nurses from the other three hospitals, varied between 45% to 59%, (see Table 5.11).
5.3.1 Summary In the following section a brief summary of the results that address hypothesis one is presented.
Opinions regarding the prescribed safe load for lifting according to registered nurses (see Table 5.3) revealed that the majority of nurses believed the load to be higher than die safe legal load (16 kg) thus supporting the need for educational inputs to rectify their knowledge deficit. Although nursing students (see Table 5.4), particularly second and 184 third year nursing students were better informed than first year students about the prescribed safe load, a considerable number of nurses still expressed the opinion that the safe load was higher than the actual prescribed safe load. These results support the need for educational inputs.
The results shown in Table 5.5 for the responses of registered nurses and nursing students to "nurses often work when they have back pain" showed accord between all groups of registered nurses and nursing students. The categories when collapsed into rejecting or accepting the statement results showed that in the opinion of 94% of registered nurses and 95% of nursing students, nurses often worked when they had back pain. This result supported hypothesis one.
When categories were collapsed for the statement "mechanical devices are available to help lift heavy patients" (see table 5.6). Sixty percent of registered nurses and 87% of nursing students rejected the statement indicating that mechanical devices were available to help lift heavy patients. This result supported hypothesis one.
Results illustrated in Table 5.7 for the statement "mechanical devices are always used if the patient is too heavy to lift" showed a significant difference between groups (p < 0.001) These findings support the premise that mechanical devices do not appear to be used by nurses when lifting heavy patients [for collapsed categories either accepting ("stt-ongly agree/agree") or rejecting ("disagree/stt-ongly disagree") the statement] 97% of registered nurses and 84% of nursing students supported the content in the statement ]. These results support hypothesis one.
Responses of registered nurses and nursing students to "nurses often lift more than the prescribed load" (see Table 5.8) revealed that the majority of nurses believed this to be the case. When categories were collapsed 98% of registered nurses and 98% of nursing students supported the statement, revealing support for hypothesis one. 185
Sixty-four percent of registered nurses and 79% of nursing students rejected the notion that nurses always think first about the mechanics of lifting before they lift a patient (see table 5.9). These findings support hypothesis one.
There was some variation between the proportion of staff from the four hospitals who had been to occupational health and safety sessions, although the majority of registered nurses had attended the more tt-aditionalsession s on fire drill and hospital fire courses (see Table 5.10). It was clear that in-service attendance by registered nurses in the more recent occupational health areas was not well attended. The important area of "back care" in-service was not well attended (see Table 5.11) and there was some variation of attendance patterns between registered nurses from the four hospitals for "lifting technique" in-service training. In the latter area the registered nurses attendance rates from hospital B and C were noticeably lower than registered nurses from the other two hospitals.
The results outiined in the preceding discussion support hypothesis one, that is nurses' attitudes towards loads lifted, lifting patients, back care, and avaitiabilty of in-service education will show a need for educational inputs to avoid acccidents/injuries.
5.4 Hvpothesis Testing the Influence of Environmental inputs and their Contribution Towards Accident/Injurv Causation
In the following section results will be presented that address the notion that certain environmental influences, for example nurses' attitudes towards nosocomial infections, poor equipment and equipment maintenance affect nurses' propensity towards accident/injury occurtence. 186
TABLE 5.12 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "LEGIONNAIRE'S DISEASE IS AN OCCUPATIONAL HEALTH RISK FOR NURSES"
Category Strongly Agree Disagree Stt-ongly Row Agree Disagree Total Hospital A 9(18%) 19 (38%) 15 (30%) 7 (14%) 50 5.1 18.1 21.8 5
Hospital B 2 (8.7%) 7 (30.4%) 12 (52.2%) 2 (8.7%) 23 2.4 8.3 10 2.3
Hospital C 3 (5.5%) 16(29.1%) 26 (47.3%) 10 (18.2%) 55 5.6 19.9 24 5.5
Hospital D 17(14.4%) 39(33.1%) 48 (40.7%) 14 (11.9%) 118 12.1 42.7 51.4 11.8
First year 2 (3.9%) 23 (45.1%) 25 (49%) 1 (2%) 51 5.2 18.5 22.2 5.1 Second year 3 (7.3%) 19 (46.3%) 18 (43.9%) 1 (2.4%) 41 4.2 14.9 17.9 4.1
Third year 3 (7%) 15(34.9%) 22 (51.2%) 3 (7%) 43 4.4 15.6 18.7 4.3
Column Total 39 138 166 38 381
iChi-Square 27.5, d.f. 18; p > 0.05]
Registered nurses and nursing students responses for attitudes towards Legionnaires' disease, shows similarity of response patterns, by all groups of registered nurses and nursing students, (see Table 5.12). All groups appear to be equally divided between the "agree" and "disagree" points on the scale. There is a difference between registered nurses and nursing students responses towards "stt-ongly agree", and there are greater numbers of registered nurses from all hospitals choosing "stt-ongly agree", compared to first and second year nursing students. These students, were less likely to choose the "stt-ongly agree" point on the scale [note the difference between the obtained frequency (19) and expected frequency (14.9) for the second year students responses to the "agree"]. The third year nursing students were noticeably more inclined to nominate "disagree"; showing a closer resemblance to the registered nurses responses, particularly the hospital B registered nurses, than the first 187 and second year nursing students. When registered nurses and nursing students responses were compared in a two by two contingency table a significant difference was not demonstrated.
For this variable when categories were collapsed either accepting ("stt-ongly/agree/agree") or rejecting ("disagree/strongly disagree") die statement, results revealed 50% of registered nurses and 51% of nursing students "disagreed/strongly disagreed" with the content contained in the statement.
TABLE 5.13 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "ANAESTHETIC GASES ARE NOT A SOURCE OF CONCERN TO NURSES WHILE THEY ARE WORKING IN THE OPERATING ROOM"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 1 (2%) 14 (27.5%) 22 (43.1%) 14(27.5%) 51 2.3 10.9 24.8 13.1 Hospital B 2 (9.5%) 7 (33.3%) 8 (38.1%) 4 (19%) 21 0.9 4.5 10.2 5.4 Hospital C 5 (8.9%) 11 (19.6%) 24 (42.9%) 16(28.6%) 56 2.5 11.9 27.2 14.4 Hospital D 2(1.8%) 20 (17.9%) 57 (50.9%) 33 (29.5%) 112 4.9 23.9 54.4 28.8
First year O(-) 7 (13.7%) 35 (68.6%) 9(17.6%) 51 2.3 10.9 24.8 13.1
Second year 1 (2%) 7 (14%) 25 (50%) 17 (34%) 50 2.2 10.6 24.3 12.9 Third year 6 (13.6%) 16(36.4%) 16 (36.4%) 6(13.6%) 44 1.9 9.4 21.4 11.3 Column Total 17 82 187 99 385
[ Chi-Square 41.2, d.f. 18; p< 0.01]
Registered nurses and nursing students responses towards the statement, "anaesthetic gases are not a source of concern to nurses while they are working in the operating room" are shown in Table 5.13. Similarities between registered nurses, first year and second year nursing students are evident, with the majority of nurses nominating 188
"disagree". For this statement third year nursing students were equally divided between "agree" (36.6%) and "disagree" (36.4%). The difference between the obtained frequency (35) and die expected frequency (24.8) for the "disagree" point on die scale for first year nurses' responses, contributed to the significant difference (p < 0.001). There was no significant difference observed when registered nurses and nursing students responses were reduced to a two by two contingency table. Most nurses beUeved anaesthetic gases were a problem, and the results when collapsed for the statement revealed 74% of registered nurses and 74% of nursing students supported this view.
TABLE 5.14 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "DERMATITIS IS NOT A COMMON OCCUPATIONAL HAZARD FOR NURSES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 1 (1.9%) O(-) 17 (32.7%) 34 (65.4%) 52 0.7 2.7 23.8 24.7 Hospital B 1 (4%) 1 (4%) 13 (52%) 10 (40%) 25 0.4 1.3 11.5 11.9 Hospital C 2 (3.3%) 4 (6.7%) 21 (35%) 33 60 0.9 3.1 27.5 28.5 Hospital D 1 (0.8%) 8 (6.5%) 54 (43.5%) 61 (49.2%) 124 1.8 6.5 56.8 58.9
Fu-st year O(-) 4 (6.2%) 40 (61.5%) 21(32.3%) 65 0.9 3.4 29.8 30.9
Second year O(-) 1 (2.2%) 24 (53.3%) 20(44.4%) 45 0.6 2.4 20.6 21.4 Thu-d year 1 (2%) 4 (8%) 24 (48%) 21 (42%) 50 0.7 2.6 22.9 23.8 Column Total 6 22 193 200 421
[Chi-Square 25.9, d.f. 18; p > 0.05]
Table 5.14 clearly shows that the majority of registered nurses and nursing students eidier disagreed, or strongly disagreed, with the statement, "dermatitis is not a common occupational hazard for nurses". The chi-square statistic showed there were no significant differences between the seven groups highlighting the accord between all 189 groups for this variable. This result was confirmed when registered nurses and nursing students responses were compared in a two by two contingency table. When categories were collapsed either accepting, ("stt-ongly agree/agree") or rejecting ("disagree/stt-ongly disagree") the statement it was revealed that 93% of registered nurses and 93% of nursmg students believed dermatitis was a common occupational hazard.
TABLE 5.15 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "SLIPPING ON WET FLOORS CAUSE ACCIDENTS/INJURIES TO NURSES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 23(44.2%) 27(51.9%) 2(3.8%) O(-) 52 22.9 28.3 0.8 Hospital B 11(42.3%) 15(57.7%) 0 (-) O(-) 26 11.4 14.1 0.4 Hospital C 32(54.2%) 25(42.4%) 2(3.4%) O(-) 59 26 32.1 0.9 Hospital D 50 (41%) 69 (56.6%) 3 (2.5%) O(-) 122 53.7 66.4 1.9 First year 24(30.4%) 55(69.6%) 0 (-) O(-) 79 34.8 43 1.3 Second year 27(51.9%) 25(48.1% 0 (-) O(-) 52 22.9 28.3 0.8 Third year 27(52.9%) 24(47.1%) 0 (-) O(-) 51 22.4 27.8 0.8 Column Total 194 240 0 441
IChi-Square 19.5, d.f.l8; p > 0.05]
It is evident from the results in Table 5.15 that the majority of registered nurses and nursing students either stt-ongly agreed, or agreed, with the statement" slipping on wet floors cause accidents/injuries to nurses". The chi-square statistic did not elicit any differences between the groups of nurses, showing evidence as to the efficacy of this variable as a conttibuting envu-onmental cause towards accident/injury occurrence. It is noteworthy, that there were no responses from nursing students for the "disagree" or 190
"stt-ongly disagree" categories, and less than 4% of registered nurses from hospital A, C and D who responded to the "disagree"category. This result was supported when registered nurses and nursing students responses were observed in a two by two contingency table. When categories were collapsed into either accepting ("strongly agree/agree") or rejecting ("disagree/stt-ongly diasagree") the statement, the results revealed that 97% of registered nurses and 100% of nursing students supported the statement. TABLE 5.16 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO: "NURSES ARE OFTEN INJURED DUE TO THE POOR DESIGN OF THE ENVIRONMENT"
Category Strongly Agree Disagree Stt-ongly Row Agree Disagree Total Hospital A 22 (44%) 24 (48%) 4 (8%) O(-) 50 18.2 27.7 3.9 0.2 Hospital B 8 (32%) 12(48%) 4(16%) 1 (4%) 25 9.1 13.8 1.9 0.1
Hospital C 21 (36.8%) 33 (57.9%) 3 (5.3%) O(-) 57 20.8 31.6 4.4 0.3
Hospital D 47 (39.8%) 56 (47.5%) 15 (12.7%) O(-) 118 43 65.3 9.1 0.6 First year 7(11.7%) 49(81.7%) 4 (6.7%) O(-) 60 21.8 33.2 4.6 0.3 Second year 17 (39.5%) 26 (60.5%) O(-) O(-) 43 15.7 23.8 3.3 0.2 Third year 24 (50%) 22 (45.8%) 1 (2.1%) 1 (2.1%) 48 17.5 26.6 3.7 0.2 Column Total 146 222 31 2 401
[Chi-Square 46.6, d.f. 18; p < 0.001]
Table 5.16 highlights the importance nurses attach to the statement, "nurses are often injured due to the poor design of the environment". Over four fifths of registered nurses and over 92% of nursing students either, "strongly agree", or "agree", with the statement. First year nursing students were relatively more likely to nominate "agree"(81.7%) than the "stt-ongly agree" (11.7%) point on the scale. The first year nursing students' responses to "strongly agree" conttibuted to the significant difference 191 revealing a difference between the obtained frequency (7) and the expected frequency (17.5). Observation of registered nurses' and nursing students' responses in a two by two contingency table also revealed a significant difference. When the categories were collapsed into accepting ("strongly agree/agree") or rejecting a ("disagree/stt-ongly disagree") the results revealed that 89% of registered nurses and 96% of nursing students supported the statement.
5.4.1 Summarv In the summary a brief outiine of the results that address hypodiesis two is presented.
The results for the statement "Legionnaire's disease is an occupational health risk for nurses", revealed 50% of registered nurses and 51% of nursing students rejected the statement (see Table 5.12). This result did not support hypothsis two.
Seventy-four percent of registered nurses and 74% of nursing students beUeved anaesthetic gases were a source of concern while working in the operating room (see Table 5.13). These results support the notion that nurses believe nosocomial infections contribute towards accidents/injuries demonstrating support for hypothesis two.
Dermatitis was believed to be a common occupational hazard for nurses according to 93% of registered nurses and 93% of nursing students (see Table 5.14). These results supported hypothesis two, showing that environmental inputs contributed towards accidents/injuries.
Slipping on wet floors was believed to be a cause of accidents/injuries by 97% of registered nurses and 100% of nursing students in this study (see Table 5.15). These data supported the notion that environmental inputs contributed towards accidents/injuries.
Eighty-nine percent of registered nurses and 96% of nursing students believed nurses 192 were often injured due to the poor design of their environment (see Table 5.16). These results supported hypothesis two.
The evidence supports the influence of environmental inputs contributing towards accident/injury causation. Nurses indicate anaesthetic gases, dermatitis, slipping on wet floors and poorly designed environments contribute towards accidenty^mjury occurrence.
5.5 Hvpothesis Testing the Influence of Management Inputs and Their Contribution Towards Accident/Iniurv Causation Results from the registered nurses, from the four participating hospitals, and the three nursing students' groups towards the influence of mangement inputs, and their contribution towards accident/injury causation are presented in this section. The results of the variables addressed in this section include nurses' attitudes towards occupational health and safety training, hepatitis B immunisation, provision of in-service by management and ward staffing.
TABLE 5.17 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS: " EMPLOYER/INSTITUTION HAVING AN OCCUPATIONAL HEALTH AND SAFETY COMMnTEE"
Category yes no Don't know No response
Hospital A 27(45%) 7(11%) 26(44%) 1
Hospital B 20(80%) 1(4%) 4(16%) 1 Hospital C 34(62%) O(-) 21(38%) 1 Hospital D 91(73%) 2(2%) 31(25%) 1 First year 8(10%) 1(1%) 72(89%) 0 Second year 1(2%) 1(2%) 50(96%) 0 Third year 6(12%) 7(13%) 38(75%) 1 193
Inspection of Table 5.17 shows registered nurses' and nursing students' knowledge of the existence of employer/institution occupational health and safety committees. The majority of registered nurses from hospital B, C, and D indicated tiiat they were aware of such committees (80%, 62% and 73% respectively), however only 45% of registered nurses from hospital A were aware of such a committee. By comparison, the majority of nursing students reported that they did not know whether such committees existed, that is, over three quarters of the nursing students in this study.
TABLE 5.18 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS "NURSING REPRESENTATION ON OCCUPATIONAL HEALTH AND SAFETY COMMITTEES"
Category yes no Don't know No response
Hospital A 20(36%) 4(7%) 32(57%) 5
Hospital B 15(60%) 1(4%) 9(36%) 1
Hospital C 27(49%) 0 28(51%) 0
Hospital D 67(56%) 4(4%) 40(25%) 6
Fu-st year 7(15%) 1(2%) 38(83%) 35
Second year 1(2%) 0 42(98%) 9
Third year 4(13%) 0 26(87%) 21
In Table 5.18 it can be seen that the majority of registered nurses from hospitals A and C did not know whether there was nursing representation on occupational health and safety committees (57% and 51% respectively). Sixty percent of registered nurses from hospital B, and 56% of nurses from hospital D, indicated that they believed there was nursing representation on such committees. It is clear, that the majority of nursing students did not know whether or not there was nursing representation on occupational health and safety committees, with over 80% of nursing students responding in this way. 194
TABLE 5.19 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS "EMPLOYER/INSTITUTIONS' OCCUPATIONAL HEALTH AND SAFETY UNITS FOR STAFF"
Category yes no Don't know No response
Hospital A 4(6%) 11(18%) 46(75%) 0
Hospital B 3(12%) 7(28%) 15(60%) 1
Hospital C 6(12%) 12(22%) 36(66%) 1
Hospital D 30(26%) 11(9%) 76(65%) 8
First year 4(5%) 3(4%) 73(91%) 1
Second year 0 4(8%) 47(92%) 1
Thu-d year 3(6%) 9(18%) 38(76%) 1
Inspection of Table 5.19 shows registered nurses' and nursing students' responses to the question "does your employer/institution have an occupational health and safety unit for the staff?". It is evident that the majority of registered nurses indicated that they did not know. A similar pattern of responses was elicited from nursing students, with the majority of students nominating the "don't know" category, (91% of first year nurses, 92% of second year nurses and 76% of third year nurses).
TABLE 5.20 REGISTERED NURSES RESPONSES TOWARDS: " HEPATITIS B IMMUNISATION"
Category Yes No No response
Hospital A 25(45%) 31(55%) 5
Hospital B 9(37%) 15(63% 2
Hospital C 7(13%) 46(87%) 2
Hospital D 43%(35%) 81(65%) 1
Registered nurses' immunisation patterns are shown in Table 5.20. The results indicate that die majority of registered nurses do not appear to be immunised against hepatitis B. 195
Registered nurses from hospital C show the highest levels of non-immunisation, with over 80% of the registered nurses in that category. Between 55% to 64% of registered ntu-ses from the other three hospitals also indicated they were not immunised.
TABLE 5.21 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "EXTRA NURSING STAFF ARE ALWAYS AVAILABLE TO HELP LIFT HEAVY PATIENTS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) 1 (1.9%) 23 (44.2%) 28(53.8%) 52 0.4 3.7 28.4 19.5
Hospital B O(-) 2 (7.7%) 13(50%) 11 (42.3%) 26 0.2 1.9 14.2 9.8
Hospital C 1 (1.6%) 3 (4.9%) 21 (34.4%) 36 (59%) 61 0.4 4.4 33.3 22.9
Hospital D O(-) 3 (2.5%) 65 (53.3%) 54 44.3%) 122 0.8 8.7 66.6 45.8
Fkst year 2 (2.7%) 11 (14.9%) 53 (71.6%) 8 (10.8%) 74 0.5 5.3 40.4 27.8
Second year O(-) 3 (6%) 34 (68%) 13 (26%) 50 0.3 3.6 27.3 18.8
Third year O(-) 8 (16.3%) 28 (57.1%) 13(26.5%) 49 0.3 3.5 26.8 18.4
Column Total 3 31 237 163 434
[ Chi-Square 66.9, d.f. 18; p < 0.001]
Table 5.21 shows the registered nurses' and nursing students' responses towards the statement "extt-a nursing staff are always available to help hft heavy patients". It is clear that the majority of registered nurses did not agree with the statement, and the response pattern for each of the four groups of registered nurses appears to be quite similar for each category. Nursing students also responded in a similar pattern to the registered nurses, with the majority either disagreeing, or strongly disagreeing, with the statement. There were differences in the pattern of responses between registered nurses and nursing students 196 for the "agree" category, with a higher percentage of nursing students nominating "agree", compared to only a relatively small percentage of registered nurses who responded to the "agree" point on the scale. The significant difference revealed by the chi square statistic was largely attributable to the difference between the comparatively higher obtained frequencies (11) and lower expected frequencies (5.3) from first year nursing students' responses to "agree". When registered nurses' and nursing students' responses were reduced to a two by two contingency table, a significant difference was also revealed. The results for collapsed categories for this statement showed that 96% of registered nurses and 86% of nursing students believed extra nursing staff were not always available to help lift heavy patients.
TABLE 5.22 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES FILL OUT AN ACCIDENT/INJURY FORM EVERY TIME THEY ARE INVOLVED IN AN ACCIDENT/INJURY"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 1 (2.1%) 5 (10.4%) 25(52.1%) 17 (35.4%) 48 0.6 5.6 30.0 11.8
Hospital B O(-) 3 (12.5%) 17 (70.8%) 4(16.7%) 24 0.3 2.8 15.0 5.9
Hospital C 1 (1.7%) 6 (10.2%) 39(66.1%) 13 (22%) 59 0.8 6.9 36.9 14.5
Hospital D 2 (1.7%) 14(11.6%) 72 (59.5%) 33 (27.3%) 121 1.6 14.1 75.7 29.7
Fu-st year 1 (2.2%) 11(24.4%) 27 (60%) 6 (13.3%) 45 0.6 5.2 28.1 11
Second year O(-) 4 (9.5%) 31 (73.8%) 7(16.7%) 42 0.5 4.9 26.3 10.3
Third year O(-) 2 (4.2%) 31 (64.6%) 15(31.3%) 48 0.6 5.6 30 11.8
Column Total 5 45 242 94 387
[ Chi-Square 21.2, d.f. 18; p > 0.05 ] 197
Registered nurses' and nursing students' responses towards the statement, " nurses fill out an accident/injury form every time they are involved in an accident/injury" are shown in Table 5.22. It is evident that the majority of all groups of nurses either disagreed, or strongly disagreed, with the statement. Second and third year nursing students also showed similar response patterns to the registered nurses with die majority of these groups of students also disagreeing or strongly disagreeing. First year students repUes showed a similar trend, however, higher percentages of first year nurses chose the "agree" category, compared to all other groups. Observation of first year nursing students' responses for the "agree" cell revealed a difference between the obtained frequency (11) and expected frequency (5.2). A significant difference was not revealed when registered nurses and nursing students responses were observed in a two by two contingency table.
For this particular statement when the categories were collapsed 87% of registered nurses and 86% of nursing students did not believe nurses filled out an accident/injury form every time they were involved in an accident/injury. 198
TABLE 5.23 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "REGISTERED NURSES MAKE JUDGEMENTS ABOUT THE SERIOUSNESS OF PATIENTS' ACCIDENTS/INJURIES BEFORE DECIDING TO REPORT IT"
Category Stt-ongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) 22 (44%) 20 (40%) 8 (16%) 50 1.3 25.4 18 5.2
Hospital B O(-) 6 (25%) 16 (66.7%) 2 (8.3%) 24 0.6 12.2 8.6 2.5
Hospital C 2 (3.6%) 21 (38.2%) 23 (41.8%) 9 (16.4%) 55 1.5 27.9 19.8 5.8
Hospital D 1 (0.8%) 51 (42.9%) 52 (43.7%) 15 (12.6%) 119 3.2 60.5 42.9 12.5
First year 3 (7%) 28(65.1%) 9 (20.9%) 3 (7%) 43 1.2 21.8 15.5 4.5
Second year 2 (5.3%) 30 (78.9%) 6 (15.8%) O(-) 38 1 19.3 13.7 4
Third year 2 (4.7%) 31(72.1%) 8 (18.6%) 2(4.7%) 43 1.2 21.8 15.5 4.5
Column Total 10 189 134 39 372
[ Chi-Square 55.8, d.f. 18; p < 0.001]
It can be seen in Table 5.23, registered nurses' and nursing students' responses towards the statement, "registered nurses make judgements about the seriousness of patients' accidents/injuries before deciding to report it", differed in their responses. Most registered nurses appeared to be equally divided between the "agree" point on the scale, and the "disagree" point, however, hospital B registered nurses were less incUned to nominate "agree" when compared to other three groups. By comparison, most of the nursing students nominated "agree". These differences can be observed from the frequencies displayed in die "agree" cell for second year nurses' responses as there were greater numbers of obtained frequencies (30) than expected frequencies (19.3). These differences were also evidenced by first year nurses responses to "agree" [where the obtained frequency (28) and expected frequency (21.8) differed] as well as their 199 responses to "disagree" [the obtained frequency was nine and the expected frequency was 15.5]. The difference between the registered nurses and nursing students was reflected in die chi-square statistic which elicited a significant difference (p < 001). A significant difference was also revealed when registered nurses' and nursing students' responses were observed in a two by two contingency table.
When categories were collapsed for this particular statement 58% of registered nurses and 77% of nursing students "disagreed/strongly disagreed" with statement.
TABLE 5.24 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "ADMINISTRATIVE STAFF ENCOURAGE NURSES TO REPORT THEIR ACCIDENTS/INJURIES"
Category Strongly Agree Disagree Sttrongly Row Agree Disagree Total
Hospital A 2 (3.8%) 28 (53.8%) 15 (28.8%) 7(13.5%) 52 2.5 26.8 17.8 5.3
Hospital B 1 (4.3%) 10 (43.5%) 9(39.1%) 3 (13%) 23 1.1 11.8 7.7 2.3
Hospital C 5 (8.9%) 34 (60.7%) 11(19.6%) 6(10.7%) 56 2.7 28.8 18.8 5.7
Hospital D 8 (7.1%) 59 (52.2%) 38 (33.6%) 8(7.6%) 113 5.4 58.2 38 11.4
First year 0 (-) 19 (63.3%) 7 (23.3%) 4(13.3%) 30 1.4 15.4 10.1 3
Second year O(-) 12(44.4%) 12 (44.4%) 3(11.1%) 27 1.3 13.9 9.1 2.7
Third year O(-) 11 (31.4%) 21 (60%) 3 (8.6%) 35 1.7 18 11.8 3.5 Column Total 16 173 113 34 336
[ Chi-Square 28.0, d.f. 18; p >0.05]
The greater number of registered nurses and nursing students agreed that administt-ative staff encouraged nurses to report their own accidents/injuries, (see Table 5.24). Observation of the data shows that although first year nursing students were more inclined to nominate "agree" (63.3%) and third vear students to choose 200
"disagree"(60%), closer examination of the raw numbers show that a large number of nursing students from all years apparently did not know. This accounts for the small number of responses for the categories shown in the table for the nursing students. The chi-square statistic did not show a significant difference between groups and this result was supported when registered nurses' and nursing students' responses were reduced to a two by two contingency table. When categories were collapsed, 60% of registered nurses and 54% of nursing students "strongly agreed/agreed" with the statement.
TABLE 5.25 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "ADMINISTRATIVE STAFF ENCOURAGE NURSES TO REPORT PATIENTS' ACCIDENTSANJURIES"
Category Stt-ongly Agree Disagree Stt-ongly Row Agree Disagree Total Hospital A 14 (26.9%) 36 (69.2% 1 (1.9%) 1 (1.9%) 52 11.3 37.4 2.5 0.8
Hospital B 2 (8%) 23 (92%) O(-) O(-) 25 5.4 18 1.2 0.4
Hospital C 20 (32.8%) 38 (62.3%) 2 (3.3%) 1 (1.6%) 61 13.3 43.9 2.9 1
Hospital D 34 (27.6%) 85(69.1%) 4 (3.3%) O(-) 123 26.8 88.5 5.8 1.9
First year 7 (16.7%) 34(81%) O(-) 1 (2.4%) 42 9.1 30.2 2 0.7
Second year 2 (6.3%) 26(81.3% 3 (9.3) 1 (3.1%) 32 7 23 1.5 0.5
Thu-d year 4 (8.7%) 32 (69.6%) 8 (17.4%) 2 (4.3%) 46 10 33.1 2.2 0.7
Column Total 83 274 18 6 381
[ Chi-Square 46.3, d.f. 18; ]3 < 0.001]
Inspection of Table 5.25 shows registered nurses' and nursing students' responses towards the statement " administrative staff encourage nurses to report patients' accidents/injuries". Observation of the data shows the majority of all nurses strongly 201 agree or agree with the statement. However, as with the nursing students' responses demonstated in Table 5.24, closer inspection of Table 5.25 reveals, that again, many of the nursing students did not know which helps to explain the reduced raw numbers reflected in the table. The chi-square statistic revealed a significant difference between the groups (p < 0.001). A two by two contingency table for registered nurses' and nursing students' responses also revealed a significant difference. When the categories were collapsed for this statement 96% of registered nurses and 87% of nursing students accepted the statement.
TABLE 5.26 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "ADMINISTRATIVE STAFF MAKE DECISIONS ABOUT THE IMPORTANCE OF NURSES ACCIDENTS/INJURIES IN THE REPORTING PROCESS"
Category Sttrongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 3 (7.1%) 21 (50%) 17 (40.5%) 1 (2.4%) 42 2.9 26 12.5 0.6
Hospital B 2(11.1%) 11 (61.1%) 5 (27.8%) O(-) 18 1.2 11.2 5.3 0.3
Hospital C 3 (7%) 28(65.1%) 11 (25.6%) 1 (2.3%) 43 2.9 26.7 12.8 0.7
Hospital D 6 (7%) 54 (62.8%) 25 (29.1%) 1 (1.2%) 86 5.9 53.3 25.5 1.3
First year 2 (7.4%) 19 (70.4%) 5 (18.5%) 1 (3.7%) 27 1.8 16.7 8 0.4
Second year O(-) 13 (65%) 7 (35%) O(-) 20 1.4 12.4 5.9 0.3
Third year 2 (7.4%) 17 (63%) 8 (29.6%) O(-) 27 1.8 16.7 8 0.4
Column Total 18 163 78 4 263
[Chi-Square 8.8, d.f. 18; p >0.05 ]
Results for the statement "administrative staff make decisions about the importance of nurses accidents/injuries in the reporting process" appear in Table 5.26. The majority of 202
registered nurses have responded to the "agree" point on the scale, witii 50% of hospital
A nurses responding in this way and stightiy more than half the registered nurses from hospitals B, C, and D.
A similar trend which was evidenced in the two previous statements, is also shown for this particular statement. Although the larger percentage of nursing students tended to respond to the "agree" category, it would seem a large number of nursing students did not know.
There also appears to be similarities in responses between registered nurses and nursing students to the "disagree" category, although, it is evident that there are larger percentages of hospital A nurses disagreeing [see the difference between obtained frequencies (17) and expected frequencies (12.5) for this point on the scale] compared to all other groups who disagreed.There are no significant differences between groups for this particular statement which was reflected in the chi-square statistic. A two by two contingency table which reported registered nurses and nursing students responses also did not reveal a significant difference. Sixty-seven percent of registered nurses and 71% of nursing students accepted the statement when categories were collapsed.
5.5.1 Summary
The following section presents a brief summary that addresses hypothesis 3.
Table 5.17 illustrates registered nurses' and nursing students' responses to the question
"employer/institution having an occupational health and safety committee". The results for this question demonstt-ated that the majority of registered nurses (with the exception of registered nurses from Hospital A) were aware of the existence of these committees, however nursing students were not.
A similar result emerged when registered nurses and nursing students were asked about nursing representation on OH&S committees. The majority of registered nurses were aware; however, over 80% of nursing students were unaware (see Table 5.18). The 203
majority of registered nurses and nursing students were unaware of the existence of
OH&S units for staff (see Table 5.19).
Hepatitis B immunisation patterns for registered nurses revealed that the majority of registered nurses were not immunised against hepatitis B (see Table 5.20). These results
support hypothesis 3.
Ninety-six percent of registered nurses and 86% of nursing students believed extra
nursing staff were not available to help Hft heavy patients ( see Table 5.21). These results
support the notion that management inputs contribute to accident/injury causation.
The results for the statement "nurses fill out an accident/injury form every time they are
involved in an injury" revealed that 87% of registered nurses and 86% of nursing
students did not beheve this to be the case (see Table 5.22). This result supports the
thesis that management inputs in the opinion of nurses in this study, contributed towards
accident/injury causation.
Fifty-eight percent of registered nurses and 77% of nursing students rejected the notion
that "registered nurses make judgements about the seriousness of patients
accidents/injuries before deciding to report it" (see Table 5.23).
The statement "administrative staff encourage nurses to report their accidents/injuries" revealed that 60% of registered nurses and 54% of nursing students supported the
statement (see Table 5.24).
Ninety-six percent of registered nurses and 87% of nursing students accepted the statement "administt-ative staff encourage nurses to report patients' accidents/injuries"
(see Table 5.25). 204
Administt-ative staff make decisions about the importance of nurses accidents/injuries in the reporting process was accepted by 67% of registered nurses and 71% of nursing students (see Table 5.26). The evidence from the results suggest there are several relevant variables that appear to show diat particular management inputs contt-ibute towards accidentAnjury occurrence.
5.6 Hypothesis Testing the Influence of Nurses' Social Expectations and Performance and Their Contribution Towards Accident/Iniurv Causation
The following section includes the results that examine nurses' attitudes towards then- own performance and the effects of social inputs and their contribution towards accident/injury causation.
TABLE 5.27 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS: "HAVE YOU PERFORMED NURSING CARE WHEN YOU HAVE HAD BACK PAIN?"
Category yes no No response
Hospital A 42(69%) 19(31%) 0
Hospital B 18(72%) 7(28%) 1 Hospital C 38(72%) 15(28%) 2 Hospital D 78(65%) 42(35%) 5 Fu-st year 18(22%) 63(78%) 0 Second year 19(36%) 31(64%) 2 Thu-d year 20(39%) 30(61%) 1
Observation of Table 5.27 displays registered nurses' and nursing students' responses 205 to the question," have you performed nursing care when you have had back pain?". The percentage results show registered nurses and nursing smdents answers are in reverse of each other. The majority of registered nurse answered positively to this question with 69% of hospital A nurses, 72% of hospital B nurses, 72% of hospital C nurses and 65% of hospital D nurses indicating they agreed with the question. It is noteworthy, that 36% of second year students and 39% of third year students also indicated that they performed nursing care whilst experiencing back pain. In fact the first year nursing students responses appear to be markedly different to all the other groups, with 22% of first year students nominating "yes" and 78% nominating "no".
TABLE 5.28 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "I ALWAYS REPORT PATIENTS' ACCIDENTS/INJURIES HOWEVER TRTVIAL"
Category Stt-ongly Agree Disagree Stt-ongly Row Agree Disagree Total
Hospital A 8 (15.7%) 31 (60.8%) 12 (23.5%) O(-) 51 8.7 30.6 10.6 1.1
Hospital B 5 (19.2%) 17 (65.4%) 4 (15.4%) O(-) 26 4.4 15.6 5.4 0.6
Hospital C 14 (23.3%) 32 (53.3%) 13 (21.7%) 1 (1.7%) 60 10.2 36 12.4 1.3
Hospital D 27 (22%) 72 (58.5%) 22 (17.9%) 2 (1.6%) 123 21 78.8 25.5 2.7
First year 5 (8.8%) 40 (70.2%) 9 (15.8%) 3 (5.3%) 57 9.7 34.2 11.8 1.3
Second year 5 (10.6%) 28 (59.6%) 13 (27.7%:I 1 (2.1%) 47 8 28.2 9.7 1
Third year 6 (13%) 26 (56.6%) 12(26.1%;) 2(4.3%) 46 7.9 27.6 9.5 1 Column Total 70 246 85 9 410
[ Chi-Square 17.6, d.f. 18; p > 0.05]
The results for the statement, "I always report patients' accidents/injuries however trivial" is shown in Table 5.28. Both registered nurses and nursing students either "agreed" or "strongly agreed" with this particular statement. The majority of registered 206 nurses indicated that they agreed, showing homogeneity of response patterns for each of the registered nurse groups. Second year and third year students were similar in their responses to registered nurses for the agree point on the scale, with slightiy more than half choosing this category, compared to first year nursing students where almost three quarters agreed [see the difference in the obtained frequency (40) and the expected frequency (34.2) for first year nurses' responses to "agree"]. There were no significant differences revealed by the chi-square statistic for this particular variable. A non significant finding was confirmed when registered nurses and nursing students responses were observed in a two by two contingency table. Collapsing of the categories revealed 78% of registered nurses and 73% of nursing students accepted die statement.
TABLE 5.29 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "I OFTEN NEGLECT TO REPORT MY OWN ACCIDENTS/INJURIES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 12 (23.5%) 33 (64.7%) 6(11.8%) O(-) 51 4.9 34 11 1.1
Hospital B O(-) 22 (84.6%) 4 (15.4%) O(-) 26 2.5 17.3 5.6 0.6
Hospital C 9 (14.8%) 39 (63.9%) 10(16.4%) 3 (4.9%) 61 5.9 40.6 13.1 1.4
Hospital D 11(9%) 87(71.3%) 21 (17.2%) 3 (2.5%) 122 11.8 81.2 26.3 2.7
First year 3 (5.9%) 28 (54.9%) 17 (33.3%) 3 (5.9%) 51 4.9 34 11 1.1
Second year O(-) 35(71.4%) 14 (28.6%) 0(1.1) 49 4.7 32.6 10.6 1.1
Thirdyear 4(9.1%) 25 (56.8%) 15(34.1%) O(-) 44 4.2 29.3 9.5 1
Column Total 39 269 87 9 404
[ Chi-Square 44.5, d.f. 18; p < 0.001]
The majority of registered nurses and nursing students in this study agreed they often 207 neglected to report their own accidents/injuries, (see Table 5.29). The majority of nursing students, (54.9% of first year students, 71.4% of second year nursing students and 56.8% of third year nursing students) agreed with the statement.
It is interesting to note that a large percentage of nursing students also nominated "disagree" (33.3% of first year students, 28.6% of second year students and 34.1% of third year nursing students) compared with registered nurses who were not so inclined to choose "disagree" (11.8% of hospital A nurses, 15.4% of hospital B nurses, 16.4% of hospital C nurses and 17.2% of hospital D nurses). On inspection of first year nursing students' responses to "disagree", it can be seen there were differences between obtained frequencies (17) and expected frequencies (11) which contributed to the significant difference (p < 0.001). A significant finding was also revealed when registered nurses and nursing students responses were reduced to a two by two contingency table.
When these data were collapsed into two categories 81% of registered nurses 65% of nursing students accepted the statement. 208
TABLE 5.30 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "I KNOW SOME REGISTERED NURSES ARE DISINCLINED TO REPORT PATIENTS' TRIVIAL INJURIES"
Category Stt-ongly Agree Disagree Stt-ongly Row Agree Disagree Total
Hospital A 1 (2.2%) 29 (63%) 13 (28.3%) 3 (6.5%) 46 1.5 26.5 14.6 3.3
Hospital B O(-) 11 (47.8%) 12 (52.2%) 0 (-) 23 0.8 13.2 7.3 1.7
Hospital C 1 (1.9%) 23 (43.4%) 24(45.3%) 5(9.4%) 53 1.8 30.5 16.9 3.8
Hospital D O(-) 51 (45.9%) 44(39.6%) 16 (14.4%) 111 3.7 63.9 35.3 8.1
First year 3 (6.5%) 32 (69.6%) 9(19.6%) 2(4.3%) 46 1.5 26.5 14.6 3.3
Second year 2 (5.4%) 30(81.1%) 5(13.5%) O(-) 37 1.2 21.3 11.8 2.7
Third year 5(11.9%) 30(71.4%) 7 (16.7%) 0 (-) 42 1.4 24.2 13.4 3.1
Column Total 12 206 114 26 358
[ Chi-Square 60.8, d.f. 18; p < 0.001]
The results for the statement, "I know some registered nurse are disinclined to report patients' trivial injuries" are shown in Table 5.30. There are significant differences as evidenced by the chi-square statistic, principally between the registered nurses and nursing students. This difference is due to approximately 70%-80% of nursing students nominating agree. The differences in the obtained and expected frequenciesfo r diese three groups for the "disagree" point demonstrates diis, (for example, for first year nurses the obtained frequency was nine and the expected frequency was 14.6, for second year nurses, the obtained frequency was five and the expected was 11.8, and for third year nurses the obtained frequency was seven and the expected frequency was 13.4). Registered nurses from three of the hospitals were almost equally divided between 209
"agree", (47.8% of Hospital B nurses, 43.4% of hospital C nurses and 45.9% of hospital D nurses) and "disagree", (52.2% of hospital B nurses, 45.3% of hospital C nurses and 39.6% of hospital D nurses). Registered nurses from hospital A had divided their responses between "agree" and "disagree", ( 63% and 28.3% respectively) but not so markedly as the registered nurses from the other three hospitals. A two by two contingency table representing registered nurses' and nursing students' reponses also revealed a significant difference. When the categories were collapsed these data revealed 50% of registered nurses and 81% of nursing students "strongly agreed/agreed" with the statement.
TABLE 5.31 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES DO NOT LIKE TO CLAIM COMPENSATION FOR ACCIDENTS/INJURIES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 6 (14.3%) 28 (66.7%) 7 (16.7%) 1 (2.4%) 42 3.9 25.1 11.9 1.1
Hospital B O(-) 19 (86.4%) 3(13.6%) O(-) 22 2 13.2 6.2 0.6
Hospital C 10 (19.6%) 26(51%) 13(25.5%) 2(3.9%) 51 4.7 30.5 14.4 1.4
Hospital D 10 (9.7%) 72 (69.9%) 21 (20.4%) 0 (-) 103 9.5 61.6 29.1 2.8
First year O(-) 20 (40.8%) 24 (49%) 5 (10.2%) 49 4.5 29.3 13.9 1.3
Secondyear 1 (2.9%) 15 (44.1%) 18 (52.9%) 0 (-) 34 3.1 20.3 9.6 0.9
Thirdyear 4(11.4%) 21 (60%) 9(25.7%) 1(2.9%) 35 3.2 20.9 9.9 0.9
ColumnTotal 31 201 95 9 336
[ Chi-Square 60.8, d.f. 18; p < 0.001 ]
Over half the registered nurses from hospitals A, C, and D and six sevenths of the hospital B nurses, agreed that nurses did not like to claim compensation for 210 accidents/injuries, (see Table 5.31). A significant difference was elicited for this variable by the chi-square statistic, principally between registered nurses and third year nursing students and the first and second year nursing students. The third year nursing students' responses more closely resembled the registered nurses, with 60% agreeing with the statement. In contrast, the first year nursing students and second year nursing students were more likely to nominate "disagree". Inspection of the observed frequency (24) and the expected frequency (13.9) for first year nurses' responses to the "disagree" point, [as well as the observed frequency (18) and expected frequency (9.6) for the second year nursing students' responses for this point], illustrates where some of the differences can be attributed. A significant difference was also revealed when registered nurses' and nursing students' responses were observed in a two by two contingency table. Collapsed categories for this statement revealed 78% of registered nurses and 51% of nursing students accepted nurses did not like to claim compensation for accident/injuries. 211
TABLE 5.32 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES WHO TAKE TIME OFF FOR ACCIDENTS/INJURIES ARE THOUGHT TO BE MALINGERERS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 14 (29.8%) 18 (38.3%) 12 (25.5%) 3 (6.4%) 47 8.9 19.1 15.7 3.3
Hospital B 3 (12%) 9 (36%) 8 (32%) 5 (20%) 25 4.7 10.2 8.3 1.8
Hospital C 19 (33.9%) 17 (30.4%) 19 (33.9%) 1 (1.8%) 56 10.6 22.8 18.7 3.9
Hospital D 24(21.6%) 48 (43.2%) 33 (29.7%) 6 (5.4%) HI 21.1 45.1 37 7.8
First year 2 (3.6%) 21 (38.2%) 24 (43.6%) 8(14.5%) 55 10.4 22.4 18.3 3.9
Second year 4(12.1%) 12 (36.4%) 16 (48.5%) 1(3%) 33 6.3 13.4 11 2.3
Thirdyear 4 (9.5%) 25 (59.5%) 11 (26.2%) 2 (4.8%) 42 8 17.1 14 3 Column Total 70 150 123 26 369
[ Chi-Square 45.9, d.f. 18; p < 0.001]
Inspection of the results displayed in Table 5.32 for the statement "nurses who take time off for accidents/injuries are thought to be malingerers", show a spread of responses by nurses including "strongly agree", "agree" and "disagree". For the "strongly agree" point on the scale, approximately 20-30% of registered nurses from hospitals A, C, and D and just over 50% of hospital B nurses strongly agreed. Comparatively smaller percentages of nursing students nominated "strongly agree", with 3.6% of first year nurses, 12.1% of second year nurses and 9.5% of third year nurses responding in this manner. Observation of the "strongly agree" cell for the Hospital C registered nurses' responses show a difference in the obtained frequency (19) and an expected frequency of 10.6 which partially contributed to the significant difference. 212
For the "agree" point on the scale registered nurses and nursing students were similar in dieir responses, with just over a third of hospital A, B, C, and D registered nominating "agree". Similarly, over a third of first and second year nurses and just over one half of thu-d year nurses agreed. When registered nurses and nursing students responses were reduced, a two by two contingency table also revealed a significant difference.
Inspection of the data for collapsed categories revealed 63% of registered nurses and 52% of nursing students "strongly agreed/agreed" with the statement. 5.6.1 Summarv In this following section a brief summary is presented that addresses hypothesis 4.
"Have you performed nursing care when you have back pain?" revealed that the majority of nurses in this study believed that to be the case (see Table 5.27). This result supports the notion that nurses' attitudes towards their own performance and social expectations contribute towards accident/injury causation.
Seventy-eight percent of registered nurses and 73% of nursing students believed they always reported patients' accidents/injuries however trivial (see Table 5.28). This result shows that social inputs appear to be an important factor in accident/injury causation.
Results for "I often neglect to report my own accidents/injuries" revealed that 81% of registered nurses and 65% of nursing students believed this statement. This result supports the notion that social inputs appear to contribute towards accident/injury causation.
The responses to the statement" I know some registered nurses are disclined to report patients' trivial injuries" demonstrated that 50% of registered nurses and 81% of nursing students accepted the statement (see Table 5.30). This result supported the hypothesis that social inputs appear to conttibute to accident/injury causation. 213
Seventy-eight percent of registered nurses and 51% of nursing students accepted the statement that indicated nurses did not like to claim compensation for their accidents/injuries (see Table 5.31). This result supports the notion that social inputs contribute towards accident/injury causation.
"Nurses who take time off for accidents/injuries are thought to be malingerers" was accepted by 63% of registered nurses and 52% of nursing students (see Table 5.32). This result showed support for the hypothesis 4.
The influence of social inputs in the accident/injury sequence is supported by the results outhned in the above section.
5.7 Hypotheses Testing Nurses' Attitudes towards the type of Organisational Processes Contributing Towards Accident/Injurv Causation
This section provides the results of nurses' attitudes towards availability/co-operation of ancillary staff and ergonomic design that address the idea that particular organisational inputs, conttibute towards accident/ injury causation. 214
TABLE 5.33 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "YOU CAN USUALLY GET EXTRA HELP FROM WARDSPERSONS TO LIFT HEAVY PATIENTS"
Category Stt-ongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 1 (1.9%) 29 (55.8%) 16 (30.8%) 6(11.5%) 52 3.3 29.9 12.4 6.4
Hospital B 2 (7.7%) 18 (69.2%) 3(11.5%) 3(11.5%) 26 1.7 14.9 6.2 3.2
Hospital C 4 (6.8%) 29 (49.2%) 16 (27.1%) 10 (16.9%) 59 3.8 33.9 14.1 7.3
Hospital D 3 (2.5%) 65 (53.7%) 29 (24%) 24(19.8%) 121 7.7 69.5 28.9 14.9
First year 9 (12.5%) 50 (69.4%) 11 (15.3%) 2 (2.8%) 72 4.6 41.4 17.2 8.9
Second year 2 (4.2%) 25(52.1%) 17(35.4%) 4 (8.3%) 48 3.1 27.6 11.5 5.9
Third year 6(13.3%) 27 (60%) 9 (20%) 3 (6.7%) 45 2.9 25.9 10.7 5.5
Column Total 27 243 101 52 423
[Chi-Square 38.2, d.f. 18; p <0.01]
SHghtiy more than half the registered nurses and nursing students in this study agreed that you can usually get extt-a help from wardspersons to lift heavy patients, (see Table 5.33). A large percentage of nurses also chose to disagree with this statement, particularly the second year students, where the difference between the obtained frequency (17) and expected frequency (11.5) produced a major contribution to the significant difference. A significant difference was revealed when registered nurses' and nursing students' responses were collapsed into a two by two contingency table. Inspection of the data for the collapsed categories showed 58% of registered nurses and 72% of nursing students ("strongly agreed/agreed") accepted the statement. 215
TABLE 5.34 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "WARDSPERSONS ARE ALWAYS WILLING TO HELP NURSES LIFT HEAVY PATIENTS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 2(4.1%) 7 (14.3%) 25 (51%) 15 (30.6%) 49 1.7 11.9 23.2 12.3 Hospital B 1 (4%) 10 (40%) 10 (40%) 4 (16%) 25 0.8 6.1 11.8 6.3 Hospital C 3 (5.3%) 20(35.1%) 17(29.8%) 17(29.8%) 57 1.9 13.8 26.9 14.3 Hospital D 3 (2.6%) 15(13%) 62(53.9%) 35(30.4%) 115 3.9 27.9 54.3 28.8 First year 2 (4.2%) 18 (37.5%) 22(45.8%) 6(12.5%) 48 1.6 11.7 22.7 12 Secondyear 2 (4.4%) 10 (22.2%) 25(55.6%) 8(17.8%) 45 1.5 10.9 21.3 11.3
Third year O(-) 13 (29.5%) 20(45.5%) 11(25%) 44 1.5 10.7 20.8 11 Column Total 13 93 181 96 383
[Chi-Square 33.0, d.f. 18; p <0.01]
Approximately 80% of registered nurses from hospitals A and D, and sUghdy more than one half of the registered nurses from hospitals B and C either disagreed, or strongly disagreed that wardspersons were always willing to help lift heavy patients, (See Table
5.34). Second and third year nursing students' responses more closely reflected the registered nurses responses from hospitals A, and D, with approximately 70% indicating they either disagreed or strongly disagreed. In contrast, to the other two groups of students, 58.3% of first year students nominated these two categories, which resembled the registered nurses responses from B and C. A significant difference between registered nurses and nursing students responses was elicited by tiie chi-square statistic. This can, in part be explained, by just over 35% of registered nurses from 216 hospital B, C, and first year nurses who chose " agree" in contt-ast to comparatively fewer numbers of registered nurses from hospital A, and D, and from second and third year nursing students. Observation of the "sttongly agree" cell for first year nurses show a difference between the obtained frequency (6) and the expected frequency (12) which partially contributed to the significant difference.The two by two contingency table showing registered nurses' and nursing students' responses did not reveal a significant difference. When categories were collapsed for the "strongly agree/agree" and "disagree/strongly disagree" points on the scale, results revealed 75% of registered nurses and 67% of nursing students "disagreed/strongly disagreed" with the statement.
5.7.1. Summary A brief outhne is presented in this section for the statments that adress hypothesis 5.
Fifty-eight percent of registered nurses and nursing students accepted the statement that "you can usually get extra help from wardspersons to help hft heavy patients" (see Table 5.33). This result did not support the hypothesis.
The statement "wardspersons are always willing to help nurses lift heavy patients' revealed 75% of registered nurses and 67% of nursing students did not believe this to be the case (see Table 5.34). This result supported the belief that organisational processes contributed towards accident/injury causation.
The results outlined in the Section 5.7 put forward the questions that addressed the influence of organisational processes involved in accident/injury causation. 217
5.8 Hypothesis Testing Nurses' Attitudes towards Physical Iniurv.
Verbal and Physical Abuse. Infectious Diseases as Client/patient
Centred Processes Contributing Towards Accident/Iniurv Causation.
Section 5.8 contains several tables which provide information that examine the effect of
patient/client centred processes and their role in the accident/injury process. The results
of nurses' attitudes towards physical injury, verbal and physical abuse, infectious
diseases are presented.
TABLE 5.35 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS: "HAVE YOU EVER BEEN PHYSICALLY INJURED BY A PATIENT?"
Category yes no
Hospital A 26(47.3%) 29(52.7%)
Hospital B 8(32%) 17(68%)
Hospital C 24(39.3%) 37(60.7%)
Hospital D 46(37.4%) 77(62.6%)
First year 9(11.1%) 72(88.9%)
Secondyear 7(13.5%) 45(86.5%%)
Thhdyear 12(23.5%) 39(76.5%)
[Chi-square 35.4, d.f. 6; p < 0.001]
In Table 5.35 the results for the question,"have you ever been injured by a patient?" are displayed. Although the majority of nurses in this smdy had not received an injury from a patient, there appeared to be substantial numbers of registered nurses who had received an injury, with almost one half of hospital A nurses, and over a third of the nurses from hospitals B, C, and D. It is obvious, on inspection of the data, that the 218 nursing students' injury levels increased each year, for example, 11.1% of first year nursing, 13.5% of second year nursing students and 23.5% of third year students. There was a significant difference elicited by the chi-square statistic between the groups.
TABLE 5.36 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES WORRY ABOUT CONTRACTING HEPATTTIS B FROM A NEEDLE-PRICK INJURY"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 16 (29.6%) 31 (47.4%) 7 (13%) O(-) 54 16 29.5 8.2 0.3
Hospital B 10(41.7%) 9 (37.5%) 5 (20.8%) O(-) 24 7.1 13.1 3.7 0.1
Hospital C 21 (34.4%) 35 (57.4%) 4 (6.6%) 1 (1.6%) 61 18.1 33.3 9.3 0.3
Hospital D 46 (37.7%) 56 (45.9%) 20 (16.4%) O(-) 122 36.2 66.6 18.6 0.6
First year 9 (20%) 33 (73%) 3(6.7%) O(-) 45 13.4 24.6 6.8 0.2
Second year 7 (14%) 29 (58%) 14 (28%) O(-) 50 14.8 27.3 7.6 0.2
Thurd year 10 (22.2%) 26 (57.8%) 8(17.8%^ 1 (2.2%) 45 22.2 57.8% 17.8% 2.2%
Column Total 119 219 61 2 401
[ Chi-Square 34.1, d.f. 18; p <0.01]
It is clear, both registered nurses and nursing students worry about contt-acting hepatitis B from a needle-prick injury, (Table 5.36). The chi-square statistic was significant, principally due to differences between registered nurses' and nursing students' responses to the "disagree" category. Inspection of the cell for the "stt-ongly disagree" category for second year nursing students revealed a difference between the obtained frequency (14) and expected frequency (7.6). This result conttibuted to the significant difference. Observation of registered nurses' and nursing students' responses in a two 219 by two contingency table did not reveal a significant difference. When the categories were collapsed, the results showed 85% of registered nurses and 81% of nursing students accepted the statement.
TABLE 5.37 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES WORRY ABOUT CONTRACTING AIDS FROM A NEEDLE-PRICK INJURY"
Category Stt-ongly Agree 1Disagre e Strongly Row Agree Disagree Total
Hospital A 30 (56.6%) 20 (37.7%) 3 (5.7%) O(-) 53 23.7 24.3 4.8 0.1
Hospital B 12 (48%) 11 (44%) 2 (8%) O(-) 25 11.2 11.5 2.3 0.1
Hospital C 33 (55.9%) 22 (37.3%) 4 (6.8%) O(-) 59 26.4 27.1 5.4 0.1
Hospital D 53 (43.8%) 52 (43%) 15(12.4%) 1(0.8%) 121 54.1 55.5 11.1 0.3
First year 22 (29.7%) 47 (63.5%) 5 (6.8%) O(-) 74 33.1 34 6.8 0.2
Second year 19 (38.8%) 26(53.1%) 4 (8.2%) O(-) 49 21.9 22.5 4.5 0.1
Third year 22 (47.8%) 18 (39.1%) 6 (13%) O(-) 46 20.6 21.1 4.2 0.1 Column Total 191 196 39 1 427
[ Chi-Square 21.9, d.f. 18; p > 0.05]
Combining the responses from registered nurses and nursing students for the strongly agree, and agree categories, over six sevenths of all groups of nurses were worried about contracting AIDS from a needle-prick injury, (see Table 5.37). Approximately 10% of all groups disagreed, again showing parallel responses from both registered nurses and nursing students groups. There was no significant difference elicited by the chi-square statistic between the groups for this particular variable, and this proved to be the case when responses were simplified to a two by two contingency table for these participants. When categories were collapsed, 90% of registered nurses and 91% of nursmg students accepted the statement. 220
TABLE 5.38 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES ARE MORE CONCERNED ABOUT CONTRACTING AIDS FROM AN INFECTIOUS SOURCE THAN HEPATITIS B"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 26 (54.2%) 15 (31.3%) 6 (12.5%) 1 (2.1%) 48 19.5 20.5 7.4 0.6
Hospital B 9 (36%) 10 (40%) 6 (24%) O(-) 25 10.2 10.7 3.9 0.3
Hospital C 27 (45.8%) 21 (35.6%) 10 (16.9%) 1(1.7%) 59 24 25.2 9.1 0.7
Hospital D 43 (36.1%) 46 (38.7%) 29 (24.4%) 1 (0.8%) 119 48.4 50.7 18.4 1.5
First year 13 (22%) 43 (72.9%) 3 (5.1%) O(-) 59 24 25.2 9.1 0.7
Second year 20 (40.8%) 22 (44.9%) 5 (10.2%: 2(4.1%) 49 19.9 20.9 7.6 0.6
Thu-d year 25 (59.5%) 14(33.3%) 3 (7.1%) O(-) 42 17.1 17.9 6.5 0.5 Column Total 163 171 62 5 401 [ Chi-Square 47.9, d.f. 18; p < 0.001]
Approximately three quarters of the registered nurses and nursing students in this study either strongly agreed, or agreed, that they were more concemed about contracting AIDS from an infectious source than hepatitis B, (see Table 5.38). A small proportion of nursing students nominated disagree (between 5% to 10%), compared to registered nurses where greater numbers indicated they disagreed, (approximately one fifth of the registered nurses from hospitals B and D and 12% to 17% of registered nurses fromhospitals B and C).There was a significant difference elicited by the chi-square statistic between groups of registered nurses and nursing students. Inspection of the cell for first year nurses' responses to "agree" revealed a difference in the obtained frequency (43) and the expected frequency (25.2); this result partially conttibuted to the significant difference. A signficant difference was revealed when data were observed for registered nurses' and nursing students' responses in a two by two contingency table. 221
When categories were collapsed, 78% of registered nurses and 91% of nursing students accepted die statement.
TABLE 5.39 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES ARE NEVER HIT/KICKED BY PATIENTS."
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) O(-) 15 (29.4%) 36 (70.6%) 51 0.6 0.1 23.1 27.2
Hospital B O(-) O(-) 11(42.3%) 15 (57.7%) 26 0.3 0.1 11.8 13.9
Hospital C O(-) O(-) 19 (32.2%) 40 (67.8%) 59 0.7 0.1 26.7 31.5
Hospital D 4 (3.2%) 0 55(44.4%) 65 (52.4%) 124 1.4 0.3 56.2 66.1
First year 1 (1.4%) 1 (1.4%) 42 (57.5%) 29 (39.7%) 73 0.8 0.2 33.1 38.9
Second year O(-) O(-) 24 (47.1%) 27 (52.9%) 51 0.6 0.1 23.1 27.2
Third year O(-) O(-) 31 (60.8%) 20 (39.2%) 51 0.6 0.1 23.1 27.2
Column Total 5 1 197 232 435
[ Chi-Square 32.4, d.f. 18; p <0.05]
There was considerable uniformity between registered niu-ses and nursing students either disagreeing, or strongly disagreeing, nurses were never hit/kicked by patients, (see Table 5.39). Almost 100% of registered nurses and nursing students indicated they did not agree, and the differences between the groups was shown in the pattern of distribution for the "disagree" and "strongly disagree" categories. In most cases the majority of subjects were more incHned to nominate "strongly disagree", however, first year nurses and third year nurses showed greater numbers choosing disagree.This was particularly evident in the cell for the first year nurses' responses to "stt-ongly disagree" reveahng a 222
difference between the obtained frequency (29) and the expected frequency (38.9). Only
3.2% of registered nurses from hospital D and 2.8% of first year nurses either "strongly agreed" or "agreed" with the statement. A significant difference was elicited by the chi-square statistic. When registered nurses' and nursing students' responses were simplified into a two by two contingency table the results were not significant. The collapsed categories for this statement revealed that 98% of registered nurses and 98% of nursing students "disagreed/sQ-ongly disagreed".
TABLE 5.40 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "SOMETIMES NURSES ARE PHYSICALLY ASSAULTED BY THEIR PATIENTS "
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 22 (42.3%) 30 (57.7%) O(-) O(-) 52 14.6 36 1 0.4
Hospital B 7 (28%) 18 (72%) O(-) O(-) 25 7 17.3 0.5 0.2
Hospital C 22 (37.9%) 36(63.1%) O(-) O(-) 58 16.3 40.2 1.1 0.4
Hospital D 35 (28.5%) 82(66.7%) 4 (3.3%) 2 (1.6%) 123 34.6 85.3 2.3 0.9
First year 7(9.7%) 62(86.1%) 2 (2.8%) 1 (1.4%) 72 20.2 49.9 1.3 0.5
Second year 12 (25.5%) 33 (70.2%) 2 (4.3%) O(-) 47 13.2 32.6 0.9 0.3
Third year 15 (30%) 35 (70%) O(-) O(-) 50 14.1 34.7 0.9 0.4
Column Total 120 296 8 3 427
[ Chi-Square 29.1, d.f. 18; p < 0.05]
There was an overall similarity in registered nurses' and nursing students' ratings for the statement, " sometimes nurses are physically assaulted by their patients", (see Table
5.40) The pattern of responses show that most nurses were more inclined to nominate 223
"agree", with slightiy more than half the registered nurses from hospitals A, C, and D and just over two thirds of the hospital B nurses responding in this way. First year nursing students were noticeably more inclined to respond to agree (86.1%), compared to 70% of second and third year students.This was reflected in the obtained frequencies (62) and expected frequencies (49.9) for the first year nursing students' responses to "agree", and this contributed to the significant difference revealed by the chi-square statistic. Observation of the two by two contingency table for registered nurses' and nursing students' responses did not reveal a significant difference. When the categories were collapsed for this statement, 97% of registered nurses and 97% of nursing students accepted the statement.
TABLE 5.41 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES UNDERSTAND THAT BEING HTT/KICKED BY A PATIENT IS A FACT OF LIFE, ALTHOUGH THEY DO NOT CONDONE YT "
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 4 (7.8%) 28 (54.9%) 7 (13.7%) 12 (23.5%) 51 3.5 27.1 14.1 6.2
Hospital B 3(11.5%) 15 (57.7%) 6(23.1%) 2 (7.7%) 26 1.8 13.8 7.2 3.2 Hospital C 6 (9.8%) 32 (52.5%) 18 (29.5%) 5 (8.2%) 61 4.2 32.5 16.9 7.4
Hospital D 9 (7.3%) 57 (46.3%) 35 (28.5%) 22(17.9%) 123 8.5 65.5 34.1 15
First year 2 (2.9%) 41( 59.4%) 23 (33.3%) 3 (4.3%) 69 4.8 36.7 19.1 8.4
Second year 1 (2.2%) 27 (58.7%) 15 (32.6%) 3 (6.5%) 46 3.2 24.5 12.7 5.6
Third year 4 (9.3%) 23 (53.5%) 12 (27.9%) 4 (9.3%) 43 3 22.9 11.9 5.2
Column Total 29 223 116 51 419
[ Chi-Square 27.0, d.f. 18; p > 0.05]
There is general agreement between all groups of registered nurses and nursing students. 224
that nurses understand being hit or kicked by a patient is a fact of life, although they do not condone it, (see Table 5.41). Slightly fewer than half the registered nurses from hospital D agreed, compared to approximately 50% of registered nurses from hospital
A, B, and C who also nominated " agree".
Nursing students were remarkably similar to the registered nurses for their responses to
"agree", with slightiy more than 50% in each group nominating this category. For the
"strongly disagree" category, two groups in particular differed to all other groups, namely 23.5% of registered nurses from hospital A and 17.9% of hospital D nurses compared to less than 10% of nurses in all other groups nominating this category. Notice the Hospital D registered nur.ses' reponses to the "strongly agree" category where the obtained freqency (22) differed to the expected frequency (15), as well as the "agree" category, where the obtained frequency (57) was less than the expected frequency
(65.5).
There were no significant differences elicited by the chi-square statistic for this particular variable, as was the case for responses from registered nurses and nursing students in a two by two contingency table. When the categories were collapsed these data revealed that 59% of registered nurses and 62% of nursing students accepted die statement. 225
TABLE 5.42 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "IT IS NOT UNUSUAL FOR NURSES TO BE VERBALLY ABUSED BY THEIR PATIENTS"
Category Strongly Agree Disagree Stt-ongly Row Agree Disagree Total
Hospital A 34 (65.4%) 16 (30.8%) O(-) 2 (3.8%) 52 20.3 25.9 4.2 1.7 Hospital B 13 (50%) 9 (34.6%) 2 (7.7%) 2 (7.7%) 26 10.1 12.9 2.1 0.8
Hospital C 28 (46.7%) 21 (35%) 7(11.7%) 4 (6.7%) 60 23.4 29.9 4.8 1.9
Hospital D 48 (38.7%) 64(51.6%) 11 (8.9%) 1 (0.8%) 124 48.3 61.7 10 4
First year 14(18.7%) 54 (72%) 5 (6.7%) 2 (2.7%) 75 29.2 37.3 6 2.4
Second year 18 (36.7%) 22 (44.9%) 6 (12.2%) 3 (6.1%) 49 19.1 24.4 3.9 1.6
Third year 15 (30%) 31 (62%) 4 (8%) O(-) 50 19.5 24.9 4 1.6
Column Total 170 217 35 14 436
[ Chi-Square 52.6, d.f. 18; p < 0.001]
Inspection of the numerical data presented in Table 5.42 for the statement, " is is not unusual for nurses to be verbally abused by their patients", showed that the majority of registered nurses and nursing students either agreed, or strongly agreed, with the statement. Registered nurses from hospitals A, B, and C were more inclined to "sttrongly agree" ( 65.4%,50% and 46.7% respectively) compared to registered nurses from hospital D where the majority of nurses nominated "agree" (51.6%). The majority of the first, second and third year nursing students were more inclined to choose "agree", (72%, 44.9% and 62% respectively). There was a significant difference elicited by the chi-square statistic which was principally due to differences between the proportion of first year nursing students responses to "strongly agree" [see the obtained frequency (14) and expected frequency (29.2)] and for the "agree" point on the scale [ note the 226
obtained frequency (54) and the expected frequency (37.3)].There was also a difference
between the obtained frequency (34) and expected frequency (20.3) for Hospital A
registered nurses' responses to "strongly agree", and this result also contributed to the
significant difference. When results were observed in a two by two contingency table for
registered nurses' and nursing students' responses a significant difference was not
revealed.
When categories were collapsed for these data 88% of registered nurses and 88% of
nursing students "stt-ongly agreed/agreed" with the statement.
5.8.1 Summary
Outhned in the following section a brief summary that addresses hypothesis 6 is
presented.
"Have you ever been physically injured by a patient?" revealed that the majority of nurses
in this study had not sustained an injury in this way. Although a high proportion of
registered nurses consisting of one half to over a third of registered nurses had sustained
an injury. The results for nursing students demonstrated that 11.1 % of first year nurses.
13.5% of second year nurses and 23.5% of third year nurses had also been physically
injured by a patient..
Eighty-five percent of registered nurses and 81% of nursing students believed that nurses
worried about contracting hepatitis B from a needle prick injury (see table 5.36). This
result supported the notion that nurses' attitudes toward infectious diseases showed that patient/client centred processes contributed towards accident/injury causation.
Results showed that 90% of registered nurses and 90% of nursing students believed that nurses worried about contracting AIDS from a needle-prick injury (see Table 5.37). This result supported hypothesis 6.
Seventy-eight percent of registered nurses and 91% of nursing students believed nurses were more concerned about contracting AIDS from an infectious source than hepatitis B 227
(see Table 5.38). This result supported hypothesis 6.
The statement "nurses are never hit/kicked by patients" was shown to be believed by 98% of registered nurses and 98% of nursing students (see Table 5.39). This result supported hypothesis 6.
Ninety-seven percent of registered nurses and 97% of nursing students supported the statement "sometimes nurses are physically assaulted by their patients" (see Table 5.40). This result supported hypothesis 6.
The statement "nurses understand that being hit/kicked by a patient is a way of life but do not condone it" was shown to be believed by 59% of registered nurses and 62% of nursing students (see Table 5.41). This result supported hypothesis 6.
Eighty-eight percent of registered nurses and 88% of nursing students believed that it was not unusual to be verbally abused by their patients (see Table 5.42). This result supported hypothesis 6.
Section 5.8.1 has presented the evidence that addresses the influence of client/patient processes and their contribution towards accident/injury causation.
5.9 Hypothesis Testing Nurses' Attitudes Towards the Type of Nurse Centred Processes Contributing Towards Accident/injury The following section presents several tables that examine the effect of nurse centred processes on accident/injury causation. These include nurses' attitudes towards days missed from work, accident form procedures, compensation claims and work motivation. 228
TABLE 5.43 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS "HAVE YOU MISSED ANY WORK/STUDIES DUE TO ACCIDENTS/INJURIES IN THE WORKPLACE?"
Category yes no No response Hospital A 20(37%) 34(63%) 1
Hospital B 9(36%) 16(64%) 1
Hospital C 17(28.3%) 43(71.7%) 1
Hospital D 30(24%) 95(76%) 0
First year 6(7.4%) 75(92.6%) 0
Second year O(-) 52(100%) 0
Third year 6(11.8%) 45(88.2%) 2
[Chi-square 41.4, d.f. 6; p < 0.0001]
Table 5.43 shows registered nurses and nursing students responses towards the question, "have you missed any work/studies due to accidents/injuries in the workplace?". On inspection of the data it is clear that the majority of registered nurses in this study have not missed work due to accidents/injuries sustained in the workplace. It appears that over 60% of registered nurses from hospital A, B, and C were in this category with 95% of registered nurses from hospital D also in this category. Nursing students responses showed that very few students had missed days due to injuries/accidents. It is clear, second year students missed the least days (and in fact it was zero days), with not more than 12% for third year students and 7.4% of first year students. The chi-square statistic reflected these trends and showed a significant difference between the groups. 229
TABLE 5.44 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS "HAVE YOU BEEN ENTITLED TO CLAIM COMPENSATION AND HAVE NOT DONE SO?"
Category yes no No response
Hospital A 13(24.5%) 40(75.5%) 3
Hospital B 4(17.4%) 19(82.6%) 3 Hospital C 11(19%) 47(81%) 2 Hospital D 24(20.5%) 93(79.5%) 8 First year 3(3.8%) 75(96.2%) 4 Second year O(-) 51(100%) 1 Third year 2(4%) 48(96%) 1
[Chi-square 30.7, d.f. 6; p < 0.0001]
Inspection of Table 5.44 shows the responses of registered nurses and nursing students to the question indicated they, " have you been entitied to claim compensation and not done so?". It is clear that the majority of both registered nurses and nursing students indicated a negative response. However approximately 20% of registered nurses apparentiy were entitled to claim compensation and did not. A small number of nursing students from first year (3.8%) and third year (4%) also indicated they were entitled to claim compensation but had not done so. A significant difference was elicited by the chi- square statistic essentially between registered nurse groups and nursing student groups. 230
TABLE 5.45 REGISTERED NURSES AND NURSING STUDENTS RESPONSES TOWARDS "HAVE YOU EVER FILLED OUT AN ACCIDENT FORM FOR A PATIENT?"
Category yes no
Hospital A 47(85.5%) 8(14.5%)
Hospital B 19(76%) 6(24%)
Hospital C 52(85.2%) 9(14.8%)
Hospital D 88(70.4%) 37(29.6%) First year 13(16%) 68(84%)
Second year 9(17.3%) 43(82.7%) Third year 9(17.6%) 42(82.4%)
[Chi-square 165.6, d.f. 6; p < 0.001]
The majority of registered nurses had filled out an accident/injury form (see Table 5.45).
Over three quarters of the registered nurses from hospitals A, B, and C, and 70% of hospital D registered nurses replied in the positive to this question. By comparison, the nursing students showed that they were inexperienced in this area, (16% of first year students, 17.3% of second year students and 17.6% of third year students). These trends eUcited a significant difference by the chi-square statistic. 231
TABLE 5.46 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NEEDLE-PRICK INJURIES OFTEN GO UNREPORTED*
Category Stt-ongly i\gre e Disagree Strongly Row Agree Disagree Total
Hospital A 37 (68.5%) 16 (29.6%) 1 (1.9%) O(-) 54 30 21.3 2 0.7
Hospital B 19 (73.1%) 7 (26.9%) O(-) O(-) 26 14.5 10.2 1 0.3
Hospital C 44(72.1%) 15 (25.6%) 2 (3.3%) O(-) 61 33.9 24 2.3 0.8
Hospital D 70 (56.9%) 41 (33.3%) 8 (6.5%) 4 (3.3%) 123 68.4 48.5 4.6 1.5
First year 5 (12.2%) 34 (82.9%) 1 (2.4%) 1 (2.4%) 41 22.8 16.2 1.5 0.5
Second year 17 (37.8%) 27 (60%) 1 (2.2%) O(-) 45 25 17.7 1.7 0.6
Third year 31 (60.8%) 18 (35.3%) 2 (3.8%) O(-) 51 28.4 20.1 1.9 0.6
Column Total 223 158 15 5 401
[ Chi-Square 66.3, d.f 18; p < 0.001]
It is clear the majority of registered nurses and nursing students believed that needle-prick injuries often went unreported (see Table 5.46). The greater number of registered nurses nominated, "stt-ongly agree", or "agree". The results also showed third year nurses' responses were more consistent with the registered nurses' responses, showing 95% of third year students had also nominated "stt-ongly agree" or "agree". The first and second year students resembled each other, for example a higher proportion of first and second year students nominated "agree", (82.9% and 60% respectively). This was reflected in the cell frequencies for first year nurses' responses to "agree" [note the differences between the obtained frequencies (34) and the expected frequencies (16.2)] and second year students' responses [observe the differences between the obtained frequencies (27) and the expected frequencies (17.7)]. A significant difference was elicited between groups by the chi-square statistic. Registered nurses' and nursing 232 students' responses when observed in a two by two contingency table did not reveal any significant results.
When categories were collapsed 94% of registered nurses and 96% of nursing students accepted the statement.
TABLE 5.47 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "SAFETY PROCEDURES PROTECT NURSES FROM RADIATION HAZARDS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 5(10.6%) 25 (53.2%) 12 (25.5%) 5 (10.6%) 47 4 25.8 14.8 2.5
Hospital B 2 (8.3%) 15 (62.5%) 5 (20.8%) 2 (8.3%) 24 2 13.2 7.5 1.3 Hospital C 3 (5.9%) 23 (45.1%) 22(43.1%) 3 (5.9%) 51 4.3 28 16 2.7
Hospital D 10 (8.8%) 65 (57.5%) 31 (27.4%) 7 (6.2%) 113 9.5 62 35.5 6
First year 5 (9.4%) 30 (56.6%) 18 (34%) O(-) 53 4.5 29.1 16.6 2.8
Second year 4(9.1%) 21 (47.7%) 18 (40.9%) 1 (2.3%) 44 37 24.1 13.8 2.3
Thu-d year 3 (6.4%) 29(61.7%) 13 (27.7%) 2 (4.3%) 47 4 25.8 14.8 2.5
Column Total 24 225 104 6 379
[ Chi-Square 15.7, d.f. 18 ; p > 0.05]
Slightly more than 50% of registered nurses from hospitals A, B, and D, and 45.1% of hospital C nurses agreed that safety procedures protected them from radiation hazards, (see Table 5.47). On closer inspection of Table 5.47 it can be seen that neariy as many registered nurses from hospital C (43.1%) disagreed as agreed. Nursing students also agreed with the statement, however, similar percentages of second year nursing students 233 agreed(47.7%) as well as disagreed (40.9%), reflecting hospital C registered nurses' responses. The third year students responses reflected those registered nurses from Hospitals A, B, and D, with slightly more than 20% of these registered nurses also nominating "disagree". A significant difference was not elicited between the groups for this particular variable. This results was supported when registered nurses' and nursing students' responses were observed in a two by two table. Sixty-two percent of registered nurses and 63% of nursing students, when the categories were collapsed "stt-ongly agreed/agreed" with the statement.
TABLE 5.48 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "SAFETY PROCEDURES FOR NURSES ARE ALWAYS FOLLOWED DURING PATIENTS' X-RAY EXAMINATIONS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 4 (8.2%) 18 (36.7%) 21 (42.9%) 6 (12.2%) 49 4 20.1 19.4 5.5
Hospital B 3(11.5%) 8 (30.8%) 13 (50%) 2 (7.7%) 26 2.1 10.7 10.3 2.9
Hospital C 5 (8.9%) 20 (35.7%) 20 (35.7%) 11(19.6%) 56 4.5 23 22.2 6.3
Hospital D 11 (9.4%) 54(46.2%) 36(30.8%) 16(13.7%) 117 9.5 48 46.4 13.1
First year 4 (9.8%) 16 (39%) 19 (46.3%) 2 (4.9%) 41 3.3 16.8 16.3 4.6
Second year 2 (4.3%) 15 (32.6%) 26 (56.5%) 3 (5.2) 46 3.7 18.9 18.3 5.2
Third year 2 (4.2%) 26 (54.2%) 17 (35.4%) 3 (6.3%) 48 3.9 19.7 19 5.4 Column Total 31 157 152 43 383
[ Chi-Square 22.7, d.f. 18; p > 0.05]
Registered nurses' and nursing students' responses were divided in their attitudes towards "safety procedures for nurses are always followed during patients' X-ray examinations", (see Table 5.48). The majority of registered nurses from hospitals A and B disagreed, (42.9% and 50% respectively) however, hospital C nurses were equally 234 divided between agree (35.7%) and disagree (35.7%) with the greater number of hospital D nurses choosing "agree" (46.5%). A substantial number of hospital D nurses also nominated "disagree" (56.5%). Nursing students varied theu-responses between "agree" (39% of first year nurses, 39% of second year nurses and 54.2% of thu-d year nurses) and "disagree", (46.3% of first year nurses, 56.4% of second year nurses and 35.4% of third year nurses). The chi-square statistic did not elicit any significant differences between the groups, as was the case when registered nurses' and nursing students' responses responses were observed in a two by two contingency table. When data was collapsed for all groups, 51% of registered nurses and 51% of nursing students rejected the statement.
TABLE 5.49 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES HAVE NO NEED TO BE CONCERNED ABOUT THE EFFECTS OF RADIATION ON THEIR BODIES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 2 (3.8%) 1 (1.9%) 16 (30.2%) 34(64.2%) 53 1.4 0.5 19.9 31.2
Hospital B 1 (3.8%) O(-) 13 (50%) 12(46.2%) 26 0.7 0.2 9.8 15.3
Hospital C 2 (3.4%) O(-) 16(27.1%) 41(69.5%) 59 1.6 0.5 22.2 34.7
Hospital D 3 (2.4%) 2(1.6%) 40(32.3%) 79(63.7%) 124 3.4 1.1 46.6 72.9
First year 1 (1.3%) O(-) 36 (46.2%) 41(52.6%) 78 2.1 0.7 29.3 45.9
Second year 2 (3.8%) 1 (1.9%) 20 (38.5%) 29(55.8%) 52 1.4 0.5 19.5 30.6
Thu-d year 1 (2%) O(-) 25 (50%) 24(48%) 50 1.4 0.5 18.8 29.4
Column Total 12 4 166 260 442
[ Chi-Square 17.4, d.f. 18; p > 0.05]
It is evident that nurses are concerned about the effect of radiation on their bodies as 235 inspection of the data displayed in Table 5.49 shows. Both registered nurses and nursing students responded to either "disagree" or "strongly disagree" for this particular variable. The majority of registered nurses from hospital A, C, and D nominated "strongly agree" ( 64.2%, 69.5% and 63.7% respectively) as did nursing students in first and second year (52.6% and 55.8% respectively). Third year nursing students were almost equally divided between "disagree" (50%) and "strongly disagree" (48%). The nursing groups' responses were homogenous. There was no significant difference revealed when registered nurses' and nursing students' responses were observed in a two by two contingency table. This trend was apparent when the categories were collapsed for this statement revealing that 95% of registered nurses and 97% of nursing students "disagreed/strongly disagreed" that they had no need to be concemed about the effects of radiation on their bodies. TABLE 5.50 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "TERATOGENIC AGENTS ARE A HAZARD TO NURSING PERSONNEL"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 11(27.5%) 23 (57.5%) 4 (10%) 2 (5%) 40 13.9 23.8 2 0.4
Hospital B 7 (33.3%) 14 (66.7%) O(-) 0 (-) 21 7.3 12.5 1 0.2
Hospital C 19 (46.3%) 20 (48.8%) 2 (4.9%) 0 (-) 41 14.3 24.3 2 0.4
Hospital D 43 (43%) 51 (51%) 6 (6%) 0 (-) 100 34.8 59.4 4.9 0.9
First year 12(21.4%) 42(75%) 2 (3.6%) 0 (-) 56 19.5 33.3 2.8 0.5
Second year 8 (27.6%) 20 (69%) 1(3.4%) O(-) 29 10.1 17.2 1.4 0.3
Third year 13 (43.2%) 23 (60.5%) 1 (2.6%) 1 (2.6%) 38 13.2 22.6 1.9 0.4
Column Total 113 194 16 3 325
[ Chi-Square 27.1, d.f. 18; p> 0.05] 236
Teratogenic agents were viewed by most nurses as a hazard (see Table 5.50). On inspection of the data the greater numbers of registered nurses nominated diat they agreed or disagreed with the statement, (over 94% of registered nurses from hospitals B, C, and D, and 84% of hospital A registered nurses). Nursing students responded in a similar pattern to the registered nurses, with 75% of first year students, 69% of second year students and 60.5% of third year students also agreeing to this statement. There were no significant differences between the groups as was the case when registered nurses' and nursing students' responses were observed in a two by two contingency table. Ninety-three percent of registered nurses nurses and 95% of nursing students accepted the statement when categories were collapsed. TABLE 5.51 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "CHEMICAL AGENTS USED FOR STERILISING METHODS DO NOT CAUSE ACCIDENTS/INJURY TO NURSES"
Category Stt-ongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) 2 (4.3%) 32(68.1%) 13 (27.7%) 47 0.1 4.1 31.9 10.9
Hospital B 1 (4.5%) 3(13.6%) 14 (63.6%) 4(18.2%) 22 0.1 1.9 14.9 5.1
Hospital C O(-) 5 (9.4%) 35 (66%) 13(24.5%) 53 0.2 4.6 36 12.3
Hospital D O(-) 11(11.2%) 63(64.3%) 24(24.5%) 93 0.3 8.5 66.6 22.7
First year O(-) 3 (6.5%) 35(76.1%) 8(17.4%) 46 0.1 4 31.2 10.6
Second year O(-) 1 (2.4%) 31 (73.8%) 10(23.8%) 42 0.1 3.6 28.5 9.7
Thu-dyear O(-) 5(13.2%) 25 (65.8%) 8(21.1%) 38 " 0.1 3.3 25.8 8.8
Column Total 1 30 235 80 346
[ Chi-Square 22.7, d.f. 18; p > 0.05]
The majority of registered nurses responses showed they disagreed that chemical 237 agents used to steritise articles did not cause accidents (see Table 5.51). Registered nurses' responses were similar to nursing students, who were also more inclined to nominate "disagree". The majority of all registered nurses and nursing students chose to "disagree" or "strongly disagree" with this statement. Understandably there were no significant differences between the groups by the chi-square statistic, and this proved to be the case when registered nurses' and nursing students' responses were observed in the two by two contingency table
When categories were collapsed for this statement 90% of registered nurses and 92% of nursing students "disagreed/strongly disagreed" with the content of the statement.
TABLE 5.52 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES OFTEN SUSTAIN BURNS FROM STERILISERS"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 12 (25%) 28(58.3%) 8(16.7%) O(-) 48 9.7 28.7 9.3 0.3
Hospital B 16(24%) 16(64%) 3 (12%) O(-) 25 5.1 14.9 4.9 0.1
Hospital C 13 (24.5%) 26(49.1%) 14(26.4%) O(-) 53 10.8 31.6 10.3 0.3
Hospital D 29 (25.4%) 55 (48.2%) 28 (24.6%) 2(1.8%) 114 23.1 68.1 22.1 0.7
First year 2 (6.3%) 23(71.9%) 7 (21.9%) O(-) 32 6.5 19.1 6.2 0.2
Second year 3 (9.4%) 26(81.3%) 3(9.4%) O(-) 32 6.5 19.1 6.2 0.2
Thu-d year 4(11.1%) 29 (80.6%) 3(8.3%) O(-) 36 7.3 21.5 7 0.2
Column Total 69 203 66 2 340
[ Chi-Square 30.4, d.f 18; p < 0.05] 238
Clearly the majority of registered nurses and nursing students viewed sustaining bums from sterilisers as a common event, (see Table 5.52). The majority of registered nurses from each of the four hospitals either agreed or strongly agreed. Although, the first and second year nursing students chose to "agree" in greater numbers than the registered nurses were inclined to, with over 70% of all groups responding to the positive ends of the scale.
On examining the third year students' responses, although the majority chose "agree", [note the difference between the obtained frequency (29) and the expected frequency (21.5) for this cell], a greater percentage of third year students chose "strongly agree" when compared to students from the other two years. Approximately, one fifth of the registered nurses and first year students also indicated that they disagreed with the statement.
The results showed a significant difference between groups mainly due to differences between registered nurse and nursing student groups. This significant difference was not revealed when registered nurses' and nursing students' responses were observed in a two by two contingency table.
Seventy-seven percent of registered nurses and 87% of nursing students accepted the statement when categories were collapsed. 239
TABLE 5.53 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "RSI IS NOT A COMMON OCCUPATIONAL HAZARD FOR NURSES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 2 (4.5%) 14(31.8%) 14(31.8%) 14(31.8%) 44 2.2 23 13.7 5.2
Hospital B 4(16%) 14(56%) 6(24%) 1(4%) 25 1.2 13 7.8 3
Hospital C 2 (4.2%) 25(52.1%) 14(29.2%) 7 (14.6%) 48 2.4 25 14.9 5.7
Hospital D 7 (6.3%) 68(61.3%) 28(25.2%) 8(7.2%) 111 5.4 57.9 34.5 13.1
First year 1 (2.1%) 26(55.3%) 17(36.2%) 3(6.4%) 47 2.3 24.5 14.6 5.6
Second year O(-) 13(39.4%) 17(51.5%) 3(9.1%) 33 1.6 17.2 10.3 3.9
Third year 1 (2.6%) 21 (53.8%) 12(30.8%) 5(12.8%) 39 1.9 20.3 12.1 4.6
Column total 17 181 103 41 347
[ Chi-Square 42.4, d.f. 18; p < 0.001]
RSI was not seen as a common occupational hazard by the majority of registered nurses, first and third year nursing students, (see Table 5.53) who all agreed with the statement. This is in contrast to the second year nursing students, who largely disagreed (51.5%). Approximately one quarter of registered nurses from the four hospitals also nominated "disagreed", compared to first and third year nursing students where approximately one third disagreed. Inspection of the cell for first year nurses' responses to "disagree" highlighted the difference between the obtained frequencies (17) and the expected frequencies (14.6) for this response and this result partially conttibuted to the significant difference for this statement. In the two by two contingency table registered nurses' and nursing students' responses did not reveal a significant difference. Sixty percent of registered nurses and 52% of nursing students accepted the statement when categories were collapsed. 240
TABLE 5.54 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES NEVER HAVE TO LIFT PATIENTS THAT ARE TOO HEAVY FOR THEM"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 3 (5.8%) 3 (5.8%) 10 (19.2%) 36(69.2%) 52 1.8 4.4 16.7 29.1
Hospital B O(-) 1 (3.8%) 7 (26.9%) 18(69.2%) 26 0.9 2.2 8.4 14.6
Hospital C 2 (3.3%) 2 (3.3%) 15 (24.6%) 42 (68.9%) 61 2.1 5.1 19.6 34.2
Hospital D 1(0.8%) 3(2.4%) 33(26.4%) 88 (70.4%) 125 4.3 10.5 40.2 70
First year 2 (2.6%) 15 (19.7%) 39(51.3%) 20 (26.3%) 76 2.6 6.4 24.5 42.6
Second year 4 (7.8%) 4 (7.8%) 21(41.2%) 22(43.1%) 51 1.7 4.3 16.4 28.6
Third year 3 (6%) 9 (18%) 17 (34%) 21 (42%) 50 1.7 4.2 16.1 28 Column Total 15 37 142 247 441
[ Chi-Square 73.1, d.f. 18; p < 0.001]
There is a strong cortelation between registered nurses responses from the four hospitals to never having to lift patients that are too heavy. Over three quarters of the registered nurses in this study either disagreed, or strongly disagreed, with this statement, (see Table 5.54). Nursing students' responses did not reflect the same tendency shown by the registered nurses who "strongly disagree" and were more inclined to "disagree". First year nursing students' responses for the "disagree" point on the scale conttibuted to the significant difference due to the variation between the obtained frequencies (39) and the expected frequencies (24.5). A significant difference was also revealed when registered nurses' and nursing students' responses were inspected in a two by two contingency table. When categories were collapsed 94% of registered nurses and 79% of nursing students choose to reject the notion that nurses never had to lift patients that were too heavy for them. 241
TABLE 5.55 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "BACK INJURIES ARE NOT A PROBLEM FOR NURSES"
Category Strongly Agree Disagree Stt-ongly Row Agree Disagree Total
Hospital A 1 (2%) O(-) 12 (23.5%) 38(74.5%) 51 0.3 0.2 13.8 36.7
Hospital B O(-) 1 (3.8%) 7(26.9%) 18(69.2%) 26 0.2 0.1 7 18.7
Hospital C O(-) O(-) 14 (23%) 47 (77%) 61 0.4 0.3 16.4 43.9
Hospital D 1 (0.8%) O(-) 37(29.6%) 87(69.9%) 125 0.8 0.6 33.7 89.9
Furst year 1 (1.3%) 1 (1.3%) 26 (32.5%) 52 (65%) 80 0.5 0.4 21.6 57.5
Second year O(-) 0(-0 12(23.1%) 40(76.9%) 52 0.4 0.2 14 37.4
Third year O(-) O(-) 12 (24%) 38(76%) 50 0.3 0.2 13.5 36
Column Total 3 2 120 320 445
[ Chi-Square 15.7, d.f. 18; p >0.05]
There is a clear indication as evidenced in the data presented in Table 5.55, that over 95% of registered nurses and nursing students stt"ongly disagreed that back injuries were not a problem for nurses. In most cases, three quarters of all nurses nominated, "sttxjngly disagree". Approximately one quarter of the registered nurse population and second and third year nursing students nominated "disagree". In conQ-ast, slightiy more first year students disagreed than all the other groups. For this particular variable there were no significant differences between the groups, as was the case when these data were observed in die two by two contingency table. When die categories were collapsed for this statement 98% of registered nurses and 98% nursing students indicated they believed back injuries were a problem for nurses. 242
TABLE 5.56 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "OTHER NURSES REPORT EVERY PERSONAL ACCIDENT THEY ARE INVOLVED IN"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) 5 (12.5%) 30 (75%) 5(12.5%) 40 0.6 6.8 28.6 4
Hospital B 1 (4.8%) 4 (19%) 16(76.2%) O(-) 21 0.3 3.6 15 2.1 Hospital C O(-) 10 (18.5%) 38 (70.4%) 6(11.6%) 54 0.8 9.2 38.6 5.4 Hospital D 3 (2.9%) 23 (21.9%) 69 (65.7%) 10(9.5%) 105 1.6 17.9 75 10.5 First year 1 (2.8%) 7 (19.4%) 24 (66.7%) 4(11.1%) 36 0.5 6.1 25.7 3.6 Second year O(-) 3 (9.4%) 26 (81.3%) 3(9.4%) 32 0.5 5.4 22.9 3.2 Third year O(-) 4 (9.8%) 32(78%) 5 (12.2%) 41 0.6 7 29.3 4.1 Column Total 5 56 235 33 329
[ Chi-Square 14.2, d.f. 18; p > 0.05]
Over 70% of registered nurses from hospitals A, B, and C and 65% of hospital D nurses did not agree that other nurses reported every personal accident/injury they are involved in, (see Table 5.56). A large proportion of nursing students also did not agree with the statement, with more than half of the first year students, 81.3% of second year students and 78% of third year students disagreeing. Observation of the cell frequencies does not show any great differences between observed and expected frequencies for nursing students' responses. Approximately 10% of registered nurses from hospital A, C, and D also nominated "strongly disagree", with similar responses evidenced from first, second and third year nursing students. Hospital B nurses responses differed slightiy to all other nurses, in that they did not nominate "strongly disagree". A significant difference was not evidenced between the groups, this was also the case when registered nurses' 243
and nursing students' responses were observed in the two by two contingency table. When categories were collapsed 79% of registered nurses and 86% of nursing students "disagreed/strongly disagree" that other nurses reported every personal incident they were involved in.
TABLE 5.57 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSING STUDENTS REPORT EVERY PERSONAL ACCIDENT/INJURY THEY ARE INVOLVED IN"
Category Stt-ongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 1 (2.(%) 11(32.4%) 19 (55.9%) 3 (8.8%) 34 1.2 10.1 20 2.7
Hospital B 1 (5%) 3 (15%) 15 (75%) 1(5%) 20 0.7 6 11.7 1.6
Hospital C O(-) 9(22.5%) 26(65.4%) 5 (12.5%) 40 1.4 11.9 23.5 3.1
Hospital D 4 (4.4%) 28 (30.8%) 52(57.1%) 7(7.1) 91 3.3 27.1 53.4 7.1
First year 5 (8.8%) 24 (42.1%) 25 (43.9%) 3 (5.3%) 57 2.1 17 33.5 4.5
Second year 1 (2.2%) 13 (28.9%) 27(60%) 4 (8.9%) 45 1.6 13.4 26.4 3.5
Thirdyear O(-) 11(24.4%) 31(68.9%) 3 (6.7%) 45 1.6 13.4 26.4 3.5
Column Total 12 99 195 26 332
[ Chi-Square 19.6, d.f. 18; p > 0.05 ]
It appears that slightiy more than half the population of registered nurses from hospital A, C, and D, disagreed that nursing students reported every accident/injury they were involved in, with three quarters of the hospital B registered nurses disagreeing, (see Table 5.57). First year nursing students were more evenly divided in their responses between "agree" and "disagree", whereas, second and third year students responses more closely resembled registered nurses from hospitals A, C, and D. Approximately one third 244
of hospital A and D registered nurses also nominated "agree", with slightiy fewer registered nurses from hospital B and C choosing this response. There was littie variation in the obtained and expected frequencies which accounted for the lack of significant differences between groups for this variable. This result was also found when registered nurses' and nursing students' responses were observed in the two by two contingency table. When categories were collapsed, 69% of registered nurses and 63% of nursing students either "disagreed" or "sfrongly disagreed" that nursing students reported every accident/injury they were involved in.
TABLE 5.58 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "I AM NEVER TOO BUSY TO REPORT MY OWN ACCIDENTS/INJURIES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total Hospital A O(-) 13(25.4%) 28 (52.8%) 12(22.6%) 53 0.8 14.7 32.1 5.5 Hospital B O(-) 2 (8%) 18 (72%) 5(20%) 25 0.4 6.9 15.1 2.6
Hospital C O(-) 13(21.3%) 40 (65.6%) 8(13.1%) 61 0.9 16.9 36.9 6.3 Hospital D 5(4.1%) 21 (17.2%) 80 (65.6%) 16(13.1% 122 1.8 33.8 73.9 12.6
First year O(-) 32 (53.3%) 27(45%) 1 (1.7%) 60 0.9 16.6 36.3 6.2
Second year 1 (2.3%) 16(36.4%) 27 (61.4%) O(-) 44 0.6 12.2 26.6 4.5
Thkd year O(-) 16 (37.2%) 27(62.8%) O(-) 43 0.6 11.9 26 4.4 Column Total 6 113 247 42 408
[ Chi-Square 64.8, d.f. 18; p < 0.001]
On examination of the data in Table 5.58 it can be seen that the majority of registered 245
nurses either disagreed, or strongly disagreed, that they were never too busy to report their own accidentsyinjuries. Approximately one fifth of registered nurses from hospitals A, C, and D nominated "agree", compared to hospital B nurses where tiiere were only 8% of registered nurses who agreed.
The responses from second and third year nursing students again more closely resembled registered nurses responses compared to the first year nursing students whose responses were more evenly divided between "agree" and "disagree". The differences for the first year nursing students responses for the "agree" point on the scale revealed some variation in the difference between the obtained frequency (32) and the expected frequency (16.6) which contributed to the significant difference elicited by the chi-square statistic. This result was supported when registered nurses' and nursing students' responses were observed in the two by two contingency table. Hospital D registered nurses' responses also revealed some variation between the obtained (21) and expected (33.8) frequency for the "agree" point on the scale.
When categories were collapsed 79% of registered nurses and 55% of nursing students chose to "disagree" or "strongly disagree" that they were never too busy to report their own accidents/injuries. 246
TABLE 5.59 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "I KNOW OTHER NURSES HAVE TIME TO REPORT THEIR OWN ACCIDENTS/INJURIES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A O(-) 12 (26.7%) 28 (62.2%) 5(11.1% 45 0.6 13.1 28.5 2.8
Hospital B O(-) 4 (20%) 13 (65%) 3 (15%) 20 0.3 5.8 12.7 1.2
Hospital C 2(4.1%) 12(24.5%) 30(61.2%) 5 (10.2%) 49 0.6 14.3 31.1 3
Hospital D 2(2.1%) 29(30.2%) 60 (62.5%) 5(5.2%) 96 1.2 28 60.9 5.9
First year O(-) 13(37.1%) 22(62.9%) O(-) 35 0.5 10.2 22.2 2.2
Second year O(-) 6(20%) 23 (76.7%) 1 (3.3%) 30 0.4 8.7 19 1.8
Third year O(-) 14(41.2%) 20 (58.8%) O(-) 34 0.4 9.9 21.6 2.1
Column Total 4 90 196 19 309
[Chi-Square 21.3, d.f. 18; p > 0.05]
Approximately 60% of registered nurses from the four participating hospitals did not beheve other nurses had time to report their own accidents/injuries, (see Table 5.59). First and third year nursing students also reflected the same pattern of responses as did the registered nurses for the disagree point on the scale. Second year nursing students appear to have chosen "disagree" in greater numbers (76.6%) compared to all other groups. A littie more than one fifdi of die registered nurses also nominated die "agree" category. Slightly more first and third year nursing students chose "agree" when compared to registered nurses. All groups of nurses' responses appear homogeneous for this variable and is reflected in the chi-square results which are not significant. Responses from registered nurses and nursing students when displayed in a two by two contingency table did not reveal a significant difference. 247
When categories were collapsed for this statement it was revealed that 69% of registered nurses 66% of nursing students chose the negative points on the scale.
TABLE 5.60 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "NURSES ALWAYS REPORT PATIENTS' ACCIDENTS/INJURIES "
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 4(8.7%) 28 (60.9%) 14(30.4%) O(-) 46 5.4 25.4 14.5 0.8
Hosphal B 4 (17.4%) 11(47.8%) 8 (34.8%) O(-) 23 2.7 12.7 7.2 0.4
Hospital C 10(17.9%) 35 (62.5%) 10 (17.9%) 1(1.8%) 56 6.6 30.9 17.6 0.9
Hospital D 16(15.1%) 58 (54.7%) 31(29.2%) 1(0.9%) 106 12.5 58.5 33.3 1.7
First year 4(7.7%) 27(51.9%) 19(36.5%) 2 (2.3%) 52 6.1 28.7 16.3 0.9
Second year O(-) 25(58.1%) 17 (39.5%) 1(2.3%) 43 5.1 23.7 13.5 0.7 Third year 5 (12.5%) 18(45%) 16(40%) 1(2.5%) 40 4.7 22.1 12.6 0.7
Column Total 43 202 115 6 336 [ Chi-Square 20.6, d.f. 18; p > 0.05]
The majority of registered nurses and third year nursing students, and 80% of second and third year nursing students agreed, that nurses always reported patients' accidents/injuries, (Table 5.60). Approximately 15% of registered nurses from hospitals B, C and D also nominated "sttrongly agree", with slightiy fewer registered nurses from hospital A (8.7%) nominating this category. Although the majority of nursing students chose to agree with the statement, a littie over a third of nursing students disagreed. A third of the registered nurses from hospitals A, B, and D also disagreed, with fewer numbers of registered nurses from hospital C disagreeing. A significant difference was not elicited by the chi-square statistic, which was also the case when registered nurses' and nursing students' responses were observed in a two by two contingency table. 248
Seventy-one percent of registered nurses and 58% of nursing students accepted the statement when categories were collapsed.
TABLE 5.61 RESPONSES OF REGISTERED NURSES AND NURSING STUDENTS TO : "DOMESTIC STAFF ARE MORE INCLINED TO REPORT THEIR ACCIDENTS/INJURIES THAN NURSES"
Category Strongly Agree Disagree Strongly Row Agree Disagree Total
Hospital A 20 (43.5%) 26 (56.5%) O(-) O(-) 46 17.7 24.9 3.2 0.3
Hospital B 12(54.5%) 10 (45.5%) O(-) O(-) 22 8.5 11.9 1.5 0.1
Hospital C 23 (43.4%) 26(49.1%) 4(7.5%) O(-) 53 20.4 28.6 3.6 0.3
Hospital D 58 (53.7%) 44 (40.7%) 6(5.6%) O(-) 108 41.6 58.4 7.4 0.6
Fkst year 5 (12.5%) 28(70%) 6 (15%) 1 (2.5%) 40 15.4 21.6 2.7 0.2
Second year 3(10.3%) 21(72.4%) 4(13.8%) 1(3.4%) 29 11.2 15.7 2 0.2
Third year 8(21.6%) 26(70.3%) 3(8.1%) O(-) 37 14.2 20 2.5 0.2
Column Total 129 181 23 2 335
[ Chi-Square 52.8, d.f. 18; p < 0.0001]
It is clear that the majority of registered nurses either strongly agreed, or agreed, domestic staff were more inclined to report their accidents/injuries than nurses, (see Table 5.61). A large percentage of nursing students showed a similar trend to the registered nurses, however, approximately one eighth of first and second year nursing students, and fewer numbers of third year students disagreed. The cell frequenciesfo r the firstyea r nurses responses to "strongly agree" demonstrates this point, revealing differences between the obtained frequency (5) and expected frequency (15.4).The pattern of responses from the thirdyear students more closely reflected the registered nurses 249 choices rather than the first and second year students. A significant difference was eUcited by the chi-square statistic for this variable, as was the case when registered nurses' and nursing students' responses were observed in the two by two contingency table.
Ninety-five percent of registered nurses and 85% of nursing students "strongly agreed/agreed" widi the statement when categories were collapsed.
5.9. 1 Summarv In the following section a brief summary is presented.
Very few registered nurses and nursing students indicated that they missed work due to accident/injuries in the workplace. A significant difference was revealed between registered nurses and nursing students groups (p < 0.0001).
Approximately 20% of registered nurses and 3.8% of first year nurses and 4% of third year nurses nominated that they were entitied to claim compensation and had not done so.
The majority of registered nurses, but very few nursing students had filled out an accident form for patients.
Ninety-four percent of registered nurses and 96% of nursing students believed needle prick injuries went unreported (see Table 5.46). This result supports hypothesis 7.
Sixty-two percent of registered nurses and 63% of nursing students believed that safety procedures protected nurses from radiation hazards (see Table 5.47). This result did not support the hypothesis.
Fifty-one percent of registered nurses and 51% of nursing students did not believe that 250 safety procedures were always followed during patients x-ray examinations (see table 5.49). This result did support the hypothesis.
Ninety-five percent of registered nurses and 97% of nursing students were concemed about the effects of radiation on their bodies (see table 5.49). "Teratogenic agents were believed to be a hazard by 93% of registered nurses and 95% of nursing students (see Table 5.50). These results supported hypothesis 7.
Chemical agents used for sterilising methods were believed to cause accidents/injury to nurses by 90% of registered nurses and 92% of nursing students (see Table 5.51). Sustaining bums from sterilisers was believed to commonly occur by 77% of registered nurses and 87% of nursing students (see Table 5.53). These results supported hypothesis 7.
RSI was not believed to be a common occuaptional hazard by 60% of registered nurses and 52% of nursing students (see Table 5.53). This result did not support hypothesis 7.
Nurses never have to lift patients that are too heavy for them was rejected by 94% of registered nurses and 79% of nursing students (see Table 5.54), This result supported hypothesis 7.
Back injuries were believed to be a problem for nurses by 98% of registered nurses and 98% of nursing students (see Table 5.55). This result supported hypothesis 7. "Other nurses report every personal accident they are involved in" was not believed to be the case by 79% of registered nurses and 86% of nursing students (see Table 5.56). Sixty-nine percent of registered nurses and 63% of nursing students rejected the statement, "nursing students report every personal accident they are involved in" (see table (see Table 5.57). 251
Seventy-nine percent of registered nurses and 55% of nursing students did not agree diat they were never too busy to report their accidents/injuries (see Table 5.58). Sixty-nine percent of registered nurses and 66% of nursmg students did not believe that other nurses had time to report theu- own accidents/injuries (see Table 5.59). Seventy-one percent of registered nurses and 58% of nursing students believed nurses always reported patients' accident/injuries (see Table 5.60). These results supported hypothesis 7.
The majority of registered nurses (95%) and nursing students (85%) accepted that domestic staff were more inclined to report their accidents/injuries than nurses were (see Table 5.61). This result supported hypothesis 7.
Section 5.9 addressed the influence of nurse centred processes and their part in accident causation.
5.10 The Reliabilitv Results for the Occupational Health and Safety Nursing Instrument.
A Cronbach's alpha was computed using a split-half coefficient for all groups of registered nurses from hospitals A, B, C, and D and from all groups of nursing student groups, that is, first, second and third year groups. Additionally a reliability estimate was computed for combined groups, namely, all registered nurses and all nursing students.
The results are reported in Table 5.62. Table 5.62 demonstrates the difference between the correlation coefficient between groups of registered nurses and nursing students. The results for hospital A, C, and D are "good" and the results for hospital B are barely satisfactory. 252
The results for third year nursing students are statisfactory (r = .82) with the results for first year (r = .79) barely satisfactory and second year (r = .70) the latter being lower than is desirable, (Anastasi, 1976). The combined split half coefficient cortelation (r= .80) is satisfactory.
TABLE 5.62 RELIABILTTY ESTIMATES FOR REGISTERED NURSES AND NURSING STUDENTS Category Rehability Estimate
Hospital A nurses r = .81 Hospital B nurses r = .71 Hospital C nurses r = .88 Hospital D nurses r = .86 First year nurses r = .79 Second year nurses r = .70 Third year nurses r = .82 Combined groups r = .80
5.11 Content Validitv of the Occupational Health and Safety Nursing Instrument
The overall percentage of agreement between the five clinical experts rating the validity of attittidinal satements in tdie OH&SNI showed 94.35% agreement for all items.
For 30 items there was 100% agreement; seven items showed 80% agreement and two items showed 60% agreement (see Appendix E for raw data).
The content validity of the items in the instt-ument was low for only two items; 253
"registered nurses make judgements regarding the seriousness of patients' accidents/injuries before deciding to report it" and "nurses are often too busy to report their own accidents/injuries' (see Appendix D). For all other items the validity was uniformly high. CHAPTER SIX 254
DISCUSSION
6A Introduction
This study investigated nurses' attitudes towards occupational health and safety issues from which a theoretical model of accident/injury causation was developed. A small number of registered nurses and nursing students were interviewed with a view to categorising the resultant information by using content analysis. From these categories
The Occupational Health and Safety Nursing Instrament (OH&SNI) was developed by the author and tested with a pilot group. The refined insttiiment was then utilised as the research instrument for the main study. The final model was tested with a small number of injured nurses for validation, (reported in chapter 7).
The format observed in this chapter is similar to diat developed in Chapter 5. Discussion involves the findings for the attitudes and awareness of registered nurses and nursing students towards occupational health issues, and is presented in relation to the general research question, and specific hypotheses, (as stated in Chapter 4, Section 4.8).
6.2 Elucidation of a Nursing Model
In the following section discussion concerning the general research question which addresses the development of the theoretical model will be presented. The model is illustrated in Figure 6.1. 255
INPUTS PROCESSES OUTPUTS /^Client/patient Centred^ pdimational Needs Lack of nurse education Desired inO.H.S. Inability to co-operate Benefits No instruction/ Aggressive behaviour to reinforcement in use of Transmission of infections patients mechanical aids. General lack of inservice and training. Organisational Communi ty (Hospital)
System expectations Limited availability Management /cooperation with Lacking,poor definition or wardsmen Undesired poor communication of Lack of ergonomic Accidents design policies in O.H.S. Injury Poor general management Staff shortages priorities and practices Illness Stress Disease SQCial to Nurses Macro: Attitudes, Nurse Centred perceptions, habits Lifting heavy loads Micro: immediate social Incorrect procedures / situation demands —• Emotional factors ^ responses Carelessness
Figure 6.1 Schematic representation of the model 256
The nurse as a therapeutic agent seeks to provide a safe and healthy environment for the client and her/himself. The nurse interacts with the client in providing optimum nursing care within a safe and healthy environment.
This model proposes to reflect the inputs, processes, and outputs, diat are inherent in the hospital environment and combine to effect an unhealthy state within the nursing environment. The occupational health and safety nursing model in this study outlines three basic sub-systems which are now discussed.
6.2.1 Inputs
Four main sets of inputs need to be considered: the need for educational, environmental, management and social inputs, the lack of these contributes towards accident/injury causation..
6.2.l.i Educational Inputs The need for educational inputs are influenced by diree significant determinants: i. Lack of occupational health and safety education for nurses both in relation to occupational health and safety regulations and occupational health and safety committees; ii. Absence of regular up-date/reinforcement in clinical instruction for registered nurses in the workforce; and iii. Lack of in-service programmes and consequent lack of knowledge in relation to new problems and diseases in the areas of occupational health.
6.2.1.ii Environmental Inputs
There are many environmental inputs which might be considered and contribute towards 257 accident/injury causation. Four of particular importance in relation to occupational health in hospitals and nominated by both the registered nurses and nursing students (see Chapter 5, Tables 5.1 and 5.2), are: i. Smooth, slippery floors which become particularly hazardous when they are so often wet. ii. The greater likeUhood of the presence of nosocomial infections; iii. The poor design of the general work environment that fails to provide adequately for many of the activities required in nursing and thereby imposes additional physical and perhaps psychological stress on nurses, particularly in relation to the many aspects of dkect patient handling; iv. Poor maintenance of equipment used by nurses. (It should be noted that some of these system environmental inputs are a consequence of other system processes. For example, the poor maintenance which is an input to the nurses' environment may be a function of the hospital engineer's priorities or resource restrictions, and these reflect system processes).
6.2.l.iii Management Inputs There are two factors which have an important part in contributing to management inputs, although the general organisational climate must be seen as largely dependant upon the management beliefs and style of the senior management personnel in the hospital. i. The occupational health and safety policies of the hospital (or the lack of these and/or the failure adequately to communicate them to nursing staff, if they do exist) is one of the significant management inputs, (see Chapter 5, Table 5.1 and 5.2). n. Management policies which restrict budgets or give unsafe/unhealthy working conditions for nursing staff. For example, in an understaffed ward, a nurse may feel obliged to attempt to lift or assist a patient on her own and thus risk injury to her/himself. 258
6.2.l.iv Social Inputs
As with the preceding inputs, there is a whole range of social inputs which could have some influence on the nursing environment. For the purposes of this model, these social inputs are discussed in two categories, the macro-social and micro-social and are further tested in the following sections by the OH&SNI.
i. Macro-social inputs This category of social inputs includes all of the attitudes, perceptions and behaviours that are engendered by the broader social milieu in which the hospital and the nursing profession operate. The generalised expectations that the hospital, the patients and the medical staff variously have of nurses; the expectations that nurses have of themselves; the historically exploited "selflessness" and the anticipated "dedication" of the nursing profession, and the assumed disregard for or down-playing of personal health and safety considerations, that are all reflections of the (slowly changing) macro-social inputs.
ii. Micro-social inputs At the micro-social level, attention must turn to die immediate social environment on the ward, or in whatever other work situation in which the nurse may find her/himself. The immediate social demands and expectations imposed by the patient, the medical practioner or "the system" can become superordinate to the nurse's concern for her/his own safety and well being. The example already cited, of a nurse feeling obliged to attempt on her own to lift a patient that should involve at least two nurses illustrates the effect of such micro-social inputs. 259
6.2.l.v Inputs Summary
The inputs outlined above reflect a representative sample rather than an exhaustive catalogue of cu-cumstances that contribute to the safety (or lack of safety) of the system within which the nurse has to function. An examination of die inputs makes it clear that some of the inputs are primarily physical, some are social, some organisational and some psychological. The point stressed is that all of these system components must be appreciated as interacting to influence the way the system, and the nurse as an element in the system, can perform.
6.2.2 Processes Three sets of processes have been identified for particular attention; those centering on the patient or client, those centering on the nurse, and those which are primarily organisational.
6.2.2.i Client/patient processes i. The patterns of interaction between the nurse and patient are determined by conditions within the patient is the basis of the first cluster. The patient's emotional condition (for example, petulance, impatience, or intt-ansigence) as well as the physical condition and its concomitant requirements may have major influences on the nurse's pattern of responses, haste in decision making and in actual performance, and ultimately, safety of performance. Such apparentiy simple patient-variables as age and sex can also significantiy influence die process between nurse and patient. ii. The potential and the opportunity for the tt-ansmission of disease from patient to nurse is a second determinant of the processes which may enhance or detract from die safety of the nurse's performance. Many of the contacts which a nurse may 260
have to make with the patient or the patient's bodily products can have a high potential for the transmission of disease, and direct patient care and needs may sometimes appear to take precedence over the nurse's own self protection.
6.2.2.ii Nurse-centred processes
Four of the many processes under the direct control of the nurse are discussed. i. Attempting to lift loads that are too heavy and/or to use postures that have a high potential for injury; ii. Using incortect procedures - because of ignorance (lack of training), pressure of the immediate situational demand, or personal predisposition; iii. Mood or emotional state of the nurse, or less temporary factors such as chronic stress; iv. Simple carelessness - which, as with (ii) above, may reflect a variety of causes, including tiredness at the end of a shift (or double shift), distraction because of competing demands for attention, or once again, personal predisposition.
6.2.2.iii Organisational (hospital) processes
There are four factors which have been stated by nurses as having an influence on the organisational system: i. System expectations. This process determinant refers more to the performance expectations than to the attitudinal expectations which were commented upon as social inputs in that section. Nurses are expected to perform their duties competentiy and efficiently regardless of staff or equipment deficiencies; ii. Limited availabiUty of, or cooperation from, wardsmen or odier ancillary staff; iii. Poor ergonomics in the design of furniture, equipment and working environments, (this has been referted to as an input variable, but it has an ongoing influence on the processes in which the nurse is involved as she/he performs nursing care. 261
Consquentiy the ergonomics of the work situation must be considered as a major process component as well as an input component); iv. Staff shortages, with their manifold effects upon the operation of each unit within the system and the performance of individual nurses.
6.2.2.iv Processes Summary
The preceeding sets of processes, like the set of inputs, can only be regarded as a representative sample of those most likely to be implicated in the genesis of an accident, injury or illness. As with the inputs, several processes may combine or interact to precipitate the occurtence of an unwanted output of the kind discussed in the next section.
6.2.3 Outputs
The hospital, as a system, has many outputs, the primary one being healthy, recovered clients. However, the output of concern in this model is the unplanned set of outputs that, as Adams (1988) argued, are just as much a product of the system's functioning as are its intended ones. This unwanted set of outputs, which is of direct relevance to the model, consists of all the injured, damaged or unwell nurses (and other employees) whose involvement with the system's inputs and processes has left them as sufferers of one or more of these system- engendered consquences.
It is contended in this model that every accident, every injury, and every disease acquired by a nurse during work in the system, must be seen as a consquence of the interaction within the system between relevant inputs and processes, including, but by no means entirely dependent upon, the behaviour of the individual nurse who suffers the injury or disease. To reduce or eliminate the occurtence of specific undesired outputs such as, for example, back injuries, it is necessary to examine the system's inputs and 262 processes in terms of the categories and brief descriptions given above and identify which of these system elements in combination are contributing most to the incidence of injury.
6.2.4 Summarv of the Model
This model has been formulated from empirical data and is supported by hypotheses. The causation nursing model postulated by the investigator meets the criteria outlined by Chinn and Jacobs (1983) for the description of a theoretical model.
Concept analysis has been achieved by providing a systems approach based on Roy (1980) and Johnson (1980). The model has been supported by empirical data utilising a content analysis methodology (see Chapter 3, Section 3.2.1). A multiple causation theory has also been validated by empirical data (see Chapter 5, Tables 5.1 and 5.2). Both multicausality and the importance of utilising a systems theory orientation were emphasised by Adams (1988), who highlighted the interdependence or interactive elements of a systems theory approach and argued;
"the components and subsystems (including the persons who are part of the system) must interact widi odier components in a cooperative effort to maintain system processes and produce the systems' outputs" (Adams, 1988,188).
It is clear that this proposed model is an interactive model, with inputs, processes anc outputs interacting in a combination of different ways to influence accident/injury causation.
6.2.4 .i Definitions
A definition to describe the role of die nurse has been provided, for example the nurse is a therapeutic agent (see this Chapter, Section 6.2). 263
6.2.4. ii Goals
Aims and parameters of the study have been outiined in Chapter 1, Section 1.6 and Chapter 4, Section 4.2. These aims and parameters of this smdy have been achieved (see Chapter 5).
6.2.4.iii Relationships
Relationships have been tested via hypotheses and empuical data, (collected from open- ended responses) and the results attest to a relationship to support the efficacy of the model.
6.2.4.iv Sttructure
Structuring of theoretical relationships has been achieved by the "structuring of concepts in intertelationships to provide theoretical descriptions, explanations and descriptions." (Chinn and Jacobs, 1983, 112). This has been achieved through the structuring of the hypotheses which largely support the occupational health and safety nursing model.
6.2.4. V Assumptions
Assumptions "underlying human care values in nursing" (Watson, 1985, in Chinn and Jacobs, 1983, 195) have been identified. These assumptions have been articulated in Chapter 1, Section 1.5.4).
A multiple causation theory is supported by the raw data. A systems model best explains the interactive processes that operate within the occupational health environment of the nurse which may lead to accident/injury and disease causation. This result supports the general research hypothesis,[ (the model is depicted in Figure 6.1) (see Chapter 5, Tables 264
5.1 and 5.2)]. The following sections present the discussion concerning the argument, supporting, or otherwise, for hypotheses testing the model.
6..3 The Need for Educational Innuts to Avoid Accidents/In juries.
In the following section discussion will be presented concerning variables, namely nurses' attitudes towards lifting patients, availability of in-service education, and loads lifted which show a need for educational inputs to avoid accidentsAnjuries.
Only one third, to one fifth, of the registered nurse population in this study was aware of the cortect prescribed (legal) load for lifting, indicating that the majority of registered nurses were unaware of the cortect load, ( see Covell and Refshauge, 1986 for the legal load for safe lifting for New South Wales). Compared to all other groups, third year nurses' responses showed a better understanding of what constituted a "reasonable" weight to lift, ( See Chapter 5, Tables 5.3 and 5.4).
There may be several reasons for this. Firstiy, the registered nurses may be responding to the question from the point of view of the loads they normally lift, for example while lifting patients. It has been established that nurses generally hft loads that are too heavy for them, (Dehlin and Lindberg, 1975; Owen and Damron and Watt, 1987). Therefore, in the context of the loads they normally lift, the weights they have nominated in this research may appear to be quite reasonable to them. Secondly, it may be due to a lack of knowledge regarding weight limitations and nurses may not be aware that legal limits for safe lifting exist. Thirdly, many nurses in the workforce may lift loads that are far too heavy for them because they do not have adequate assistance.
Nurses in this research, have also indicated that they continue to work whilst experiencing back pain (see Chapter 5, Table 5.5). When asked whetfier nurses often worked when they had back pain, registered nurses from the four participating hospitals, 265 almost without exception, indicated this was so. Third year nurses responded in a similar pattern to the registered nurses, in contrast to the first and second year nursing students, where greater numbers agreed, rather than strongly agreed. It is clear, however, that over 95% of all nurses, (the first year students nurses were the exception where 91% agreed or strongly agreed) believed nurse worked whilst experiencing back pain. There was a significant difference between the groups ( p < 0.005) although this was largely due to differences between the "strongly agree" and "agree" points on the scale. There was no significant difference when registered nurses' and nursing students' responses were observed in a two by two contingency table.
It is not surprising that nurses experience back pain and often work whilst in pain. An explanation for this may well be because nurses lift weights that are too heavy for them subsquently sustaining low back injuries and as a consquence experience pain. The statement was accepted by 94% of registered nurses and 95% of nursing students.
The majority of registered nurses also indicated that mechanical devices were not available to help lift heavy patients ( see Chapter 5, Table 5.6). Fkst year student nurses, however, in contrast to the registered nurses, and second, and third year nursing students were more Ukely to agree that such devices were available. A significant difference was elicited for this particular variable ( p < 0.0001), with differences being evident between the "disagree" and "stt-ongly disagree" points on the scale as well as a significant proportion of registered nurses choosing to "agree". A significant difference was revealed when registered nurses' and nursing students' responses were examined in a two by two contingency table.
Because of their considerable experience in the workforce, registered nurses and the more senior nursing students may be, firstiy, more aware of the lack of, or limited number of mechanical devices. Secondly, it may be that registered nurses are "too busy" and do not take the time to locate and use the "Henry Lifter", as opposed to the more 266 junior nursing students, who do not have the same time contraints, and may well have time to locate and use die mechanical hfting device. Thu-dly, it may well be that die more junior nursing students are more conscientious, and try and "do the right thing". The responses when collapsed for this statement revealed that 60% of registered nurses disagreed while 87% of nursing students agreed that mechanical devices were available to help hft heavy patients.
The three remaining questions that addressed lifting loads as articulated in hypothesis 1, included " mechanical devices are always used if the patient is too heavy to lift" ( see Chapter 5, Table 5.5.7), "nurses often lift more than the prescribed load" (see Chapter 5. Table 5.8), "nurses always think first about the mechanics of lifting before they lift a patient" (see Chapter 5 Table 5.9). Overwhelming, registered nurses did not agree that mechanical devices were used if the patient was too heavy to lift. First, and second year nursing students nominated similar ratings, and were more inclined to "agree", in contrast with the third year students, who demonstrated a familiar pattern when their responses more closely resembled registered nurses responses. Again, it would appear, firstiy, that nursing students may well have more time to seek and place patients in mechanical devices. Secondly, nursing students would in most instances be accompanied by a nurse lecturer, or clinical teacher, who would ensure students carried out the right procedure. Thirdly, third year nursing students who would have had more exposure to the "reality" of the clinical setting, and therefore may be responding to the question from that particular viewpoint, which may explain why their replies more closely resembled registered nurses.
It has already been established that the majority of nurses appear to be unaware of the correct load for safe lifting, however, they may still accept that they lift more than the prescribed load, [(see Chapter 5 Table 5.8)(see Chapter 2, section 2.6.3, Figure 2.3 which shows the maximum load for manual lifting in New South Wales is 16 kilograms)]. Nurses obviously realise they lift "too much", and although a significant 267 difference was elicited for this variable, (p < 0 .001), when categories were collapsed a significant difference was not revealed. Ninety-eight percent of registered nurses and 98% of all nurses in this study accepted the statement.
These data reveal that many nurses were unaware of the prescribed load for safe lifting, and it was disturbing to find evidence supporting that the majority of nurses actually beUeved they lifted more than the safe load. An examination of the responses to the open- ended question eliciting the causes of accidents/injuries (see Chapter 5, Table 5.1 and 5.2) puts forth some of the reasons why this might be so. For example, "lifting unassisted", "going beyond your capabilities", and "lack of education in lifting" were some of the explanations forwarded by nurses and may help to explain why nurses may often be required to lift more than the prescribed load.
Another cogent reason that shows support for the need for educational inputs to avoid accidents/injuries, is highlighted by nurses' responses towards the statement, "nurses always think first about the mechanics of hfting before they lift a patient". Over half the registered nurses and nursing students believed this statement to be incorrect, although, there was a significant difference between the groups, this can probably explained by varying proportions of nurses choosing "agree", [ (a little over one third of hospital D registered nurses nominated "agree" compared to only 10% of third year nursing students), (p < 0.001)]. It may well be that both registered nurses and nursing students, "automatically lift" a patient, without consciously thinking about the biomechanics of the lift to be executed.
Discussion concerning the availiability of OH & S in-service education is now addressed. Responses from registered nurses investigating "attendance at training sessions on occupational health and safety issues since graduation", (see Chapter 5, Table 5.10) showed high levels of attendance. There were some variations from registered nurses' responses located in different hospitals, (for example over 95% of registered nurses 268 from hospital C and D, and 88.9% from hospital A) in contrast, to fewer numbers attending from hospital B (64%). It would be expected that in-service attendance would be relatively high, as registered nurses are required to attend an orientation programme on securing employment. These programmes mclude selected topics mcluding occupational health and safety education, however, the topics are generally Umited to fire procedures, patient evacuation in the event of a hospital fire and general fire procedure. It is surprising that the attendance levels are not higher and this could be explained by, firstiy, those registered nurses who have been in the workforce for some considerable period of time may well have forgotten. Secondly, these programmes have not always been available and therefore nurses have not been able to attend them.
The question that addressed the type of in-service programme attended in occupational health and safety, ( see Chapter 5, Table 5.11) supported the notion that it was mainly the traditional type of OH & S in-service educational programmes, that were provided by management and attended by nurses. For example, fire drill in-service showed over 90% of attendance by registered nurses. Hospital fire procedure in-service was also well attended, with more than 70% of registered nurses from three hospitals nominating they attended (namely hospital A, C and D) and somewhat fewer numbers from hospital B, (that is 54%).
Relatively new areas of concern for occupational health and safety education in-service attendance, namely AIDS and hepatitis B in-service, contrasted poorly with the more traditional areas. For example, attendance for AIDS in-service courses in one particular hospital (namely hospital B) revealed that only 27% of registered nurses had attended such courses. The evidence also demonstrated from the responses of the registered nurses from the other three participating hospitals slightly higher percentages of attendance (approximately one third), however, the overall figures were unacceptably low. In an area of commonly held misconceptions (Valenti and Anarella, 1986; Wertz, Sorenson, Leibling, Kessler, and Heerin, 1987) and it would appear that in-service 269 courses on the tt-ansmissiono f AIDS by needle-prick penett-ation and AIDS should be implemented with a high degree of priority, in order to provide educational inputs for registered nurses.
Similar results were obtained for hepatitis B in-service education attendance. A similar pattern emerged, with hospital B registered nurses demonstrating low attendance rates, (23%) with hospital C registered nurses showing an even lower level, (22%). The risk of transmission of hepatitis B, particularly by needleprick penetration appears to be greater than the risk of AIDS, (see Crossley et al., 1986), and these figures expose the occupational risk of hepatitis B (and indeed AIDS) to nurses if they lack factual information. Possible explanations for this situation may well include, fiirstiyin-servic e courses are being provided by management in these areas but nurses are not attending. Secondly, in-service courses are not being provided by management and nurses are not being provided with this information.
The proportions of nurses attending in-service education on lifting techniques varied considerably. The results showed, 70% of registered nurses from hospital A attending this type of in-service education, and only slightly more than half the registered nurses from hospital C and D, with less than half the registered nurses from hospital B attending. Because back injuries constitute a major occupational risk for nurses (Owen and Damron, 1984) it would seem in-service education on lifting techniques, and on going education, would be needed to provide ways to reduce the risk. It would also appear necessary to further investigate the considerable differences in attendance rates for hospital B, C, and D registered nurses compared to the registered nurses from hospital A.
Back care in-service revealed considerably lower levels of attendance by registered nurses compared to lifting techniques. In fact, only 19% of registered nurses from hospital B, and a littie over a third of the registered nurses from the other three 270 participating hospitals, showed they had attended in-service education in this area of occupational health and safety. These data, perhaps reflect an attitude of lack of care for the maintenance of back care by both employee and employer.
6.3.1 Summarv
To summarize for hypothesis 1, it was shown by the questions that investigated registered nurses' and nursing students' responses towards, "opinions as to the prescribed load for safe lifting", "mechanical devices are available to help lift heavy patients", "mechanical devices are always used if die patient is too heavy to lift", "nurses often lift more than the prescribed load" and "nurses always think first about the biomechanics of lifting before they lift a patient"; that the results from these questions when categories were collapsed either accepting or rejecting the statement they showed the need for educational inputs.
The results for questions concerning in-service education, revealed that the traditional areas in occupational health and safety were well attended, and appeared to be provided by management. However, in-service education concerning hepatitis B and AIDS demonstrated, either nurses were not attending such courses, or, alternatively, management was not providing them. In-service education in lifting techniques, and back care, revealed low attendance rates by registered nurses, (and perhaps inadequate provision by management) particularly for registered nurses in three, out of the four participating hospitals.
These data support the influence of the attitudes' of nurses towards loads lifted, lifting patients, back care and availability of in-service education and show a need for educational inputs to avoid accident/injury causation. 271 fi.4 Environmental Inputs Contributing Towards Accident/Iniurv
In section 6.4 discussion concerning nurses' attitudes towards nosocomial infections, poor equipment and equipment maintenance which addressed the role of environmental inputs and their influence in accident/injury causation will be presented.
The results for the statement, "Legionnaires' disease is an occupational health risk for nurses", showed a degree of equivocality of responses from all groups of registered nurses and nursing students. The exception to this were the responses from the registered nurses from hospital B, and C, and the third year nursing students, where slightiy more than half the number in these groups, either disagreed, or sfrongly disagreed. Generally the groups were almost equally divided between the positive and negative ends of the scale. A significant difference was not elicited for this particular statement, ( p > 0.05) as was the case when categories were collapsed revealing 50% of registered nurses and 51% of nursing students rejected the statement.
These data present an ambiguous result, and fiuther research is requu-ed to investigate why groups of nurses responded in this way. It may well be, because some of the registered nurses in this study were working in one of the hospitals associated with the outbreak of Legionnafres' disease, (see Haupt and O'Neil, 1987), and they may have been more concemed about the occupational risk, compared to staff working in hospitals further away from the "outbreak".
Anaesthetic gases were rated as a source of concern for nurses while working in the operatmg dieatre, by the majority of registered nurses, and first and second year nursing students. Third year nursing students' responses differed from other groups, with their replies being equally divided between the negative and positive ratings on the scale, and 272
this response appeared to account for the significant difference elicited, (p < 0.01) There was no significant difference demonsfrated when registered nurses' and nursing students' responses were reduced to a two by two contingency table. When categories were collapsed for this statement 74% of registered nurses and 74% of nursing students accepted die statement.
It is clear that a substantial number of nurses were concemed, that anaesthetic gases constituted an occupational risk, and it would appear to be a problem not just confined to the operating room but affecting staff working in other areas. For example, midwives routinely work with nitrous oxide in the delivery suites, (see Sonander, Stenquist and Nilsson, 1985), and probably they would have nominated it as a source of concem. The students in this study would have also completed a clinical practicum in the labour ward, and with more than two thirds of the students having also completed their clinical practicum in the operating rooms, and therefore they would have had the experience to be aware of the relative risks. These finding illusfrate the environmental occupational risk nurses are exposed to, particularly if "poorly maintained equipment" is allowed to permit the escape of gases into the environment.
Dermatitis was rated by the registered nurses and nursing students in this study as a common occupational hazard, (p > 0.05). The nursing literature does not properly address dermatitis as an occupational risk (see Chapter 2, Section 2.1). Because nurses are exposed to chemicals, drugs, the risk of certain powders in surgical gloves and infections causing dermatitis, (Van Der Meeren, and Van Erp, 1980; Mossovitch, Mossovitch and Akkan, 1986), it is not surprising that 93% of registered nurses and 93% nursing students indicated it was a risk.
The results revealed by registered nurses and nursing students towards " slipping on wet floors cause accidents/injuries", show analogous responses from all groups of nurses 273
(see Chapter 5, Table 5.14). Ninety-seven percent of registered nurses and 100% of nursing students in this study, believed slipping on wet floors contributed towards accidents/injuries. There were no significant differences elicited for this variable ( p > 0.05) as was the case, when responses of registered nurses and nursing students were observed in a two by two contingency table. An explanation for the considerable agreement expressed between nurses for this statement, may well be explained by domestic staff who wet mop the floors in the wards as nurses traverse them causing nursing staff to slip. Although signs are generally displayed warning staff of the danger, even so, because of nurses' time constraints and because diey are so often in a "hurry" as well, diey slip on the wet floors, fall and often injure themselves.
In addition to the danger of slipping on wet floors, more than 80% of the registered nurses, and 90% of nursing students in this study rated the poor design of the environment as a source of accident/injury causation for nurses. Very few nurses believed this not to be the case, although some 16% of registered nurses from hospital B disagreed with the statement and a comparatively smaller number of first year students who nominated "strongly agree" was reflected in the probability level which was significant (p < 0.001) and this was confirmed when registered nurses' and nursing students' responses were inspected in a two by two contingency table. It is clear that the poor design of nurses' work environment appeared to contribute towards accidents/injuries, and this fact was substantiated by subjects' responses during the interviewing stage of this study, (see Appendices A and B). For example, tripping on cords and tubing in operating rooms was mentioned as a source of accident/injury causation by nurses.
6.4.1 Summary
The series of questions that explored hypothesis 2, showed general support for the impact of environmental inputs causing accidents/injuries. Although there was limited 274 support, expressed by registered nurses, and nursing students towards Legionnaires' disease as a causative agent when harboured in the hospital environment, the results for the other variables were more tangible. For example, it was clear, anaestiietic gases, slipping on wet floors, and the impact of poorly designed environments in hospitals, were clearly aspects of the nurses' workplace that the registered nurses and nursing students in diis study beUeved contributed towards nurses' accidents/mjuries.
6.5 The Influence of Management Inputs and their Role in Accident/ Injury Causation
The influence of management inputs and their role in accident/injury causation is discussed in this section. The interactive nature of these inputs has already been established (see Section 6.3). Evidence concerning in-service education has already been presented for hypothesis 1, and supports the notion that educational inputs and management inputs appear to be interactive variables. The lack of certain combinations of these two inputs appear to contribute towards accident/injury causation, for example provision of in-service education.
When the subjects in this study were questioned about the existence of occupational health and safety committees, the majority of registered nurses from hospital A (80%), hospital C (62%), and hospital D (73%), appeared to be aware of such committees, with fewer numbers of registered nurses from hospital A being aware (45%). It was interesting to note, the relatively high number of registered nurses who did not appear to know, although, not surprisingly, large numbers of nursing students indicated diat they did not know (see Chapter 5, Table 5.16). The large numbers of registered nurses who were unaware of occupational health and safety committees, may be due to registered nurses who have been in die workforce for some time, and who are curtently uninformed about the changes in occupational health and safety committees. This lack of knowledge 275 could be attributed to lack of in-service education courses.
The majority of registered nurses from hospitals A, and C, did not know whedier nurses were represented on occupational health and safety committees. In contrast, slightly more than half the registered nurses from hospital B and D were better informed (see Chapter 5, Table 5.18). Greater numbers of nursing students compared to registered nurses also indicated that they did not know (that is over 80% of all students). Representation on occupational health and safety committees is required by law, (Occupational Health and Safety Act, 1983) and an explanation for why some nurses did not appear to be aware of nursing representation, may be due to firstly, those nurses who were not in adminisfrative positions may not have access to this type of information. Secondly, communication of this type of information may not have been provided to nurses at the "grass roots", particularly to those registered nurses employed by hospital A and C. Thirdly, nursing students because of their relative inexperience of committees within the hospital organisational stmcture may understandably not be aware of such committees.
The concept of an occupational health unit for staff is not common in Australia (theu* presence being restricted to one of the larger teaching hospitals, for example Royal Perth Hospital, Western Australia, Australia or to The Occupational Health and Safety Service associated with Sydney Hospital, Ausfralia ). Therefore it is hardly surprising that the vast majority of subjects in this study were unaware of this type of unit. However, what is surprising, is that some of the subjects in this study indicated they existed with 26% of hospital D registered nurses responding in this way (see Chapter 5, Table 5.19).
Hepatitis B immunisation patterns for registered nurses revealed that a high percentage of registered nurses were not immunised. These data showed between 55% of registered nurses from hospital A, to 87% of hospital C registered nurses appeared not to be immunised. The reasons why this might be so, could include, firsfly, the belief by 276 some registered nurses that they are not at risk. Secondly, a concem by some nurses tfiat they may risk side-effects (see Morgan-Capner and Eddleston, 1983). Thirdly, there may be motivational reasons, for example nurses may believe they are too busy to artange to have the series of injections to provide immunisation.
The provision of extra nursing staff was addressed by the statement" extt-a nursing staff are always available to help lift heavy patients" (see Chapter 5, Table 5.21). Clearly both registered nurses, and nursing students, believed this was not the case, and these responses may be due to the shortage of nursing staff, or the reluctance of some wardsmen to help lift heavy patients (see Chapter 5, table 5.1).
Eighty-seven percent of registered nurses and 86% of nursing students revealed that they did not fill out an accident form every time they were involved in an accident, or sustained an injury ( see Chapter 5, Table 5.22). There was no significant difference between groups (p > 0.05), and this was reflected in registered nurses' and nursing students' responses when observed in a two by two contingency table. Clearly, nurses did not fill out accident/injury forms each time they were injured, and there may be several reasons for this, firstly, if the injury was slight, nurses may decide not to report it and tt-eat it her/himself. Secondly, at the time of the accident/injury nurses may "believe" they do not have the time to fill out a form. Thirdly, in some cases management may discourage nurses fromreportin g and fiUing out accident/injury forms, for example, "adminisfration discouraging you from reporting and intimidation" (see Chapter 5, Table 5.2).
There was evidence of equivocation between the response pattems from registered nurses for the statement," registered nurses make judgements about the seriousness of patients' accidents/injuries before deciding to report it", (see Chapter 5, Table 5.23). There was a significant difference between groups for this statement, (p < 0.001) probably explained by the large number of nursing students (over 65 % of first year students, 78.9 % of 277 second year students and 72.1 % of third year students) who agreed with the statement. A significant difference was also observed when registered nurses' and nusing students' responses were inspected in a two by two contingency table. The difference between registered nurses' responses could be attributed to some nurse unit managers who may make judgements about the seriousness of a cUents' accident/injury before deciding to report it. It would seem unlikely diat nursing students at theu* stage of relative clinical inexperience would be involved in the decision making process, and in fact, they would be encouraged to report any accidents/injuries to the nurse lecturer who would ensure the nurse unit manager was informed.
The findings for the registered nurses' responses when asked whether adminisfrative staff encouraged nurses to report their accidents/injuries, (see Chapter 5, Table 5.24) showed that slightly more than half the registered nurses in three of the participating hospitals agreed with the statement. Approximately 60% of hospital B registered nurses also agreed. A substantial number of registered nurses also disagreed, in fact approximately one third of the registered nurses from hospitals A, B, and D. First year nursing students in this case, more closely resembled the registered nurses' pattern of responses. A significant difference was not elicited for this variable (p > 0.05), as was the case when registered nurses' and nursing students' responses were observed in a two by two contingency table. This may well be explained by first year nursing students more readily identifying with the "ideal" situation. Second year nursing students were equally divided between "agree" and "disagree", with third year nursing disagreeing (60%). It is possible third year students were more disceming of the "system" and could judge more critically about the reality of the administrative processes within the hospital system.
In contt-ast, to die previous statement, for most cases over 90% of registered nurses, and almost the same number of nursing students, believed adminisfrative staff encouraged nurses to report patients' accidents/injuries. The significant difference between the 278 groups can probably be explained by approximately 50% of first year students indicating that they did not know, (p < 0.001). A significant difference was observed when registered nurses' and nursing students' responses were observed in a two by two contingency table. These data clearly support the notion that administrative staff encourage nurses to report patients accident/injuries but may be less willing or enthusiastic about encouraging nurses to report their own accidentsAnjuries.
Registered nurses' and nursing students' responses towards, "adminisfrative staff make decisions about the importance of nurses in the accident/injury process" (see Chapter 5, Table 5.26) showed that the majority of nurses believed it to be tme. There was no significant difference elicited between the groups, (p > 0.05), as was the case when regsitered nurses' and nursing students' responses were observed in a two by two contingency table. The reasons why nurses may agree, in this case could be explained by, firstly, it may be that administrative staff do not report the minor accidents/injuries nurses sustain. Secondly, it may be the case in some hospital organisations that administrative staff discourage nurses from reporting, for example those accidents/injuries that are compensatable, (see Chapter 5, Table 2.1) in order to reduce compensation insurance premiums.
6.5.1 Summary
These findings show the influence of management inputs into accidentAnjury causation. It would appear that aldiough management has provided in-service education in the more traditional areas of occupational health and safety, they have been slow to implement in- service courses in the areas that constitute current risks, for example hepatitis B and AIDS fransmission. It is also evident that management have not effectively encouraged immunisation against hepatitis B as evidenced by the large numbers of registered nurses in this study who are not immunised. 279
The availability of adequate ward staffing levels was addressed by a variety of questions (see Section 6.5) and it is clear, that nursing staff in their opinion are often required to lift heavy patients without adequate or extra nursing staff. Adminisfrative staff also appear to influence nurses in the reporting of accidents/injuries and although they encourage nurses to report patients' accidents/injuries they appear to be less inclined to encourage nursing staff to report their own. In fact, it appears that some adminisfrative staff even discourage nursing staff from reporting their accidents/injuries.
It can be seen that management inputs as articulated in the theoretical model, have a cogent effect on the accident/injury sequence.
6.6 The Influence of Social Expectations and Performance and their Contribution Towards Accident/Iniurv Causation
This section addresses the role of social inputs in the proposed theoretical model and discussion is presented conceming their efficacy.
Approximately 70% of registered nurses, and 61% to 78% of nursing students in this study, had performed nursing care whilst experiencing back pain, (see Chapter 5, Table 5.27). These data, represent a high proportion of registered nurses who apparently continue to deliver nursing care while experiencing back pain, and even though fewer numbers of nursing students indicated this was so, the incidence appears to be high. This may well be explained by some of the replies from the students during the interviewing stage of this study, for example, "many times you hurt your back but you don't tell anyone", (see Appendix A) and "lifting unassisted" (see Chapter 5, Table 5.1).
Nurses were asked whether they reported patients' trivial accidents/injuries (see Chapter 5, Table 5.28) and it was clear, that all groups either sfrongly agreed, or agreed, this was 280 the case. In fact, 70% of all registered nurses nominated the positive ratings on the scale. A significant difference was not elicited for this variable, demonstrating the accord between aU groups, ( p > 0.05). This result was also observed in a two by two contingency table for registered nurses' and nursing students' responses. These results suggest, firstly, nurses are concemed about dieir patients and ensure that their rights are protected by reporting all their accidents/injuries. Secondly, it may weU be nurses are content to make judgements about their own acccidents/injuries but not prepared to, in the case of patients.
The above findings appear to be re-inforced by nurses' responses towards " I often neglect my own accidents/injuries", and although some of the nursing students replied that they did not know, over 70% of registered nurses in this study agreed this was the case, (see Chapter 5, Table 29). Several reasons why nurses may be disinclined to report their own accidents have been postulated by Bruce and Mancy, (1982) (see Chapter 2, Section 2.6.2). They have suggested, " the ward may be too busy" and "nurses are discouraged from reporting", (Bmce and Mancy, 1982, 112). These results suggest that there may well be discrepancies between injuries reported in hospital records and those sustained by nurses and not reported formally. Discrepancies between formal and non-formal reporting have been discovered in the study by Lion, et al., (1981) in the area of assaults. They discovered that assaults sustained by nurses varied considerably between those reported in the hospital ward report (237) and those assaults formally reported, which were found to be much less (40) (see Chapter 2, section 2.8). This may well be the case for participants in this study and requires further investigation. Consideration must also be given to the many minor injuries sustained by nurses who would probably believe such injuries were not worth reporting.
When nurses were asked whether they knew some registered nurses who were disincUned to report patients' tt-ivial injuries, (see Chapter 5, Table 5.30) it appeared that a substantial number of nurses (both registered nurses and nursing students) believed it 281 to be so. It appeared nurses in some instances, were prepared to believe theu- colleagues may be less prepared to report patients' ttivial accidents/injuries than they were. There was a significant difference elicited for this variable (p < 0.001) which probably accounted for hospital B registered nurses' responses, who were more inclined to disagree, (52.2%). These results were supported when a significant difference was observed in a two by two contingency table. The findingsfo r the majority of subjects in this study suggest the probable effects of social expectations on the behaviour of nurses. For example, nurses may believe they are expected to report all accidents/injuries but when asked if their colleagues reported patients' trivial injuries they were in fact reporting in tmth what they actually did, (that is not all trivial accidents/injuries are reported). It would appear that the student nurses perceived this to be the case, when they nominated that patients' trivial injuries were not reported. The effect of social inputs and how they impinge on nurses' attitudes, and behaviour, appear to be reflected in their responses towards, " nurses do not like to claim compensation for accidents/injuries' and "nurses who take time off for accidents/injuries are thought to be malingerers". Although significant numbers of nursing students did not know whether nurses claimed compensation for work injuries, the majority of registered nurses agreed that this was the case, [(see Chapter 5, Table 5.31) (p < 0.001)]. A significant difference was also observed when registered nurses' and nursing students' responses were inspected in a two by two contingency table. Some of the reasons why this may be so have been revealed by registered nurses replies during the pilot stage of the study, (see Chapter 3, Table 3.16). They included in then- responses, "nurses take sick leave in preference to workers' compensation because; 1. "less problems with adminisfration (and they are a problem)", 2. "less paper work". 3. "you don't have to wait ten weeks for your pay". It is evident that nurses do not like to claim workers' compensation, and an additional reason may include, the necessity to include information about compensation claims on employment applications. It appears nurses would prefer not to divulge this type of information, as they see the potential for discrimination, (see Chapter 5, Table 5.2). 282
Approximately 60% of registered nurses, and almost one half of registered nurses from hospital B, strongly agreed, or agreed, with "nurses who take time off for accidents/injuries are thought to be mahngerers" (see Chapter 5, Table 5.32). By comparison the majority of first, and second year students disagreed, with third year nursing students more closely resembling the responses of the registered nurses, ( p < 0.001). A significant difference was also revealed for registered nurses' and nursing students' responses in a two by two contingency table.
The majority of nurses in this study who beUeved nurses were seen as malingerers if they took time off work due to accidents/injuries, may have firstly, perceived that others viewed taking of time for these reasons as a negative event. Secondly, it may well be some nurses felt aggrieved if others took time off, as it would probably increase the workload for those who remained. Thirdly, perhaps some nurses genuinely believe nurses are malingerers if they take time off work due to accidents/injuries, for example a back injury. In contrast to the registered nurses, the first and second year nursing students appear to have expressed an "ideal view", compared to third year students who may be "better" sociaUsed in the ways of what actually occurs in the hospital "system".
6.6.1 Summary It is clear from these findings, that micro-social, and macro-social inputs, have a profound effect on nurses' attitudes, and how they perceive the functioning of the system in which they operate. These attitudes are reflected in nurses' unwillingness to take timeo f for accidents/injuries and theu- disinclination to claim compensation (even when they are entitled to). Nurses have indicated that they are prepared to perform nursing care even though they may be experiencing back pain. They are reluctant to report their own injuries but they have shown that they are diligent in reporting their patients' accidents/injuries. 283
(f.7 The Influence of Organisational Processes and Their Contribution Towards Accident/Iniurv Causation
The role of organisational processes and their influence in accident/injury causation and how it affects nurses' attitudes will be examined in this next section.
There was some degree of difference in the attitude of registered nurses towards, extra help was usually available from wardspersons, (see Chapter 5, Table 5.33). Slightly more than half of the registered nurses in this study agreed this was the case, however approximately 40% of registered nurses from hospitals A, C, and D did not agree. It is noteworthy, that the third year nursing students more closely resembled the registered nurses' responses. There was a significant difference elicited between the groups of nurses, (p < 0.01) as was the case for registered nurses' and nursing students' responses when observed in a two by two table. The difference in opinions between the registered nurses from hospital A, C, and D compared to those registered nurses from hospital B may be partiy explained by an examination of the responses displayed in Chapter 5, Table 5.1. These replies show there were more numerous reasons from nurses from these three hospitals compared to registered nurses from hospital B and they included, "wardsmen not available/refusing to help, against union mles to lift heavy patients". Because, this type of behaviour had been exposed to some registered nurses, it would explain why substantial numbers of registered nurses responded to the negative ratings on the scale in particular hospitals.
By comparison, responses towards "wardspersons are always willing to help nurses lift heavy patients" (see Chapter 5, Table 5.34), showed that over 80% of registered nurses from hospitals A, C, and D, and slightiy more than half the hospital B nurses, either sfrongly disagreed, or disagreed, with this statement. It was interesting to note, that the majority of nursing students also responded in a similar manner, with more first year 284
sttidents agreeing than the other two groups of students. The reason for the majority of nurses believing wardspersons not being willing to help, may weU be explained by the reasons offered for die above statement.
The question, "nurses are often injured due to the poor design of the environment" was addressed in Section 6.4 (which examined the influence of environmental inputs for hypothesis two). It would appear that these data also support the influence of organisational processes and highlights the interactive nature of inputs and processes as articulated in die dieoretical model.
6.7.1 Summary
Although fewer statements have been presented in this section for the support of organisational processes, it is clear, many of the inputs and processes already presented interact with each other to effect accident/injury causation, and organisational processes appear to conttibute to the accidentAnjury sequence.
6.8 Client/Patient Centred Processes and their Effect in the Accident/Injurv Causation Sequence.
Section 6.8 presents the argument that examines nurses' attitudes towards physical injury, verbal and physical abuse, and infectious diseases and how they contribute towards client/patient processes.
Evidentiy a substantial number of registered nurses in this study had been physically 285 injured by a patient, ( see Chapter 5, Table 5.35). Almost 50% of registered nurses of hospital A, and over one third of registered nurses from the other three hospitals indicated this to be the case. A surprisingly high number of nursing students, considering their relative lack of exposure to the clinical area, also stated they had been physically injured by a patient, (that is, more than 10% of first year students, 13% of second year students and slightiy more than 20% of third year students). These data are similar to Wills, (1987) who found that 31% of registered nurses in his study had been physically injured. The mean average for registerednurse s from all hospitals in this study is 39%, which is sUghtly higher than the findingsb y Wills. Physical injury appears to present itself as an occupational risk, and this can be explained by, firstly, injuries sustained by environmental factors, for example, an accident/injury sustained by slipping on wet floors. Secondly, an injury may be sustained which has been deliberately perpefrated by some other person, or persons.
The responses of registered nurses and nursing students to the attitudinal statements conceming physical injury, verbal and physical assault, ["nurses are never hit/kicked by patients" ( see Chapter 5, Table 5.39), "sometimes nurses are physically assaulted by theu- patients" (see Chapter 5, Table 5.40), "nurses understand that being hit/kicked is a fact of life , although they do not condone it" ( see Chapter 5, Table 5.41), "It is not unusual for nurses to be verbally abused by their patients" ( see Chapter 5, Table 5.42)] indicated that these areas represented occupational risk factors for nurses.
Almost 100% of registered nurses, and over 97% of nursing students agreed that nurses were hit or kicked by patients, the significant difference between groups could be explained by first year nursing students indicating that they did not know, (p < 0.05). Results from registered nurses' and nursing students' responses when inspected in a two by two contingency table did not reveal a significant finding. A similar response pattem was eUcited for nurses' attitudes towards "sometimes nurses are physically assaulted by their patients", with approximately 95% of registered nurses either agreeing. 286 or sttongly agreeing, with this statement. Again, first year students were inclined to respond that they did not know, demonsfrating a significant difference between die groups, (p < 0.05) and yet when registered nurses and nursing students responses were inspected in a two by two contingency table a significant difference was not apparent. Slightly more than half the registered nurses and nursing students either agreed or sfrongly agreed that "nurses understand that being hit/kicked by a patient is a fact of Ufe, although they do not condone it", however for this variable there were substantial numbers of nurses who also responded to the disagree point on the scale. A significant difference was not elicited for this variable, (p > 0.05) as was the case when registered nurses' and nursing students' responses were observed in a two by two contingency table. Again, there was considerable agreement between registered nurses, and nursing students to suggest that it was not unusual for nurses to be verbally abused by their patients, and interestingly a higher proportion of nursing students than registered nurses agreed, (p < 0.001). When registered nurses' and nursing students' responses were inspected in a two by two contingency table a significant difference was not observed further supporting the sfrong agreement between groups for the positive points on the scale.
It is clear that registered nurses, and nursing students, in this study clearly believed physical injury/assault and verbal abuse were occupational risks, and they regarded it as a significant problem (see Levy and Hartocollis, 1976). These findings appear to support the notion expressed by Lanza, (1984) and Holden, (1985) who argued that assault was much higher than previously believed. It may weU be explained by nurses sustaining these type of injuries from firstiy, caring for "casualties" in accident and emergency departments who are affected by alcohol, and or drugs, and as a consquence become violent and assault nursing staff when tteated. Secondly, because of the nature of some of the diagnoses of patients that are cared for by nurses, (for example those patients who have been diagnosed as suffering from senile psychosis) they may be at risk from aggressive acts carried out by these patients. 287
Registered nurses and nursing students were also concerned about the risk of acquiring hepatitis B and AIDS from a needleprick penettation from an infectious source. Three statements in the OH&SNI canvassed these views. Namely, "nurses worry about conttacting hepatitis B from a needle-prick injury", (see Chapter 5, Table 5.36) "nurses worry about conttacting AIDS from a needle-prick injury", (see Chapter 5, Table 5.37) and "nurses are more concemed about conttacting AIDS from an infectious source", (see Chapter 5, Table 5.38).
On examination of these data, clearly most nurses in this study were concemed about these issues. The majority (80%) of all subjects were worried about contracting hepatitis B from a needle-prick injury, and it is interesting to note how few registered nurse were immunised against hepatitis B, (see Section 6.5), consquentiy these results are not surprising. Over six sevenths of aU groups of nurses were also concemed about conttacting AIDS from a needle-prick injury (see Neilson, 1988). Three quarters of the subjects in this research were more concemed about conttacting AIDS froma n infectious source, than hepatitis B, even though AIDS is recognized as a lower risk factor ( see Lifson, et. al., 1986; Koltz et al., 1986).
An explanation of why all groups of nurses in this study were concemed about conttacting AIDS, regardless of the relative risk, probably reflects societies' attitude as a whole, in that most individuals appear to be fearful of conttacting AIDS. The attitude expressed by nurses may well be explained by a lack of knowledge associated with conttacting AIDS. It is clear, that many nurses in this study have also not been privy to information about hepatitis B and AIDS (see Chapter 5, Table 5.16). These reasons explain cogently why nurses in this study may well be worried. 288
6.8.1 Summarv
The evidence presented in section 6.8 cogently shows that nurses are concemed about physical injury/assault and verbal abuse. Substantial numbers of registered nurses (39%) indicated they had been physically injured by a patient. Physical assault was rated by almost 100% of the registered nurses in this study, and 97% of nursing students, as constituting a problem. Verbal abuse was also believed to be a common occupational hazard encountered by nurses.
AIDS and hepatitis B were also explicated by nurses to represent occupational risk factors. Three quarters of the nurses in this study were more concerned about conttacting AIDS, than hepatitis B from a needle-prick injury, however, conttaction of hepatitis B by needle-prick and needle-prick injuries generally, were nominated by large numbers of nurses in this study as areas for concem. These factors appear to support the notion that nurses believe client/patient centred processes contribute towards accident/injury causation.
6.9 Nurse Centred Processes and Their Perceived Contribution Towards Accident/Iniurv Causation
This next section examines the notion that nurse centted processes contribute towards accident/injury causation.
The propensity for registered nurse and nursing students to continue working when injured, (see Chapter 5, Table 5.43) suggests that relatively few nurses are inclined to take time off. In fact, 95% of registered nurses from hospital D indicated they had not taken days off and nurses employed in the other three participating hospitals showed that 289 between 63% to 71.7% registered nurses also had not taken any time off work. Sttident nurses, not surprisingly, showed that even fewer numbers had taken days off for these reasons, (p < 0.0001). Registered nurses appear reluctant to take time off, and these reasons may include, "alttnism", "dedication" and perhaps "fear of management retribution", ( see Appendix A and B). Because nursing students are expected to attend 100% of their cUnical experience in the hospital, or community setting, or make the time up, may well be motivated to attend regardless of how they feel. They may well be motivated to attend because of dieir interest.
The question that addressed entitiement to claim workers' compensation (see Chapter 5, Table 5.44) revealed that almost 20% of registered nurses in this study were so entitied, but had refrained from claiming. It was surprisingly, given their relatively small exposure to the clinical area, that 3.8% of first year nurses, and 4% of third year students had also neglected to claim for compensation. There was a significant difference elicited for this particular variable, ( p < 0.0001). Reasons why this may be the case for registered nurses may be due to firstiy, fear of prospective employment, or of continued employment, (see Chapter 5, Table 2.1). And secondly, it may be that registered nurses use thefr sick leave for injuries that may be compensatiable (Bmce and Mancy, 1982).
Over 70% of registered nurses in this study had completed patient accident forms, in contrast to 16% nursing students who revealed that they had received very Uttie experience, (see Chapter 5, Table 5.45). A significant difference was elicited for this variable, (p < 0.001). It would appear from the low numbers of nursing students indicating they had this type of experience there was a need to provide students with some insttniction in this area during their educational course, for example, it would be appropriate to include it during care of the safety needs of patients. 290
As reported in Section 6.3, back injuries represented an occupational health hazard for nurses, and when further questioned about whether nurses had to lift patients that were too heavy for them, ( see Chapter 5, Table 5.54) over three quarters of the registered nurses and nursing students agreed it was the case. There was a significant difference for this variable, [(p < 0.001) (as was the case when registered nurses' and nursing students' responses were observed in a two by two contingency table)] which can be accounted for by larger numbers of first and second year nursing students who nominated "agree". These data support the earlier findings (see Section 6.3). Ninety -five percent of the nurses in this study indicated that back injuries were a problem for nurses, (See Chapter 5, Table 5.55). A significant difference was not elicited for this statement, ( p > 0.05) and this finding was supported when registered nurses' and nursing students' responses were observed in a two by two contingency table. Because nurses often lift patients that are too heavy for them, it would appear reasonable to expect that this may conttibute to back injuries, and supports die findings by Watt (1986) who reported on the "staggering weights" nurses lifted during a shift.
Nurses also appeared to be reluctant to report their own accidents/injuries, and similar issues have been addressed for hypothesis 4, (see Section 6.6). Over 70% of registered nurses in this study disagreed that, "other nurses report every personal accident they are involved in" (see Chapter 5, Table 5.56). SUghtiy more second, and third year nursing sttidents, compared to first year students disagreed, however, overall the majority of die responses resembled those of the registered nurses. There were no significant differences between the groups, ( p > 0.05), as was the case when registered nurses' and nursing students' responses were inspected in a two by two contingency table.
Registered nurses were prepared to disagree that nursing students reported every personal accident/injury they were involved in, (see Chapter 5, Table 5.57) with over 65% of all registered nurses beUeving this to be tme. It may well be difficult for registered nurses to make an informed judgement on this issue, as they would have had 291 limited exposure to nursing students from the tertiary style of education. This may well be explained by firstiy, nursing students not working directiy under tiie conttol of the nurse unit manager, but rather under the dfrection of the university nurse lecturer and therefore nurse unit managers not being aware of the incidence of accident/injury for nursing students. Secondly, registered nurses may weU be makmg uniformed decisions when they responded to the question. A large proportion of first year nursing smdents agreed students reported all their accidents/injuries, however, second and third year students' responses more closely resembled the registered nurses. These data show evidence to suggest that there appears to be some reluctance by students during their formative years being prepared to report their own accidents/injuries. There were no significant differences elicited for this variable, ( p > 0.05). A non-statistical finding was also evidenced on inspection of registered nurses' and nursing students' responses in a two by two contingecy table. This particular question, in retrospect, would have been more properly constmcted if the word "every" had been replaced with a non -absolute term. Rephrasing the question to read, for example, "nursing students report most personal accidents/injuries they are invovled in" would have been more likely to have eUcited a more valid response from participants and dierefore the results woidd have been easier to evaluate. It would be expected that the responses would be possibly biased against the statement when phrased in such an absolute way.
Seventy-nine percent of registered nurses, and 60% of second, and third year nursing students, with slightly fewer numbers of first year nursing students (45%) disagreeing or sttongly disagreeing with " I am never too busy to report my own accidents/injuries" (see Chapter 5, Table 5.58). A significant difference was elicited for diis variable, ( p < 0.001) as was the case when registered nurses' and nursing students' responses were observed in a two by two contingency table. It is not surprising that the majority of registered nurses believed they were too busy to report thefr own accidents/injuries and their responses may be explained by "staff shortages" and "staff freeze" (see Chapter 5, Table 5.1). 292
The questions that pursued whether other nurses had time to report their accidentsAnjuries, (see Chapter 5, Table 5.59), whether nurses always reportedpatients ' accidentsAnjuries, (see Chapter 5, Table 5.60) and whether domestic were more inclined to report accidentsAnjuries compared to nurses, ( see Chapter 5, Table 5.61) showed the influence of nurse-centted processes.
The majority of registered nurses agreed patients' accidents/injuries were always reported and there were no significant differences elicited for this variable, (p > 0.05). When registered nurses' and nursing students' responses were reduced to a two by two contingency table a non-significant result was evidenced. Again these findings re-inforce the notion that patients' accidents/injuries are reported.
Ninety percent of registered nurses, and eighty percent of nursing students, believed domestic staff were more inclined to report their accidents/injuries compared to nurses. However, a substantial number of first year nursing students indicated that they did not know, [ ( p < 0.0001) A significant result was also revealed when registered nurses' and nursing students' responses were observed in a two by two contingency table]. An explanation of why nurses might believe this to be so may be due to firstly, domestic staff are not involved in direct patient care and as a consquence, do not have the same demands placed on them. For example, they have time to be away from the ward to report and treat their accidents/injuries. Secondly, domestic staff may sustain more accidents/injuries than nurses. Thirdly, domestic staff may sustain different types of injuries. The second and diird points require further investigation.
Ninety-four percent of registered nurses, and 94% of nursing students agreed, or Sttongly agreed, diat needle-prick injuries often went unreported. There was a significant difference elicited between the groups, (p < 0.001) ( see Chapter 5, Table 5.46)] and this can be explained by again a substantial number of first year students indicating diat diey 293 did not know. Although when registered nurses' and nursing students' responses were reduced to a two by two contingency table a signficant result was not observed.This latter finding was partially explained due to a large proportion of the participants who supported the statement. These findings support the tiiesis that needle-prick injuries are under-reported, (Hammond, 1983) and this may be due to nurses making judgements about the relative risk of conttacting infectious diseases before deciding to report needle -prick injuries.
Slightly more than half the registered nurses and approximately a third of the nursing students agreed that safety procedures protected nurses from radiation hazards, (see Chapter 5, Table 5.47). There was no significant difference elicited between the groups, (p > 0.05) as was the case for registered nurses' and nursing students' responses observed in a two by two contingency table. This result can probably be explained by patients in the Illawarra Area Health Service, having to go to Sydney for radiotherapy tteatment and as a consquence reducing the risks to the nursing population. The responses of registered nurses and nursing students to the question of whether or not "nurses always followed safety procedures during patients' X-ray examinations", showed that more than half the registered nurses in this study, thought that nurses did not follow safety procedures. There was some division of opinion between registered nurses from hospital D, where slightly more than half the subjects agreed with the statement. These responses resembled third year nursing students' responses (see Chapter 5, Table 5.48). A significant difference was not elicited, (p > 0.05) and this findings was confrimed by registered nurses' and nusing students' responses when observed in a two by two contingecy table. These findings may be explained by individual nurses deciding whether or not to put on a lead apron for protection, or stand behind the screens in the x-ray department whUe x-rays were being taken. These data appear to support the notion that some nurses appear to be "careless" for their own protection, and these findings support "carelessness" as a nurse centted process contributing towards accident/injury. 294
Approximately 95% of all nurses in this study were concemed about the effects of radiation, (see Chapter 5, Table 5.49). These findings could be atttibuted to tiie age of the subjects, as in this study as many subjects are during thefr peak reproductive years and exposure to radiation would constitute a risk. These data would explain why tiiere was no significant difference elicited for this variable, ( p > 0.05) as was the case when registered nurses' and nursing students' responses were observed in a two by two contingency table.
Teratogenic agents were viewed by well over three quarters of the population of all registered nurses and nursing students as constituting a hazard to themselves (see Chapter 5, Table 5.50). There were no significant differences elicited demonsttating the accord between all groups of nurses, (p > 0.05) and this was supported when registered nurses' and nursing students' responses were observed in a two by two contingency table. An explanation for these results may be similar for the preceding variable, as teratogenic are known to have deleterious effects on the unbom fetus, (see Gregory, 1985), and understandably nurses appear to be concemed about these effects.
Chemical agents used for sterilising purposes were also viewed by 80% of all nurses as constituting an occupational risk, (see Chapter 5, Table 5. 51). Nurses have good cause to be concemed about the occupational risks of chemical agents. For example, sfrong concenttations of formaUn are used as a steriUsing agent in renal units and intensive care units to sterilise equipment and accidental spiUs can cause severe chemical bums.
Sustaining bums from sterilisers was shown to be a problem by 77% of registered nurses and 87% of nursing students, (see Chapter 5, Table 5.52). It is not surprising that bums are seen to constitue a problem as firstiy, nurses appear to often bum themselves on autoclaves. Secondly, because nurses are so often in a hurry it was not surprising large numbers of nurses perceived bums sustained by sterilisers as a risk. 295
The statement, "RSI is not a common occupational hazard for nurses", (see Chapter 5, Table 5. 53) elicited some division of opinion between nurses. Approximately 63% of registered nurses from hospital A, chose negative ratings, in conttast to nurses from hospitals B, C and D, where the majority of nurses chose positive ratings. Students' responses also varied, with first and third year students sttongly agreeing, or agreeing, however, the majority of second year students disagreed or sttongly disagreed, [(p < 0.001), although the responses of registered nurses and nursing students when observed in a two by two contingency table were not significant). These responses may well be explained by, firstiy RSI may not include the types of repetitive skills requfred by keyboard operators. Secondly, it may be that other injuries disguise RSI. For example, nurses appear to be more inclined to sustain back injuries which may mask RSI. These findings suggest the need for more research in this area.
6.9.1 Summary
Nurse centred processes have been isolated as pervasive influences in the accident/injury causation sequence. Certainly nurses appear to be reluctant to take days off for accidents/injuries, and to claim workers' compensation. It was clear, that nurses believed back injuries constituted a problem, and nurses uidicated they were reluctant to report their own injuries. It was interesting to note 90% of registered nurses and 80% of nursing students believed domestic staff were more inclined to report their injuries compared to nurses.
Particular nurse centted problems and hazards that were isolated by nurses in this research, included needle-prick injuries, hazards associated with patients' x-ray procedures, teratogenic hazards, problems with chemical agents used for sterilising purposes, and sustaining bums from sterilisers. 296
6.10 The Reliabilitv Coefficient of the OH^SNT
The results for the overall reliability coefficient is reported in Chapter 5, Section 5.7. The overall split half coefficient for the OH&SNI using Cronbach's alpha (r = .80) was "satisfactory", given it reflected the reliability of the instilment for the two groups of subjects in the study. It shows a "satisfactory" degree of intemal consistency between the two groups (see Anastasi, 1976). The reUabiUty coefficients for subjects from Hospital C (r = .88) and hospital D (r = .86) were "very good", and satisfactory for Hospital A. A possible explanation for the relatively low correlation coefficient for Hospital B (r = .71) could be due to the comparatively small sample size.
A standardised procedure for instmctions and administering the OH&SNI were maintained for three of the four hospital staff samples , with the exception for Hospital D. Administtative reluctance to allow the researcher to dfrectly address the unit nurse managers as a group at Hospital D meant that instmctions had to be given to the nurse unit managers at the same time as they were given to the rest of the ward staff. Given the "good" reliability estimate for Hospital D, this may provide a possible explanation as to why it was better than both Hospital A and Hospital B.
The rehability estimates for the nursing student groups (see Chapter 5, Table 5.63) were not as high as those for the registered nurses. A standardised format for administtation to the three groups was maintained by the investigator. Reasons for the reliability coefficient not being as reliable for the nursing student group may include, firstiy, the OH&SNI may have been a more appropriate instmment to investigate registered nurses' attitudes and experiences than those of nursing students. Secondly, the nursing Sttident groups included students who had completed at least some part of their nursing education in die ttaditional apprenticeship system and this may have provided a degree of "error variance" which was not conttolled for in this study (see Anastasi, 1976). 297
6.11 Content Validitv
Chapter 5, Section 5.8 provides a summary on the results of the content validity of the items contained in the OH&SNI. A large proportion of the items contained in the instmment received endorsement from the five clinical experts involved in making clinical judgements (see Appendix E). Again the high level of "agreement" by the panel of experts was due to being generated from the registered nurses and nursing students in the open-ended interviews and, consequentiy, content validity would have been an "inbuilt" feature. The two items that received only 60% agreement by the panel of experts were fkstiy, "registered nurses make judgements regarding the seriousness of patients' accidents/ injuries before deciding to report it" and secondly, "nurses are often too busy to report thefr own accidents/injuries". An explanation for why there was less agreement for the ffrst item could be that some evaluators believed registered nurses should not make decisions and the correct procedure was to report the accident/injuries regardless of the seriousness. For the second item, it is possible some evaluators believed the "right" procedure was to report the accident/injury regardless the demands on the nurse's time. In ideal circumstances this would be the appropriate course of action. However the author was investigating existing practices and often the "right" procedure is not always foUowed in reaUty.
In seven of the items there was 80% agreement, and this appeared a reasonable percentage of agreement in that it represented only one of the five evaluators who did not agree.
The overaU agreement between evaluators for items in the instmment established diat the OH&SNI contained content validity . 298
6.12 Summarv
The main results of the investigation can be summarised as follows:
1. Hypothesis 1 was supported by several variables, and showed that there was a need for more information about safe loads to lift and encouraging nurses to use mechanical aides when lifting heavy patients. There appeared to be a need for management to provide in-service education, particularly conceming AIDS and hepatitis B tt-ansmission.
2. Hypothesis 2 investigated the role of environmental inputs into the accident/injury sequence. Legionnaires' disease was perceived as an occupational risk by half the subjects in this research. Anaesthetic gases and dermatitis were nominated as risk factors by a large percentage of the subjects in this research. Wet floors were seen in the opinion of the nurses in this study to cause accidents/injuries, and the poor design of nurses' working environment were also seen to be contributing factors in accident/injury causation.
3. The variables that were investigated for their influence on managements inputs showed that although the majority of nurses in this study were aware of the existence of OH&S committees, the majority of nurses were uninformed regarding nursing representation. Knowledge about occupational health and safety units for staff members was limited. It was alarming to discover that large numbers of registered nurses in this study were not immunised against hepatitis B. There were differences between registered nurses' immunisation pattems in the different hospitals involved in this study, in fact, the number varied between 55% to 87% of registered nurses who were not immunised. These findings suggested a difference in the provision, and or encouragement of immunisation by management from the different hospitals. These results support the interactive nature of this model with management inputs interacting with educational input factors. Adequate staffing was articulated as a problem. 299 particularly in regard to inadequate provision of extta staff to help lift heavy patients. SUghtly more than half the registered nurses in this sttidy believed administtation encouraged nurses to report their accidents/injures, however, there were greater numbers of nurses (approximately 90%) who believed administtation encouraged nurses to report patients' accidents/injuries. However, it appears that administtation may make some decision for nurses accidents/injuries in the reporting process.
4. Social expectations and influences were seen to be cogent factors as postulated in the theoretical model which affected accident/injury causation. For example, nurses believed they were expected to perform nursing care whilst experiencing back pain. It was clear that the majority of nurses in this study reported patients' accidents/injuries however, over 70% of registered nurses agreed that they often neglected to report their own. In conttast, however, there was some difference of opinion as to whether nurses believed thefr colleagues reported patients' accidents/injuries and substantial numbers of subjects indicated they agreed that their colleagues may be less prepared to. The effects of the hospital system on the socialisation of nurses' behaviour, was noted by subjects' responses towards claiming workers' compensation for injuries. It was clear that over half the registered nurses in this study believed they would be disinclined to claim workers' compensation. Clearly, social expectations influenced nurses' behaviour and was demonsttated by nurses' responses towards whether nurses were thought to be malingerers, if they took time off for accident/injuries. Clearly the majority, (more than half the registered nurses in this study) beUeved it was tme.
5. The organisational processes isolated as contributing factors in the accident/injury sequence sttengthened the interactive nature of the inputs and processes in this model. The results revealed that die majority of nurses agreed extta help was not available from wardspersons, however, the majority believed that wardspersons were not always willing to help lift heavy patients. The interactive nature of organisational processes and envfronmental inputs was highUghted by the results of registered nurses' and nursing 300
sttidents' responses towards nurses believing that they often sustained injuries from the poor design of the envfronment.
6. Hypothesis 6 was shown to be supported by several variables, including the substantial numbers of registered nurses and nursing students who had been physically injured by a patient. Verbal and physical assault were seen to be occupational risks by the majority of nurses in this study. Thirty-nine percent of nurses in this study indicated that diey had been hit or kicked by a patient. Again, as was demonstt-ated for hypotheses 1,2 and 3, hepatitis B and AIDS were seen to be occupational risk factors, particularly from needle-prick penefration. These results add further support for the interactive nature of this model.
7. A variety of nurse centted processes were seen to be centtal factors contributing to accident/injury causation and support for hypothesis 7 was confirmed. Very few nurses indicated they were prepared to take days off for work sustained accidents/injuries. Twenty percent of registered nurses in this study who were entitled to claim workers' compensation had not done so. Most registered nurses (70%) indicated they had experience in filling out patient accident forms, however very few nursing students (16%) revealed diat they had this type of experience. It was clear, back mjuries were a major source of concem for nurses, and over three quarters of the registered nurses in this study indicated that they lifted patients that were too heavy for them. Further support for nurses' reluctance to report their own accidents/injuries (see Section 6.6) was highUghted, with the majority of registered nurses disagreeing that nursing students reported all their injuries. Nurses showed that they reported patients' accidents/injuries, witfi the greater number of nurses believing domestic staff were more inclined to report thefr accidents/injuries, compared to nurses. Numerous nurse-centted determinants were seen as occupational risk factors, for example, the reluctance of nurses to report needle-prick injuries was demonsttated, the apparent disregard nurses showed for thefr health, in not following safety procedures while patients' were receiving x-ray 301 examinations, the problem of teratogenic agents, the apparent risk of chemical agents used in sterilising equipment, sustaining bums from sterilisers; all these factors were seen to be occupational risk factors for nurses.
8. Finally, a reliability coefficient was derived and content validity was established for the OH&SNI. CHAPTER SEVEN 302
AN OCCUPATIONAL HEALTH AND SAFETY TNTFRACTTVF SYSTEMS MODFI
7.1 Introduction
This chapter presents data from injured nurses to test the validity of the occupational health and safety interactive systems model, based on the definition of a theoretical model proposed by Chinn and Jacobs, (1983), (see Chapter 1, Section 1.5.4). To test the appUcability of the model the following instrament was developed.
7.2 Instrumentation
The causative interview insttument was constmcted based on the inputs and processes articulated in Chapter 1, Section 6.2. Socio-demographic information was sought from injured nurses, to elicit information regarding the nurses' position, clinical setting, age, gender, years as a registerednurs e and nursing qualifications. Data involving the injury was also sought and the injured nurse was asked to relate the time and type of injury. The injured nurse was then requested to describe in her/his own words the sequence of events that led to the injury, including details about the actual injury. The injured nurse was then asked to include what they beUeved to be the principle causes. Further information was sought regarding educational factors, and six questions pursued whether these inputs affected the injury. The following section investigated envfronmental factors and contained four questions. Contributing social factors and thefr influence included three questions. The influence of cUent demands or processes contained three questions. Organisational demands contained a series of seven questions and finaUy nursing processes contained five questions (see Appendix K). 303
7.3 Selection of Subjects
The selection of injured nurses was carried out in collaboration with the Illawarra Area Health Service. Due to the confidential nature of the information conceming workers' compensation, and generally, the difficulty in securing accurate data from hospitals, die foUowing method was instituted. The personnel manager of the Illawarra Area Health Service mailed the instmment, designed by the investigator, with a pre-paid stamped addressed envelope, to all nurses whose employer had received workers' compensation for time taken off work as a result of a work sustained injury during the last twelve months. The instmment was coded to ttace the hospital were the nurse sustained the injury. However, the identity and address of the subject was not revealed to the author. A letter was included to explain the relevant details about the research, and information regarding how to fill out the form. The personnel manager also included a letter with the instmment to explain how the process of confidentiality was being maintained.
7.4 Demographic Data
Seventy-two injured nurses were selected, comprising the total population of injured nurses within the Illawarra Area Health Service. It was revealed from the computer search carried out by the personnel department, that the injured nurses were employed in eight locations. These included the five hospitals involved in the pilot study and main research project. The diree additional locations included three hospitals with very smaU numbers of registered nurses, two of which were speciality hospitals, and one a 20 bed community hospital which also provided a community service to patients in thefr homes.
The response rate for this part of the study was very poor. A foUow-up letter was mailed to die subjects two weeks after they received the form. In total 16 forms were completely filled in. However, it became apparent that some of die subjects had moved 304
from the address held by the Illawarta Area Health Service as 4 unopened envelopes were retumed to the investigator marked "address unknown". The response rate consisted of 23.5% (this number included 16 subjects' forms, less four forms retumed with address unknown leaving a total of 68 potentially accessible subjects). This type of "loss of participants caused by migration" is recognised as a potential major problem with this type of study (Woods in Woods and Catanzaro, 1988, 183). This problem was evidenced in this particular study as some of tiie envelopes were retumed marked "address unknown". It is also possible that other participants may not have received their survey forms.
7.5 Individual Profiles
The present study has reported the perceptions of registered nurses and nursing students towards accident and injury causation. The following section contains case history data and responses to those factors outlined in the model and perceived by injured nurses to be contributing factors towards accident/injury.This part of the study aimed to test the vaUdity of the model rather than coUect comprehensive data on accident/injury statistics, as insurmountable problems presented themselves associated with client confidentially and diefr legal rights to anonymity. The difficulties involved m collecting data on a local level for this part of the study were considerable. However, when statewide or Ausfralia wide data collection was investiagated die problems appeared insuperable, particularly so, as only a single investigator was involved.
INOl This subject is a registered nurse who was working in die accident and emergency department at the time the incident occurred (approximately 1 am). She was 35 years of age at the time of the incident and she had been working as a general nurse for thirteen years. The subject stated that the incident that had occurted was "verbal abuse" and noted it had commenced when the patient was brought to the accident and emergency department by friends, after having been involved in a fight. On admission the patient 305
was hyperventilating, seemingly affected by alcohol, threatenmg violence and exttemely aggressive. The subject related that the patient proceeded to "use the most foul gutter language which was directed at me", she further indicated that abuse and foul language were common occurrences in the accident and emergency department. In responding to the questions posed in the form she stated that the principle causes of the incident appeared to be due to alcohol and aggression.
The subjects' responses to possible educational needs requfred to reduce accident injury causation showed she had not attended in-service courses on coping with aggressive patients. However, she did not believe there were any envfronmental factors operating at the time of the incident. She noted several social factors that appeared to be operating at the time, namely, she believed she was expected to "carry on" regardless of the risk to herself, and that she attended to the needs of the casualty ffrst before her own. The subject noted several client/patient processes which appeared to be operative at the time. Firstly, she saw herself in the "helper" role at the time of the incident and secondly, she stated that the patient was demanding. In terms of the organisational demands the subject believed herself to be responsible for "harmony" in the ward at the time, however she noted that the ward appeared to be adequately staffed at the time. Responses towards nursing processes showed that the subject believed she was risking her healdi due to the patients' violence.
IN02 A more dramatic sequence of events was reported by this subject compared to the previous subject. She stated her age as 44 years, and recorded that she had been employed as a general nurse for 22 years. The type of injury recorded by the subject as having had occurred was "punched and verbally abused" and she indicated that it had occurred on "night shift". She related tiiat while she was standing next to patient in a bed in the accident and emergency department, the patient who was an overdose suddenly and without waming began to "punch at her" and verbally abuse her. She 306
believed the principle cause was due to the patients' alcohol intake and bemg overdosed on dmgs. Similarly to INOl, this subject also recorded that she had not attended in-service courses on coping with aggressive patients and beUeved that lack of education in "handling" such patients contributed to her injury. Again a similar response was noted for environmental inputs with the subject stating that they appeared not to have conttibuted to the injury. The social factors seen by the subject as having contributed to the assault paralleled the previous subject, with this subject also noting that she felt obliged to "carry on" regardless of the risk, and that she had attended to the patients' needs first before considering her own. She also believed that cUent demands placed her in the "helper" role, and that the patient was demanding. In conttast to the previous subject she did not believe there were any organisational processes effective at the time of the injury. She believed she was risking her health at the time of the injury.
IN03 In conttast to the two previous case histories this particular subject was assaulted by a member of the public who was not a patient. The subject stated that she was 24 years of age at the time, and had been employed as a midwife for a period of four years in a maternity ward. She recorded the time of "assault" as 10.40 pm. The subject was approaching her car having completed evening shift when she was approached by a man in die car park who grabbed her arm. She swung around and hit him in the face with her keys, kneed him in the groin, and then proceeded to get in her car and drive home. Similarly as with the two previous subjects, she indicated that she had not attended in- service on courses in coping widi aggressive patients or persons, however, she reported on the need for in-service courses on self protection although under the circumstances she showed effective self defence responses. She believed there were environmental factors that conttibuted towards the assault and she noted the absence of a well Ut car park and numerous bushes which aUowed the assailant to hide behind. 307
IN04 This particular subject stated she was employed in the intensive care unit, 28 years of age, and had been working for 10 years as a general registered nurse with an intensive care and midwifery certificate. The injury she had sustained was a back injury. She recorded the event as having occurted while she was holding the leg of an unconscious patient for a physiotherapist who was applying a long leg plaster. The injury occurted because the subject was required to stand in one position for some length of time and as a consquence strained her back. She recorded on the data gathering instrament that she continues to suffer sciatic pain from "time to time" since the injury took place.
Her responses to the need for educational inputs showed that the subject had not attended in-service courses in prevention of back injuries or back care programmes, nor had she received any instraction or re-inforcement in the use of mechanical aids. This subject believed that the design of the physical environment contributed to her injury and she recorded the foUowing comment," If there had been more suitable equipment to make it easier to apply the plaster cast, for example a bed that gives easy access to holding the leg it probably would not have happened". As with the previous subjects, this subject also believed that social factors influenced her injury and that she was obUged to "carry on" regardless of the risk to herself, and that she attended to the patients' needs first rather than her own. She perceived herself to be in the "helper" role at the time of the injury and that organisational demands made her responsible for "harmony" in the ward at the time. She recorded nursing processes that were operating at the time where due to pressing demands on her time she risked her health.
INQ5 This subject was a registered nurse, 30 years of age, worked in the operating theatte and had been a registered nurse for nine and a half years. She possessed a general nursing certificate and intensive care certificate. The type of injury sustained was a lower back injury. Apparently the original back injury occurted two years ago during a game of squash. The current injury was sustained when a patient who was 308
ventilated, disorientated and confused needed to be lifted up in the bed. A colleague, a male registered nurse of similar build and height helped widi the Uft. During die Uft tiie patient "stiffened up" and thrashed around. As a result she injured her back. The principle causes according to the subject were due to the patients' disorientation, confusion and resistance. In the recorded interview the subject stated the educational factors lacking that may well have conttibuted to the injury were non-attendance at occupational health and safety courses. She indicated she had received msttiiction in tiie use of mechanical aids in 1983. Environmental factors did not appear to influence the outcome, however, client processes appeared to contribute with the subject noting she was in the "helper" role at the time the injury occurted. She did not believe there were any organisational or nursing processes operating at the time.
IN06 This particular subject also sustained a lower back injury. She was working in the matemity ward as a pupil midwife when she sustained the injury, was 27 years of age and had been working as a registered nurse for two years. The injury occurred at 8 am while she was changing a baby in a cot in the nursery. As she bent forward she tumed to the left slightly, and reached forward, as she did so she felt the muscles in her lower back spasm. She indicated that the principle causes appeared to be due to oversttetching and tuming without moving her feet. She indicated that she had recently attended in- service coittses in lifting and back care (in fact one week before she had recorded this interview, October 1989, but not before the injury occurted), during which time she received instmction and re-inforcement in the use of mechanical aids. Environmental factors, in her opinion, had contributed to the injiuy, as did the design of the cots, which made managing the baby awkward. Client demands were also seen to be contributing factors, with her in the helper role at the time of the injury and other patients being particularly demanding at the time. Social factors were also seen to be contributing factors, with the subject stating she believed the patients' needs influenced her in attending to thefr needs first before her own. The nursing processes she indicated conttibuted to the cause of her injury was the need for her to " hurry". 309
IN07 This subject also reported events that led to a back injury. The nurse was 24 years of age and working in a surgical ward at the time of the injury. She was a registered nurse and had been employed in this position for three years. The injury occurted during lunch time on day shift while she was assisting a patient with an enrolled nurse. They were helping the one day post-op patient out of bed when she fainted. While the subject "lowered the patient to the floor and then twisting to lift her back into the bed" she sttained her back. She believed she twisted and Ufted the patient from a poor position. The lack of educational factors she believed conttibuted to the injury, included non-attendance at occupational health and safety courses, no participation in lifting and back care programmes. She indicated she had attended instraction in the use of mechanical aids from a wardsman, however, that was after the injury had occurted. The environmental factor she nominated as having contributed to the injury, was the poor design of the physical environment, and she beUeved the injury would not have occurted if the bed had been closer to the ground. She saw herself in the "helper" role at the time of the injury and indicated that other patients were demanding. The organisational processes she saw contributing to the injury, were the need to make decisions hastily due to patients needs, that the ward was not adequately staffed with registered nurses or support staff. She believed she risked injury because of pressing demands on her time.
IN08 This subject was a registered nurse who worked part-time in a surgical ward. She stated her age was 31, and she had been working as a registered nurse for ten years. Her nursing qualifications consisted of a general and geriatric certificate. Her injury was sustained at 10.30 pm and the type of injury was muscle sfrain to tiie lower back. The injury occurred when she dropped a small articile which rolled under the patients' bed, after rettieving it she stood quickly and sfretched to change an inttavenous flask. At that 310
time she felt a sharp pulling to the right of her lumbar region. She stated she dismissed the thought of injury at the time, as the shift was due to finish and it wasn't until she tiied to get into her car that she realised she had damaged her back. She believed the principle causes were due to sudden standing and sttetching. On tiie data sheets she recorded various educational deficits she believed had conttibuted to the injury, she indicated that she had not attended occupational health and safety courses or in-service in lifting, back care or participated in instraction in the use of mechanical aids. Contributing environmental causes she noted were the poor design of the environment and at the time of the injury she suggested that the "giving sets" that the hospital was using had a faulty adjustment clip, and that the ball adjuster was constantly falling out, and it was the ball she was searching for at the time of she sustained the injury. She also nominated two social factors she thought contributed to the injury, namely she beUeved she was obliged to carry on regardless of the risk to herself and that she had attended to the patients' needs first rather than her own. She added one other comment under social factors, namely," at the time of my injury the area in which I was working had a high percentage of heavy dependant patients". In terms of client processes, she nominated that the other patients were demanding at the time of the injury. She stated there were various organisational processes operating namely, she believed she was required to make decisions hastily due to patients' needs, that the ward was inadequately staffed with both registered nurses and support staff. The nursing processes that appeared to contribute to the injury in her opinion were pressing demands on her timean d that fact that she was in a hurry as weU.
IN09 This was the sixth subject to record data that indicated she had sustained a back injury. She was working in die oncology/haematology ward and was 49 years of age at the time of the injury. She had been a registered nurse for seven years. This subject experienced back pain when she lifted a heavy patient with the pain becoming progressively worse over a period of two weeks during which time she worked in the ward. She was given three weeks sick leave (workers' compensation) to recoven The 311
subject recorded that after she had sustained the injury she received a two hour lecture on back care. In responding to the question that asked "are there any lack of education factors believed to have conttibuted to the injury, the subject (not surprisingly) recorded that she would have benefited from continuing back care courses before the injury occurred plus continuing courses. This particular subject did not nominate envfronmental factors as contributing causes, however, several client demands were nominated. For example, the subject saw herself in the "helper role" and believed the patient and other patients were demanding at the tune of the injury. Again a similar ttend for organisational factors became apparent with inadequate nursing and support staff bemg available. Social factors conttibuting to the cause also reflected a similar pattem to other subjects responses, namely, she believed she was obliged to "carry on" regardless of the risk and she attended patients' needs first rather than her own. At the time of the injury she perceived she was risking her own health and recorded the following comment; " I felt it was my duty to stay working because of staff shortage and would have felt guilty if I'd gone off sick, "having let the side down".
INIO This registered nurse was 50 years of age and had been working as a registered nurse of seven years. She was a registered nurse and had a post basic geriattic certificate. An injury to the lower lumbar vertebrae and sacram displacement occurred when she was lifting a very heavy patient with another nurse back into the chair after the patient had slipped down. The subject reported that the injury had occurred twice since this particular one, (febraary, 1988) and all concemed lifting patients back into bed or in and out of chairs. She believed that the principle causes were due to the patient being too heavy and very awkward and the lifting partner not being sttong enough. The subject indicated that she had not attended any occupational health and safety courses and stated that the hospital she worked in did not have mechanical aids to assist staff lift patients. She indicated that she had been present when mechanical aids were demonstated at a recent conference, and that she had taught herself how to lift cortectiy. Envfronmental factors were viewed as major contributing inputs due to the poor design 312
of chairs, beds, toilets and the lack of width of doors. Inadequate maintenance of equipment was also seen as a conttibuting factor with chafrs that did not wheel properly and water cushions not being maintained and causing slipping. The social factors present consisted of being obliged to carry on and that the patients' needs where attended first. Client demands were also perceived as contributing causes, with the subjects finding herself in the helper role and odier patients bemg demanding at the time of injury. Organisational demands appeared to be present as she viewed herself as being responsible for harmony in the ward. Management factors appeared to contribute with "the high and heavy workload, not enough staff, no Ufters, neither mechanical or human, for example a wardsman". The subject "accepted" that she risked injury and stated " every time we lift a heavy patient with another person we accept we could be risking an injury". She confirmed that she believed she risked injury due to pressing demands on her time and other factors she perceived as contributing were;
"I have since leant because of my injuries, that I am more susceptible to back injuries when the staff including me are under sttess, due to heavy workload, not enough staff, emotional sttess due to type of nursing, conflict with other staff and administtation, and in these situations my back gives up and while these situations continue to exist despite keeping myself fit, doing regular exercise, not having mechanical lifters, or sufficient staff when needed, or staff support, I am aware that we nurses are going to be continuously injured in doing our job."
INll This particular subject received her injury during a patients' cardiac artest. At the time of the injury she was working in the accident and emergency department, she was 33 years of age, and had been working as a registered nurse for two years. She had a general, first line management and accident and emergency certificates. The timeo f the injury occurred at 10.30 pm and the injury resulted in soft tissue braising, sweUing and abrasions to the left hand. The injury occurted subsquent to die third cardiac arrest in the space of 20 minutes, and because of this, there were insufficient ttoUeys to accept tiie patient. Whilst the subject was wheeling the trolley in from the outside coridoor, a faulty wheel caught on the ramp and the door swung back, and caught her hand between the door and the ttoUey. She believed the principle causes of the injury were 313
due to faulty equipment, badly designed access to the accident and emergency department and lack of ancillary staff to assist with bed moving. In her recorded interview the subject indicated that the hospital did not provide any occupational healdi and safety courses generally, or in-service courses, although during her nursing training (1985) she had attended a seminar on coping with aggressive patients. She believed envfronmental factors conttibuted to her injury, as the doorways were narrow and it was difficuh to negotiate corridors due to sharp comers and sloping ramps. Social factors were also seen as contributing causes. Firstly, she beUeved she was obliged to carry on regardless of the risk to herself. Secondly, that she attended to the patients' needs first before her own. These last two determinants appear to be common factors between subjects. As do the following client processes, namely she also found herself in the "helper role", with the patients and other patients demanding her attention at the timeo f the injury. According to the subject, organisational factors contributing towards the injury, consisted of inadequate nursing and support staff, and lack of serviceable equipment. Nursing processes operating at the time of the injury were the pressing demands on her time.
IN 12 An intta-muscular needleprick injury was sustained by this subject. She was working in a surgical ward, was 39 years of age and had graduated with a Diploma in AppUed Science (Nursing) two and a half years prior to the injury. She was resheathing a needle and was in a hurry at the time of the injury. The risk of AIDS or hepatitis B immediately crossed her mind, but because the patient was a woman and was middle aged she consoled herself with the fact that the chances of conttacting a disease was remote. The subject indicated that she believed the principle causes were due to not being careful enough and was not aware at the time that needles should not be resheathed. The lack of educational factors contributing to the injury appeared to be lack of knowledge related to procedural techniques. She believed that in-service and or lectures in "safe practices in the workplace" should have been given to all new staff. She was concemed about the risk of acquiring an infection, in particular AIDS. She 314
indicated tiiat the ward was not adequately staffed with registered nurses, and that she was in a hurry at die time she sustained the injury. Additional factors perceived by the subject as conttibuting aspects were her mexperience and short staffing of the ward.
IN13 This subject indicated she was classified as "thereafter" , was 31 years of age and was working in a general ward at the time she broke her toe. The accident occurred when she attempted to pick up a heater as it had fallen on its side. As she proceeded to pick it up, it slipped on its' wheels and fell onto her big toe causing a fracture and a laceration. The main contributing factor according to die subject was environmental, in that the heater was very poorly designed, dangerous and unsafe. She also believed she was obUged to "carry on" regardless of the risk to herself and that she believed she attended to the patients' needs first rather than her own.
IN14 He was a subject who recorded the only motor vehicle accident found in the data in the retumed interviews. He was 41 years of age at the time of the accident, and had been a registered nurse for thirteen years. The nursing qualifications consisted of a mental retardation certificate and programme officers certificate. The injury occurred at 11.05 am on his way to work and the type of injury was a whiplash. He apparently crashed his car into the rear of another car which had stopped while waiting to tum right. The sudden stopping of the car propelled him forwards until resttained by the seat belt, which caused the injury to his neck. He related the principle causes as firstly, it was raining at the time of the accident. Secondly, the driver of the other car did not signal his intention to tum right until the last moment. Thfrdly, the brakes on the car locked. Due to the nature of the accident the subject did not fUl in the rest of the form as the accident did not occur within a nursing environment. IN15 A graze and haematoma to the right shin and leg were sustained by this particular subject, who was a psychiatric nurse, 39 years of age and had been employed for six years as a nurse. The injury occurted when she caught her leg on an angle of iron on one of the patients' bed when she fell after fixing a caught blind cord. The main 315
contributing factor according to this subject were environmental as the design of the blinds were "useless" as they were matchstick blinds with cords diat didn't work. She was concemed that she might have been risking possible hepatitis B as she was unvaccinated at the time of the injury. She indicated other patients were demanding and organisational factors contributed as she was responsible for maintaining "harmony" at the time. She also stated that she believed the injury occmred because she was in a hurry at the time.
IN16 The injury sustained by this registered nurse, reflected the additional risks encountered by nurses who work in the community as well as the hospital. The subject was 57 years of age and the time of injury occurted at 10 am, and consisted of a "dog bite". She described the sequence of events that led to the injury as having occurred when she entered the patients' yard. The dog was apparently loosely tied near the back door of the patients' house when it pulled itself free and bit her, inflicting a deep laceration to her ankle. In the recorded information, the subject indicated that she had never attended occupational health and safety courses in any area which included coping with aggressive patients (but not dogs). Her responses were similar to registered nurses who had sustained injuries in a hospital setting and she suggested that envfronmental factors were significant causative factors which led to her injury. She stated that the address she was given was incorrect and that she was concemed about acquiring an infection due to the injury she had sustained. Again similarly to the other subjects who had sustained injuries within a hospital setting she noted that certain social factors contributed towards the injury namely, she attended to patients' needs first, before her own and that client processes were centtal to the events that led to the injury, namely, she saw herself in the "helper" role and she found the patient demanding. The organisational processes she perceived as conttibuting towards the injury were the need to make decisions hastily, that there was insufficient nursing and support staff and she beUeved a significant conttibuting factor was the lack of staff which caused her to attend to a patient that was not on her case load. Again this subject believed nursing 316
processes conttibuted to her injury and firstiy, it was her belief that she risked her health at the time of the injury. Secondly, that there were pressing demands on her time.
Thirdly, that she sustained the injury because she was in a hurry. Fourthy, that she was obUged to carry her own case load plus that of one of her colleagues.
7.5.1. Non-Responders
Investigation of non-responder bias was reported in Chapter 4, section 4.7.4. The method adopted was a modification of the procedure reported by Stubbs, et al., (1986,
328-330). For this particular part of the study information regarding nurses' injury statistics from the participatmg hospitals was sought in order to compare die prevalence of different types of injuries. Unfortunately most of the Dfrectors-of Nursing were not able to provide the investigator with this information. However, "Injury Reports From
Hospital D for registered nurses 1984 to 1985" were available and the results are
Ulusfrated in Table 7.1. It should be noted that the injured nurses in this part of the study were awarded compensation although hospital injury data cited in Table 7.1 does not necessarilarly reflect those, if any, registered nurses who were awarded compensation for thefr injuries.
TABLE 7.1 INJURY REPORTS FROM HOSPTTAL D REGISTERED NURSES: FOR THE YEARS 1984 AND 1985.
Type of Injury 1984 1985 N % N % Needle injury 30 22% 44 24% Eye injury 9 6% 4 2% Back injuries 24 18% 27 15% Bum 12 9% 6 3% FaU 10 8% 22 12% Electtical 0 0 0 0 Head injuries 0 0 5 3% Assault 9 6% 15 8% Limb injury 39 29% 41 22% Odier 2 2% 21 11% Total 135 100% 185 100% 317
It can be seen that for the years 1984 and 1985 back injuries constittited 18% and 15% respectively of reported injuries for registered nurses, it is not known what percentage of these registered nurses applied for compensation. However it is probable that registered nurses would be more likely to apply for compensation for back injuries compared to those sustaining a needleprick injury, unless the patient was known to be hepatitis B or AIDS infected. In the validation study a large number of the retumed survey forms from subjects showed that seven out of the 16 injuries registered nurses sustained were back injuries (or 44% of die total number).
7.5.2 Conclusions An occupational health and safety interactive systems model serves several functions in the analysis of injured nurses responses towards certain inputs, processes and outputs in the accident/injury sequence. The responses of injured nurses (although the responses from injured nurses were small in number) has been helpful both in understanding the appUcation and the usefulness of the model and how multiple causes interact to effect an accident/injury. These findings support the results from the main study, which incorporated the perceptions and experiences of registered nurses and nursing students in formulating die theoretical model. CHAPTER EIGHT 318
RECOMMENDATIONS AND CONCMISTONS
S.l Introduction
In this final chapter, a brief review of the aims and objectives in relation to the findings, together with general interpretations of the study, are presented.
The following cautions need to be exercised with regard to the generalizability of the
findings:
1) The sample of the registered nurses who participated in the survey to elicit their
perceptions of occupational health and safety reflected those nurses from a defined Area
Health Service, namely from five public hospitals concemed with the clinical teaching
programme of the tertiary institution (including the one involved in the pUot study) from
which the study was conducted.
2) The nursing student population was drawn from only one tertiary nursing institution
conducting a nursing programme and causation needs to be exercised when generaUzed
to other populations.
3) Because of the differences within the public hospital health system, those injured
nurses involved in the survey to investigate the validity of the model, may well be
different to injured nurses in other area health services as only a small number of
subjects retumed their form.
From the findings reported for the study, the investigator has been led to conclude that
the main objectives of the study have been achieved.
1. The differences between registered nurses' and nursing students' experiences and
beUefs about the occurtence of different types of accident or injury have been investigated. 319
i. nurses' attitudes towards occupational health and safety issues have been established. ii. nurses' willingness to claim compensation has been investigated. iu. nurses' beliefs about the safe load for lifting have been explored.
2. Hepatitis B immunisation pattems within the registered nurse population has been carried out.
3. The availability and nature of in-service ttaining programmes in occupational health and safety has been investigated.
4. Nurses' knowledge about occupational health and safety committees, (and nursing representation on these committees) within the nurses' professional practice area have been examined.
5. An occupational health and safety interactive systems model has been articulated, supported by hypotheses as well as data collected from injured nurses, and the validity of the model has been established.
6. It has been demonsttated that a suitable research instrament can be designed and used to investigate registered nurses' and nursing students' attitudes and awareness towards occupational health and safety issues. Some modification to the statements contained in the OH&SNI that include absolute terms wUl need to be amended. Adequate rehability and validity constmcts have been determined for registered nurses and nursing students when investigating nursing variables.
7. An insttument based on the occupational health and safety nursing model was constmcted and tested with a small number of injured nurses. 320
Several conclusions and interpretations can be drawn from the study. These are presented with accompanymg discussion of (and in association widi) inferences that can be drawn from the study.
8.2 Investigations
8.2.1 Descriptive Data: Registered Nurses
The findings conceming the registered nurses' descriptive data from the four hospitals involved in this study showed that the positions in the clinical settings, nursing certificates, area of work speciality, secondary and tertiary educational qualifications were quite similar. Both weights and heights showed similar variability for subjects from the four hospitals utilised in the research. Discriminant analyses did not reveal any significant associations between personal characteristics variables and indicator variables for the incidence of accident/injury.
8.2.2 Descriptive Data: Nursing Students
Prior nursing experience and the nature of the experience was similar for the first, second and third year nursing students in the study. As with the registered nurse population, the nursing students' height and weight distributions were similar for the three year groups and a discriminant function analysis did not reveal significant cortelations, between these variables and personal characteristic data. 321
5.3 The Occupational Health and Safety Interactive Systems Model
[ General research question Whether an occupational health and safety system model will explain the genesis of accident/injury causation with multicausal factors contributing towards nurses' accident/injury occurrence.]
An occupational health and safety Interactive Systems Model was shown to be a valid model to explicate accident/injury in the nurses' work environment. The responses from the registered nurses and nursing students in the main study, highlighted the interactive nature of both inputs, and processes, articulated in this model. The data from the individual profiles of the injured nurses validated the need for educational, envfronmental, management and social inputs to avoid accidents/injuries. Injured nurses' responses also showed the efficacy of client, organisational and nursing processes. The protocol analysis from the injured nurses showed it is important to use qualitative data analysis in addition to quantitative data to exttact the inputs and processes involved in accident/injury causation.
The model provides a tool for conceptuaUzing the inputs and processes involved in the accident/injury sequence and suggests ways of preventing accidents/injuries. For example, the need for in-service education to prevent back injuries.
8.4 The Need for Educational Incuts
[Hypothesis 1 Nurses' attitudes towards Ufting patients, availability of in-service education, and loads lifted wiU show a need for educational inputs to avoid accidents/injuries.] 322
The conclusions drawn from subjects in the study as to their opinion for the prescribed load for safe lifting showed nurses generally beUeved the "safe" load was much higher than the legal load (as outUned in The Factories, Shops and Industties Act, 1962 see Chapter 2, Section 2.6.3). The third year and second year nursing student groups showed a better understanding of what constituted a safe load to Uft, in conttast to registered nurses and first year nursing students, (see Chapter 5, tables 5.3 and 5.4). These data show the positive effect of recent educational instraction, combined with supervised clinical experience, as demonsttated by the second, and thfrd year nursing students' knowledge. The findings help explain, why particularly the registered nurses in this study experienced problems with back injuries, given they lift weights in excess of the safe limit and given "wardsmen not available/refusing to help": "against union rales to Uft heavy patients", "lifting unassisted" (see Chapter 5, Table 5.1).
These findings, in combination with nurses continuing to work whilst experiencing back pain, the unavailability of mechanical devices to help Uft heavy patients, and the reluctance of nurses to think about the biomechanics of lifting before executing a lift, explain cogently why nurses exhibit a high propensity towards back injuries. Some of the contributing factors towards why nurses sustain back injuries appear to be associated with lack of appropriate lifting equipment. For example.
"There are no Ufting devices on the ward except the monkey bars on the beds which are for the patients to use. In OT and recovery there is a "roUer" to move patients (from the) ttoUey to the OT bed. Ward 15 and ecu have a lifting device that wUl allow a patient to be Ufted into a badi from a sitting position. However, the only time I have ever used it broke and left the patient up in the afr. It took 4 people to assist the fraU lady down." (Appendix A: Subject 6, 363)
Evidence showed "Ufting heavy patients" and "inabiUty to get help from wardspersons to lift heavy patients" to be contributing factors. Not surprisingly, a large percentage of registered nurses had been exposed to some form of in-service in occupational health and safety related areas. The high attendance was 323
explained by nurses attending fraining sessions during thefr orientation programme and were largely confined to fraditional ttaining areas, for example "fire drill" and "hospital fires" ttaining.
The findings show there is a need for in-service ttaining, particularly education in AIDS and hepatitis B ttansmission routes and possible needleprick contamination. The study has shown these two areas to be a cause of concem to nurses;
" A thing that seems to ran in cycles is staff sticking themselves with needles. There is a risk of people getting hepatitis B and AIDS. You have to mention AIDS as it is a problem everyone worries about. We have young drug addicts who have cellutitis and you never know whether they might have AEDS. Also we have tiiemi n for investigation for yaundice, its generally obstractive gall bladder but it could be hepatitis or anything" (Appendix B: Subject 1, 377)
Evidence also revealed some variation between registered nurses' attendance at lifting techniques in-service and although 70% of hospital A nurses had attended this type of in-service only a littie more than half of nurses from hospitals C and D and less than half of the hospital B nurses had attended. A high proportion of registered nurses had not received back care in-service. Nurses substantiated these findings in open-ended comments, " We don't have any lifting in-service but we have had fire drill and evacuation of patients" (Appendix B, Subject 1, 333).
It would appear from diese findings that an urgent need exists for the frnplementationo f regular and on-going in-service programmes in occupational health and safety education for nursing graduates throughout their career pathway. Manuals for safe practice in lifting techniques and back care also need to be developed and placed in wards and community settings where nurses can have easy access to them. 324
8.5 Environmental Inptfts and Their Contribution Towards Accident/Iniurv Causation
[ Hypothesis 2
Nurses' attitudes towards nosocomial infections, poor equipment and equipment maintenance wiU show that envfronmental inputs contribute towards accident/injury.]
Investigations revealed that there were a variety of factors nurses perceived as constituting environmental risks in their working environment. Legionnaires' disease was seen as a risk by those nurses who worked in the hospital where an outbreak of
Legionnaires' disease was discovered, however, those nurses' employed in hospitals some distance from the outbreak were understandably not so concemed.
Substantial numbers of nurses in this study were concemed about the risk of anaesthetic gases while working in the operating rooms and perceived it as an occupationally linked hazard. Similarily nurses beUeved dermatitis was an occupational risk witii over 90% of all nurses perceiving this to be the case.
"SUpping on wet floors" was perceived as a contributing envfronmental factor towards accident/injury causation. Large numbers of registered nurses and nursing students also believed "nurses were often injured due to the poor design of the environment".
These findings highlight a need for nurses to be consulted and participate in the design of tiieir environment. Nurses, because they work in the environment, have a better understanding of the hazards involved and would be able to inform ergonomists of measures to reduce accidents/injuries. For example: 325
"Another problem is the electtical and oxygen outiets which stick out. There are electrical outlets on one side and oxygen and suction on the other side. I hit my head on it and got a black eye. Caution stickers have been put on them. The person in charge encouraged me to write out an accident form. It really hurt and I broke my glasses; it didn't occur to me to put in for new glasses; I paid for them" (Appendix B; Subject 3, 382)
These findingssugges t nurses need to be consulted in the design of thefr environment, and should be used in an on-going consultative way, to provide feedback to the organisation about hazardous problems in the environment. Further research is requfred to investigate the effects of the envfronment on nurses and accident/injury occurtence.
8.6 The Influence of Management Inputs and their Role in Accident/Iniurv Causation
[ Hypothesis 3
Nurses' attitudes towards occupational health and safety training, hepatitis B immunisation, provision of in-service by management and ward staffing will show that management inputs contribute towards accident/injury causation.]
Ntu-ses' attitudes towards occupational health and safety ttaining was discussed in Section 8.3, and these data show the interactive nature of this particular variable in the accident/injury causation sequence.
The findings conceming registered nurses' knowledge of occupational health and safety committees show a variation in the knowledge possessed by nurses in different hospitals. Approximately three quarters of the registered nurses from hospitals A, and 326
D, and 62% of hospital C registered nurses were aware of OH&S committees, with less dian 50 % of registered nurses from hospital A being aware. Substantial numbers of nursing students did not know. The majority of registered nurses in this study were unaware of nursing representation on occupational health and safety committees, although registered nurses from hospitals B and D were better informed. This is not surprising, although disappointing, as it is usually the deputy director of nursing who represents nursing staff on this committee. It may well be that information is not being disseminated to all levels of staff and these data highlight a need for better communication between management staff and ward staff.
Occupational health and safety units are non-existent for the population involved in this research and it was surprising that a small number of subjects believed such a unit existed. The findingsi n this study suggest there is a need for occupational health and safety units which could operate as a freatment area, a recording/statistical information center, and a centtal education division form which to offer ttaining programmes in occupational health and safety.
The findings for hepatitis B immunisation patterns showed overall low levels of immunisation against hepatitis B. It suggests there is a need for management to monitor immunisation levels and provide staff with information about the advantages of being immunised.
Results clearly showed that in the opinion of the subjects involved in this research, extta nursing staff were not available to lift heavy patients and again given the high incidence of back injuries sustained by nurses, management have a clear obligation to provide sufficient staff.
The majority of registered nurses and nursing students in this study did not fill out an accident form each time they were injured. This is hardly surprising, as minor injuries 327
would not be considered worth reporting and further investigation appears warranted into the severity of the type of accidentAnjury sustained by nurses. It already appears, according to the opinion of nursing students, that registered nurses afready make judgements about the seriousness of patients' accident/injuries before reporting them. Adminisfrative staff appeared to encourage nurses to report patients' accidentAnjuries but less willing to encourage ntu-ses' to report thefr own accidents/injuries. It appears there is some need for administrative staff to be more supportive in thefr attitudes and staff development communication sessions should be provided for management level staff.
8.6 The Influence of Social Expectations and Performance and their Contribution Towards Accident/Iniurv Causation.
[ Hypothesis 4
Nurses' attitudes towards their own performance and social expectations will show that social inputs contribute towards accidentAnjury causation.]
The evidence shows that the majority of registered nurses and nursing students in this study had performed nursing care whilst experiencing back pain. Back care in-service has been shown to be poorly attended or perhaps not provided by management. These data also support the need for on-going provision of back care in-service and longitudinal research is needed to investigate the long-term effects on nurses and preventative sttategies to help reduce the problem.
Social factors appeared to influence nurses in reporting their patients' accidentsAnjuries but not tiieir own, and further studies appear warranted to investigate the severity of accidentsAnjuries and whetiier it is the minor accidents/injuries nurses are not reporting. 328
Clearly nurses did not like to claim workers' compensation and this was further investigated for hypothesis 7. The majority of nurses also perceived that nurses who took time off for accidents/injuries were viewed as malingerers again showing the profound effect of social factors and how they influenced nurses' attitudes. Cortelational research appears to be requfred to more fully investigate the attitude of management compared to the ward staff for these influences.
8.8 The Influence of Organisational Processes and Their Contribution Towards Accident/Iniurv Causation
[ Hypodiesis 5
Nurses' attitudes towards the availability/co-operation of ancillary staff and ergonomic design will show that organisational processes contribute towards accidents/injuries.]
There were some differences between registered nurses from the four participating hospitals and the availability of extta help from wardspersons. Only the registered nurses from hospital B agreed that extra help was available from wardspersons, with 40% of registered nurses from the other three hospitals disagreeing. Third year students' responses reflected those registered nurses from the three hospitals, showing that the more senior students' responses more closely resembled the registered nurses responses rather than the other students. It would appear that research should be institigated into examining wardspersons attitudes and how they perceive thefr role in the workforce.
Responses from registered nurses established that registered nurses and nursing students beUeved wardspersons were not willing to help lift patients. The reasons why this might be so were discussed in Chapter 6, Section 6.7, where it appeared wardspersons believed it was against union rules to lift heavy patients. It is 329
unreasonable to expect that nurses should be prepared to lift heavy patients that wardspersons are reluctant to lift, and research should be carried out to investigate whether mechanical lifting devices are being used by wardspersons.
Poor ergonomic design has been shown to constitute a problem for nurses and this has been investigated for hypothesis two. These findings show the interactive nature of these variables and organisational processes appear to interact with environmental inputs. Longitudinal research should be carried out to investigate managements' attitudes towards environmental factors and organisational processes and how management views organisational processes and systems expectations compared to non-management staff.
8.9 Client/Patient Centred Processes and their Effect in the Accident/Injurv Causation Sequence.
[ Hypothesis 6
Nurses' attitudes towards physical injury, verbal and physical abuse, infectious diseases will show cUent/patient processes conttibute towards accident/injury causation.]
The incidence of physical injury experienced by registered nurses and nursing smdents revealed high levels of physical injury. Not surprisingly, given the findings in tiiis study, the risk of physical injury does appear to be increasing:
"Yeah that reminds me the nursing staff were saying for three days this guy was getting agitated, he woke up and ripped out the drip and got die nurse up against the wall and tiireatenedt o kill her. We got the police in and in the meantime the guy went out through the escape exit and fell three floorsfracturin g his pelvis" (Appendix A: Student 5, 362.)
These comments show cogently that, nursing students, even during the formative stage of thefr educative programme, encounter experiences of physical injury and in 330
some cases assault. One hundred percent of registered nurses and 97% of nursing students in this study indicated that they had been hit or kicked by a patient. Large numbers of registered nurses and nursing students also believed physical injury/assault and verbal abuse constituted occupational risk factors, supporting evidence by Lanza, (1984) and Holden, (1985) who suggested assault was higher than previously believed. Sclafani, (1986) discusses ways of handling physically assaultive patients and nominates protocols for crisis management and interventions that can be applied to nurses working in the general area as opposed to psychiatric locations. These types of intervention programmes could be inttoduced as "Employee Assistance Programs" in the workplace ( see Lockwood and Spickett, 1989).
Registered nurses and nursing students perceived hepatitis B and AIDS as occupationally related risk factors and findings showed high levels of concem expressed by all groups of nurses. Contamination with hepatitis B and AIDS by needleprick penetration was demonstrated as a source of worry, particularly the acquistion of AIDS in this way. In-service programmes and workshops should be designed and implementated, that allow nurses the opportunity to up-date their knowledge skills in these two areas and group discussions encouraged in order for nurses to express thefr fears in a positive, supportive envfronment.
8.10 Nurse Centred Processes and Their Contribution Towards Accident/Iniurv Causation.
[ Hypothesis 7
Nurses' attitudes towards days missed from work, accident form proceedure, compensation claims and work motivation wiU show nurse centted processes contribute towards accident/injury causation.] 331
A high percentage of registered nurses and nursing students indicated they failed to take days off due to accidentsAnjuries. The reason why this might be so have been explored ( see Chapter 6, Section 6.9). Additional studies should be carried out to investigate how nurses use thefr accrued sick leave and whether they use it to recover from accidentsAnjuries sustained whUe on duty.
Significant numbers of registered nurses and approximately 4% of ffrst and third year students failed to apply for workers' compensation even though they were entitied to do so. One student reported being asked to leave thefr part-time job if they were going to claim compensation, (see Table 5.2).
This situation appeared to be encountered by one subject working part-time in a nursing home during their tertiary nursing course. This may well be an isolated incidence, however, from this particular response it appeared this student was discriminated against. Attitudes of management staff were revealed in the interviewing stage of data coUection, for example:
I was in hospital for eight weeks in ttaction and I claimed compo, only doctors bills were paid for (while I was ttaining in the old course), and of course they thought it was all in my mind. At first the x-rays did not show anything and then diey said I had done it deliberately to get out of nursing. They made me feel so guilty and prescribed me a psychiatric consult but he thought I was alright. I kept very quiet about it after tiiat." (Appendix A: Subject 12, 371) These reasons help explain why nurses generally are not inclined to apply for compensation. Further research is needed to compare data from other Area Health Services and other industties to corroborate and compare these findings. Investigations into possible discriminatory action against nurses also needs to be investigated.
The reporting of accidents/injuries showed that most nurses reported patients accidents/injuries but were less inclined or too busy to report their own. Some of the reasons offered for this were discussed in Chapter 6, Section 6.9. It may well be that 332
some nurses' injuries were minor and were considered not worth reporting. By comparison nurses' believed domestic staff were more inclined to report their injuries than nurses were. Further studies appear wartanted in order to compare the types of accidents/injuries sustained by both nurses and domestic staff.
Nurses agreed that safety procedures protected them from radiation hazards however, the majority of registered nurses and third year nursing students did not agree nurses followed safety procedures during patients' x-ray examinations. It was not surprising, therefore, to find more than 95% of all nurses in this study beUeved radiation constitued a hazard. Teratogenic agents were also viewed by over three quarters of the population in this study as constituting an occupational risk. It would be useful to carry out further research as to why nurses' risk exposure to radiation.
Chemical agents used in sterilising procedures were perceived as a potential risk, and over 70% of nurses in this study believed sustaining bums from sterilisers commonly occurted. RSI was not perceived as an occupationally related disorder, ( see Chapter 6, Section 6.9).
8.11 The Reliabilitv Coefficient of the OH&SNI
As outUned in Chapter 6, Section 6.10, the reUability coefficient was rated "satisfactory". It would appear necessary to further test the reliability of the insttument with different categories of nurses, for example, midwives, operating room nurses, community nurses, rather than undifferentiated groups of registered nurses and nursing students as was the case in this study.
8.12 Content Validity The content validity results were generally "good" to "very good". The explanation for tills is provided in Chapter 6, Section 6.11. There were only two exceptions and 333
suggestions have been provided by the investigator to explain why this might be so. 8.1.3 Recommendations and Conclnsinns
The study that has been reported here has highlighted the complex nature of registered nurses' and nursing students' attitudes and experiences towards accident/injury occurtence, and indeed the complexity of accident/injury occurtence (see Arbous, 1951 and Kerrich, 1951). The results have served to indicate, not surprisingly, that student nurses have comparatively less experience in the workforce than registered nurses. However, it became apparent that for many of the attitudinal responses that the third year nursing students more closely resembled registered nurses responses towards attitudinal statements and suggests that the socialisation process from student nurse to graduate nurse, appears to be well estabUshed by the time student nurses graduate. The student nurses in this study have provided a vital comparative group from which to gauge the attitudes and awareness of registered nurses.
The quaUtative paradigm used in the methodology revealed important information about nurses' attitudes that may not have been elicited if quantitative methods alone were used. The two approaches served to draw out supportive evidence for the hypotheses. The case history profiles collected from injured niu-ses also served to provide support for the types of inputs and processes involved in accident/injury and showed the multipUcity of factors in accident/injury causation.
1. The study should be replicated in a different practice setting in order to test the findings that have emerged form the study, and how they might apply to other nursing contexts. For example, different contexts that might be explored are community settings.
2. The model postulated in this study requfres replication and nurses practising in a community setting would be a useful group for testing the models' generalizabiUty. 334
3. Replication would also need to be carried out to support the reliability and validity constmcts reported in the study.
4. Occupational health and safety studies should be incorporated into nursing degree curricula as well as in post-graduate areas for study. Doctoral studies should be encouraged to provide a basis for nursing research in this area.
5. Injury data recorded at hospital level should be centtalized to provide meaningful data, and nurses must be encouraged to report fully to reflect a tme picture of the accident/injury. State and federal statistical data regarding nurses' accident/injury and compensation information should be categorised as a separate sub-set of information that identifies nurses. The information compiled should be available to researchers to support thefr research studies.
6. In-service ttaining workshops in occupational health and safety nursing should be provided for registered nurses in the professional practice setting. These workshops should be provided on a regular basis for nurses as they progress in thefr career path. Training programmes should be made available to nursing staff in a range of topics, (for example, "lifting techniques" and "back-care") to re-inforce basic principles as well as provide information about occupational health and safety regulations and legal implications, understanding that regulations generally reflect the minimum safety regulations required,
7. Safety awareness information should be disseminated throughout the nurses' workplace at "grass roots level" and worker participation should be encouraged at occupational health and safety committee level. 335
8. Occupational health and safety units should be located in all hospitals to provide a combination of educative and preventative fraining programmes, record keeping for statistical analyses, a tteatment and refertal centte for specific occupational health and safety injuries and disorders, and as a counselling service to nursing and ancillary staff.
9. Further research needs to be instigated into the correlation between nurses' sick-leave figures and compensation claims in an effort to examine comparative cost-savings.
10. Ergonomic consultants should consult with and encourage the participation of nurses in the planning and design stages of any new or renovated wards or buildings used for nursing care.
11. Manuals for "safe practice" in related occupational health and safety nursing procedures should be developed by experts in thefr respective fields, (in collaboration with nurses and other appropriate members of the health team). These manuals should be made available at ward or community practice level for nursing staff and ancillary staff. Examples of these, could included, "lifting techniques", "back care", "proper disposal of needles/sharps", "radiation hazards", and "AIDS and hepatitis B education". These packages could be complemented with videos and where such packages already exist, nurses should have access to them through in-service rainmg.
12, Counselling services should be made available for nurses and other staff who are assault victims. These services could be offered via the occupational health and safety units. In-service courses in assertiveness ttaining, protocols for crisis management and intervention of physically assaultive patients, communications skills and stress management should also be offered. 336
13, Orientation programmes afready offered to nurses should be retained as they provide a useful service in the areas of "fire hazard conttol and evacuation procedure". However, within this context, these programmes should be evaluated and adapted according to the curtent occupational healdi and safety regulations.
14. Because the attitudes of registered nurses and nursing students are critical in initiating the design of action to promote a safer and healthier workforce, further detailed research is required into pysical and verbal assault, back injuries, occupational dermatitis, radiation hazards and anaesthetic gases and their long-term effects on nurses' reproductive systems.
Finally this study has explicated an occupational health and safety interactive systems model formulated from empirical research findings and supported by hypotheses and case history profiles collected from injured nurses. A reUable and valid instrament has been designed to investigate the need for educational inputs to avoid accident/ injury, environmental inputs, management inputs, social inputs, client/patient centted processes, organisational processes and nurse centred processes. These inputs and processes demonstrated factors that contributed towards accident/injury causation and highUght preventative measures to reduce accident/injury causation. Data collected from injured nurses established that multiple factors appeared to contribute towards accident/injury causation. Registered nurses and nursing students participating in this study provided comparative information and showed the change in nursing students' attitudes as they became more senior. The results of this study offer practical suggestions and recommendations to provide a safer and healthier working environment for the nurse. 337
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Nursing Students' Open Ended Interviews 355
INTERVIEWS; STUDENTS 1, 2 &3 2pm, MONDAY, 24TH MARCH, 1986.
AU three nursing students had been nursing prior to enroUing m die Diploma of Applied Science course. The students all work at the weekend in nursing positions and are in the second year of the Diploma course.
S1. On Saturday night a patient fell out of bed
S2 Post-op lady feU out of bed, plastic surgery lady who got up to the toUet, she hit the floor and braised her buttocks.
SI. I saw her accident form, no injuries sustained, signature of the nurse. The lady was 35 kilos and she was just trying to get up to go to the toilet. She was very vague. There was no report on the accident form and by looking at it you couldn't tell what had happened.
Researcher: Have any of you experienced accidents?
S3.1 injured my back ffrst about 6 years ago Ufting a very heavy person. Accident form and compensation and in bed for 2 weeks on bed rest on a hard bed, but no problems since. I did have an accident on my way to work. I was riding my bike but no cuts or anything else.
51. I cut my fingers on an ampoule but no form filled in or anything.
52. I've been hit by a patient and kicked in the rightbreas t by a 2 year old kid while giving hun an injection. I got a fat fraumabu t it cleared up. I also bumed my arm on a 356 steriliser (steam) but die wound was okay and I just went to casualty. I had an old bloke who spat at me at the C hospital and it happens every otiier day, he was going through die DTs.
S3. I was attacked by a feUow going through the DTs., he thought I was Japanese and called me a chink it happened in 1979.
SI. Yeah, hemineurin sedation has unproved a lot of that aldiough an "Abo" attacked me and one lady threw me to the floor.
S3. Verbal abuse, recentiy and frequentiy. Paraplegic, 28 years old and very frasttated, he didn't scream and yell but abused me in the nicest way.
SI. Its very upsetting particularly when you are hit.
S3. You can't hit back.
51. I was 2 weeks out of PTS and I thought this patient was unconscious," Buggered if I'm fucking asleep" he said and he hit me in the face and I feU on the floor. I was terrified.
52. If they are "off" now I won't stay in thefr way. I had one patient at PK who slashed her wrists on a brandy bottle, but she was okay when other people were in the room.
SI. What about infections, you interested in that? Researcher: Yes would you like to teU me about them?
SI. MethiciUin resistant staph was a good one, if you cut your fingero n anything you 357 didn't have to work. If people used the proper techniques it is okay but people did get affected by it.
52. To-day there is more conttol due to infection conttol and accreditation aldiough at C hospital we had patients with infectious diseases. One man a homosexual with aU die symptoms of AIDS and we had to put up an IVI and the Dr. had gloves on but I wasn't told anything, you know how to dispose of the needles etc., no private room but we knew and we put him in a private ward. We were put at risk.
53. Before Christmas 7 people with AIDS from the KV commune were admitted and that's putting you at risk. We also had a burglar at work, two, one after drags and one drank that got lost. We've had patients faUing out of bed and the bed rails just give tiiem further to fall.
51. I haven't ever found one who just rolled out, they faU climbing over the top of the raUs.
52. You don't hear them climbing over the rails- then its "NURSE". Fractured femurs (3 in 12 months), head injuries, abrasions.
53. The cardiac beds are better as they are lower and diey don't fall so far. At C. hospital die showers and toUets are near the wards so the patients don't have to go so far and tiiewheelchair s can go in and out easily. The floors have carpet (ffre proofed) and you don't have diis m most places it's good for the staff too. Mostly you get tiles in die toilets and showers which are quite slippery and dangerous when wet. You know most places are like that. The lockers are good but have hard comers and could tear die patients' skin off. If a patient needs sometfiing from die locker we tum the locker around so diey can get to it. The drag cupboard is square and at head height and just where you can walk sfraight into it. 358
51. Drags are in the room, locked in a cupboard in private hospitals as the patients have dieir own drags and so you can't get them mixed up.
52. Sometimes patients are given the wrong TVI fluidso r wrong drag if it is something like vitamin C not to worry.
SI. Sometimes with mixing drags there is nothing written on the injection vial i.e. not enough or too much and you don't know as the bottie is not labeUed.
S3. Patients can go on wrong medications as order is put in the wrong fUe and patient receiving wrong drag.
S2. Ofter the doctor fUls out the order and it is not given.
SI To protect die doctor you even go to the pouit of being dangerous, for example had to replace colostomy loss with IVI fluids but Sister didn't want to ring die doctor at 12 midnight. So as not to disttirb the doctor she ttied to flushdi e fluidsthrough , should have brought die doctor up to resite the TVI. RNs. should be able to recanulate.
52. You know what I saw, a fire escape covered over with junk, boxes of serviettes in behind a mountain of waste. I got it moved,
53, The fire escape is a wide as SI ("she is very slun") and here we are dying to take a patient down it, hopeless you couldn't get a bed out if you tried. 359 51, With smoking okay in the orthopaedic and paraplegic wards but not in any other, 52. Some sneak it. That old bloke with one leg had been smoking and dropped it on the ground there are holes in the matttess and everywhere.
S3 It's part of the admission procedure for patients they know they are not supposed to smoke,
S2 I've seen a ray lamp left on and it bumt the curtains near the patient.
SI. Yeah I've seen it happen too at GH. they have a sloping floor on a verandah. You have got to see it to beUeve it. Unstable patients using walking frames. The beds are too high, one of the commode wheels just droped off and at GH there are 2 floors with 90 patients. Its' reaUy bad you have to get all the patients showered in the moming, its the old system. Nurses feel it is a pain in the bum.
Researcher: Have you had to fillou t many accident forms?
S3. Well yes, you feel so responsible you don't like filling in reports. SI. With the heart tables you jam in an old bloke, who incidentiy is off the afr, his hand was under the table and when we lifted hun I took die skfri of his hand. I was very upset. On the accident/incident forms you fill out the time, date, what I was doing , a description, whether the doctor is notified or not and then you sign it and its wimessed.
S2 One of the common accidents is patients getting scalded because die water is too hot.
S3. That's a healdi commission rale it says die hot water must not be too hot.
S2. WeU ambulant patients go in and bum diemselves on the hot taps and if you leave 360 patients in the bathroom by diemselves some take off by diemselves and fall flat on the floor. You really feel bad, feel responsible.
51. The ttouble is everyone acts Uke a paragon of vfrtue. If something happens full time staff go to matton, if you are part-time staff you may be safe. At TH you had to front up to matton and would she give it to you. Accidents that happen to nurses are mostly back injuries.
52. I've seen 3 or 4 people who have hurt thefr back in 16 years of nursing,
51, I hurt myself but felt okay later,
53. Many times you hurt your back but you just don't tell anyone,
52, A lot of people get into ttoublei f the lift goes wrong.
51. Yes this happened to me I stUl get that sort of back sttain.
52. You need more wardsmen to help lift. Private nursing homes don't have them but you have a Henry Lifter and thats good.
Researcher: Have you experienced any problems with radiation?
SI, I feel I have been exposed to radiation. You have to ask for an apron and some people won't ask for it. They look after the patient first and you get caught before you can protect yourself. One of the problems you come across is the pre-op build up and how you give the patient tiie spfrometer and tell them not to smoke before going to OT but they need to know two weeks beforhand not twelve hours. 361
S2, Need to start before surgery. You know at WH we had a problem with Hepatitis we were barrier nursing the patient with it and the sister told us to be careful and she finished up catching it.
SI. Yes I know this nurse who looked after a patient with TB and she finished up with it she did get compensation though.
S.3 MRSA is another problem and staff get swabbed and you can't be too careful.
Researcher. Thank you very much (there is general agreement tiiey can't think of anything else) 362
INTERVIEWS:Sttidents 4 and 5 (both second year students, with prfevious nursing experience). 14 tilApril , 1986
54, We had a reaUy terrible experience with a bomb scare when somebody rang up and said there was a bomb in the hospital and the patients found out about it. We saw a brown paper bag in the linen ttoUeywit h bits and pieces of wfre hanging out of it. We were petrified and rang the police who came but it tumed out to be a practicel joke carried out by the patients. There was also the timewhe n we were in the medical wing of the psychiatric hospital and a patient escaped fromth e psych ward and he had a knife. He got me by the throat and threatened me. It was a terrible experience I will never forget it.
55. Yeah, that reminds me, the nursing staff were saying for 3 days this guy was getting agiated, he woke up and rippedou t die drip and got the nurse up against the waU and direatened to kill her. We got the police in and in die meantime the guy went out through die escape exit and feU three floors fracturinghi s pelvis etc. The doctors made a big joke out of it, for example, they said things like," had anyone fall for you today."
54. We had a patient who tried to commit suicide by throwing hunself under a bus, he was admitted to the ward witii a lot of mjuries. We were looking after him on the ward and at one stage we found him hanging out on the balcony by his finger-tips. He eventually committed suicide. It was just awful, you felt so helpless.
55. We had three different criminals under 24 hour surveUiance by the poUce. It puts a lot of pressure on you. They used to cut diemselves and put sttaightened out paper clips under tiiefr fingemailsan d tiienwoul d have to come inot hospital to get diem removed surgically. Of course that why tiieydi d it; diey were pretty difficult to look after. 363 INTERVIEW: Student nurse 6 working in die Operating Theafre
SUNDAY 10th August, 1986.
S6. The most common injuries in this area are needle pricks and back injuries. To patients it is mostly falling over when trying to get out of bed due to postural hypotension following bedrest. Accidents to staff are generally reported but simple things like tripping over on a wet floor are not. An incident form is filled in and the nurse in charge and supervisor (nursing) also know. A supervisor will always come and see you afterwards.AU injuries are reported to the Safety Committee.When a staff member does not injure themselves they tend not to report the injury/accident.
S6. Accident prevention; A nurse supervisor will talk about prevention and consquences of injury especially needlepricks. Staff are told not to re-sheath needles.
S6. Staff are taught how to lift properly during PTS by a nurse teacher. However correct Ufting does not teach you what to do if your liftmg partner gives way or the patient moves and thereby alters his centre of gravity. Last year staff tened to lift patients without a second thought and not complain about it- but recentiy staff encourage one another to phone the wardsman. Hinderances to getting a wardsman is the time it takes it always takes ages for one to arrive. No one ever says you can't have a wardsman you just have to have the initative to phone.
S6. There are no lifting devices on die ward except tiie monkey bars on the beds which are for the patients to use. In OT and recovery there is a "roller" to move patients ttoUey/OTbe d Ward 15 and CCU have a lifting device that wiU allow a patient to be Ufted into a bath from a sitting position. However the only time that I have used it it broke and left die patient up in the afr. It took 4 people to assist tiie frail lady down. Hazards to staff members in theafre is the potential to trip over extention cords and suction tubing. Floors in theafre are often slippery 364 and the "over shoes" increase the chance of sUpping. I requested not to work in Ward 15 (oncology) or OT dtuing my pregnancy due to teratogenic hazards associated with anaesthetic gases and cytotoxic drags while breast-feedmg. The Pharmacist provided the information. Potential hazards on the wards are slippery floors while being cleaned by domestic staff and staff members neglecting to place appropriate "caution wet floor" signs. Patients who are disorientated and confused will often climb out of bed (despite bed rails) and hurt themselves,Beds at the wrong height and lifting partner at disproportionate height are conttibuting factors to back sfress/uijury. 365 INTERVIEW: STUDENTS 7 AND 8 (NO PREVIOUS NURSING EXPERIENCE)
2 PM, 7TH APRIL, 1986,
57. I had an accident when I had gum boots on my feet, I slipped on the wet tiles with my welUes on while I was showering a patient. The patient was balancing on the rails as I slipped. I didn't report it.
58. One of my patients fainted, she was very big and I was holding the drip and Sue and the nurse were trying to lift her up onto the bed, she collapsed on the floor. The bed was too high and she was very heavy, but she was fine and we didn't have to report it or fiUou t an accident form. I have never had to fill one out.
57. We have both been shown how to fill one out though.
58. The most common accident is when you are trying to get the geriatric patients from the wheelchair to the toilet. You are lucky that the patients land on the toilet and not on the floor,
S7 &8, We have often pulled muscles Uftmg heavy patients.
S8. I often think how dangerous lifting is and often we have had some really good RN's tell us where to put our legs etc., when we are lifting.
S7. There are some chairs around without arms that are not good support for patients and diey are unstable and too many chafrs cluttered around the bed. One of die problems in the geriatric area is that medications are left on the lockers and around and anyone can take that medication. 366
S8. In the community there is a high risk of infection for example in die home there are not the same bugs you find in hospital, but I don't think they take enough precautions with tiiefrasepti c technique (that is the RNs.).
57. We have had to work in some really unsafe places. One of them was GH even the floors were sloped.
58. Even outside the hill were very steep and it was the first place we had to go during our ttaining and we got a bit of a shock. There were thousands of people in the corridors, just going up and down. The faciUties were awful no facilitites for showering the patients.
57. It was a horrible place to work in and it was cramped and crowded and you were left to do so much by yourself and put under a lot of pressure.
58. Some of the patients were very aggressive towards us. They didn't like us because we were not permanent and they didn't get used to us either. It was really awful. A lot of stress. 367 INTERVEEW WTTH STUDENTS 9 and 10 (NO PRIOR NURSING EXPERIENCE)
12.30 to 1.30 PM, 7 TH ARPIL,1986.
S9, Working in a nursing home you see a lot of falls and these patients had this patient up in the afr lifting her up. We ran over to stop them. When we were in CH an old man who didn't take any notice of the community nurses in using his walking frame, had a lot offaUs.
SIO. One lady had a lot of falls and she fell on the floor and they (the other patients) pushed her up against the door and we couldn't get in. We did eventually.
9. A lot of times the tiles are wet in the showers and mainly it is the old perople who fall in the showers.
SIO. There is inadequate staff in these places and you don't have enough time. You don't have enough equipment.
S9. We haven't been in the wards much yet.
Researcher. Could you tell me about the most recent accident you have been involved in?
S9. A lady with arthritis she was shaking in her feet she feU out of bed onto the floor while getting undressed. She was just badly braised and very lucky. An accident form was filled in.
Researcher. Did you fiUi n the form?
S9. No all they did was asked me what happened, but I didn't sign the form. 368 Researcher: How did you feel about the incident?
S9. I really got a shock at ffrst I didn't know whether to move her and I ran down the hall to get some help from the nurses aides, they came to help.
Researcher: What has been the most common accident you have seen during your cUnical practicums ?
SIO. Slipping in the bathrooms and falls.
Researcher: What about you personaUy?
SIO. The most common one is getting knocked over by a wheelchair. Patients catch diefr legs on the things that stick out from the wheelchafr too.
S9. I get braises walking into things, like bedtables, moveable things, ttolleys and those sort of things.
SIO. When people are washing the floors they are wet and I flew out of a room and slipped on the wet floor, I did it about tiiree times.It s a real pain.
S9. Its pretty common. We have been shown how to fill out an accident form we made up an accident and handed it in as part of an assignment. Its a pain in the neck filling fr out and I would like to write it out the way I saw it. About a hundred forms are filledi n and only one might be necessary.
SIO. Staff are pretty casual about it and just say we better make one out just in case.
S9. Probably because they are always filling them out. One man slipped while drying 369 his face he fell on a 45 degree angle as he closed his eyes. They scrape themselves on lockers as they get in and out of bed and onto the chafrs. SIO. They get a hard bang and hit themselves when they are getting out of the bath, the staff say to you "you're new aren't you", "why?", "because you are so gentle with them".
S9. The staff talk a lot you know when thefr next days off are due and you have to do 5 to 6 showers and you rash them through. A lot of it is due to understaffing.
SIO. Even an extta nurse would be helpfull. I got here at 6.30 (due on at 7AM) and I had to do 6 showers in one hour I got through 5 and that is hard, but unorganised out there at TH, unorganised but not bad.
S9. Size of the wards, they are big and they are always polishing them. The floor is so slippery and dangerous, and the bathroom is so smaU.
SIO. The worst thing at GH is the slope there is a big drop about 3 to 4 meters and there is a ramp but no handrails, you could easily fall as the drop is very high. Safety is the worst thing there.
S9. Often you don't know where the patients are they go missing in the bush and women patients go down to the highway and pick up lifts. Its very dangerous. There are bells on the doors that jmgle but they still get out.
SIO. The psychiattic ward is in the main hospital and I reaUy felt unsafe going through it and I thought they could get out and I was reaUy frightened of being attacked or something.
S9. I am concemed about lifting and back problems if you lift on your own its a real 370 problem and you can get hurt. I have an injury from riding a horse in a canter, a compressed injury of the spine and I was in bed for three days. Once you hurt you back its forever.
SIO. I am scared about not knowing first aid and I don't think we get enough on pulmonary resus. for patients who have a heart attack. My course was a crash course over two days and I had a man who had a fit in the shower and I really felt bad as I didn't know what else to do. I just called for help.
S9. I don't like to be on my own and not know where things are kept. It's just something you worry about.
Researcher: Thankyou both very much. 371 INTERVIEW: STUDENTS 11 AND 12. (ONE STUDENT IS A MALE WHO HAS
HAD NO PRIOR NURSING EXPERIENCE BUT WORKED IN INDUSTRY
BEFORE JOINING THE COURSE, AND THE OTHER IS A FEMALE WHO HAS
HAD PRIOR NURSING EXPERIENCE)
21ST, APRIL, 1986.
SI 1. I saw an accident at EB but I was't involved in it but I caught the fellow as he fell.
An accident form was not filled in as he didn't fall. The commonest type of accident is
mainly back injuries. I haven't hurt my back but one of the gfrls in OR hurt her back.
S12. Back injuries and patients falling on you are the commonest form of accident. In
fact I hurt myself at TH. during the clinical practical. We were trying to put a lady back
to bed and she was sliding and I caught her to prevent her from falling and she fell on top
of me and I hurt my back. I have hurt my back a few times and not from poor lifting
techniques but you just react. At SHI was lifting a liitie old lady with a fractured femur,
she was very heavy and she had a sfroke on the same side as her fracmre and as I was
die tallest I copped tiiat side, she stiffened up and I hurt my back. I was in ttaction like at
the modment L is in hospital in ttaction (L. is one of the students and she hurt her back
during clincial practicum lifting and is in ttaction). I was in hospital for 8 weeks in
ttaction and I claimed compo, only doctors bUls were paid for (while I was ttaining m the
old course), and of course they thought it was all in my mind. At first the X-rays did not
show anything and then they said I had done it deliberately to get out of nursing. They
made me feel so guilty and prescribed me a psychiatric consult but he thought I was
alright. I kept very quite about it after that.
Researcher: Do you have insurance now diat you are in the new system?
SI2, I have a disability and death private insurance, (in business with my husband and 372 we are both covered). But I have not had any problems since TH.
SI 1.1 don't have any and I have a scholarship with the commonwealth so I will have to sue them!
S 12. There is a lack of education even with us (that is compared with the old system) often we were put in situations where to the level of our education they are expect us to know what to do and the patient and the nurse are put in an at risk simation. It was really bad and it boils down to education and lack of supervision in the old system.
Researcher: Can you tell me about any recent accidents you have experienced?
SI 1. SUpping in the showers I have nearly sUpped a few times.
S12. Nursing homes are very bad for accidents.
SI 1, The patients put it over you are they stiffen up and you hurt yourself trying to lift them. Makes you wonder maybe they don't want to be moved,
SI2, There is inadequate planning in nursing homes.
511. GH is horrible, shocking the new block is very bad and the shower facilities are awful.
512. The areas in the showers are not big enough and it is very difficult to get a patient in diere. There is poor placement of safety rails, floors are slippery and toilets are too small. They have call bells that don't work. Supposed to be drilled in fire procedure and at GH it is totally madequate. 373 511. Once I sat tiirough a fire drill.
512. There is no fire driU in the present course. I have seen "Hospitals Don't Bum", in die other course.
Researcher: have you got any concems about infection as a safety hazard.?
511. Up in OR there was a pile of stuff it was unsterile and the case was dirty and all the stuff was dumped on tiie ttoUey.
512. But they did close OR for that case and only the essential people were left there. When I was in the previous course there was a problem with infectious diseases. When in cardio thoracic unit at DH caught glandular fever from infected blood (hate to think what I would catch now, AIDS probably) was handling a blood sample. One of the kids in nursing caught meninigitis while nursing a patient in the intensive care unit. In OR now all the nurses wear gloves all the time. In this course there is no reverse barrier nursing yet. Just finished 5 days and another 5 days to go.
Researcher: Do you have any concems about the sttessful nature of your experiences?
511. Not so obvious if in doubt you just ask.
512. The only sttess is the opposition to the course frompeopl e in the hospitals. Researcher: Could you teU me a little about accident forms?
S12. Yes, at SH when I hurt my back and prior to tiiatyo u just fill out an accident form, what you are doing when the accident occurs and witnessed and who your employer was at die tune of the accident. The lecttirer took us tiirough fiUmgou t an accident form. 374 Well at least it is a record and only useful if you can foUow through with it. People are disinclined to fill them out as they are fiightened of the repercussions. Repercussions from the ward staff and the Dfrector-of Nursing. They are really frightened of losing their jobs.
511. Like if you have too many there may be a witch hunt and you could be singled out.
512. Thats' the beauty of this course.
SI 1.1 have filled them out in the steelworks but there might be something on it each time like grease might be involved and then they can follow it through and fix it up. They don't do that in nursing.
SI2. No not in nursing that attitude is helpful but in hospitals there are inadequate floors and showers and that may mean money and hospitals just don't have any. At POW at times it was a matter of either paying the bills or the staff.
511. There is a difference between a company and a hospital with as company they cut down on costs and unions are more militant. So if they reduce the costs in die long ran for example it costs $10,000 to restt-ucture stafrs because they are a safety risk they will spend the money because in the long ran it is saved in compo cases.
512. Loss of wages a big cost and loss of productivity,
Sll, Mind you you get the sky larkers who throw things around, but not known to put die heavies on you, I got my finger caught in a roUer I had my gloves on and pulled out my mangled finger from the roller. I got a week off and tiiey sent me to a doctor and he gave me the week off. 375 SI2, Unlike nursing you carry on regardless. It is a totally different attitude. Private enterprise makes money and loss of profit is more emphaised so if safety is good, accidents are down and productivity is up. In public hospitals you don't ever see the boss no ultimate boss, some adminisfrative board, only nursing adminisfration and all they are worried about is making a good impression.
Sll, There is a psychological connection here!
S12 Nursing adminisfration don't care they just look at the staff for shifts and not as people,
511, Outside nursing automatically seek a different way of doing things but not in
nursing,
512. No in-service lectures on safety or updating practices to improve lifting or
procedures to alleviate sfress. The Henry lifter is only on ward 17 and then its kept
locked up in the store room cupboard and you couldn't get it in a hurry.
Sll. In industry they wouldn't risk it, in nursing they couldn't give a damn. Maybe
that's a reason for people leaving that is working conditions are so bad. The staffing
levels are so low and the pressure is on and injuries will be on the increase. They could
work it differentiy the way they work it in industty. If short somewhere in nursing they
send you up to another ward where you are not familiar with the new ward and you can
make mistakes. You need a better organisation more lUce mdustty there is a better way of
managing the situation.
Researcher: Thank you very much. APPENDIX B
Registered Nurses' Open Ended Interviews 376
Interview with RNl on Male surgical ward. Time;ll AMtoU.lOAM Date: 26.6.86.
RNl.The most common form of accident we have on this ward is slipping on floors. We don't have that many accidents but slipping on floors is the most common.This is mainly due to the fact that the floors are being constantiy washed and the staff are in a hiury because they are so busy and tiiey sUp on the wet slippery floors.
RNl. The last accident that happened to me was about two years ago when I sttained my shoulder lifting a patient. I did not go off duty and didn't have any tteatment and didn't fill in an injury form.I still get pain in my shoulder but when I realised what I should have done it was too late and besides we were busy and you don't like to make a fuss,
RNl. There is a problem with wet floors that would be one of the biggest hazards here. Also we have some shelves and things are stored high up on the shelves, there is a step ladder but people don't use the step ladder and they try and lift heavy things down off the shelf.The blinds are a problem too they are old heavy wooden bUnds with old cords which are not too good.I pulled the blind down and hurt my hand. They really need replacing the DON CEO were up here the other day to look at them so they might get replaced soon.
RNl. One of the problems here is the amount of sttess. Sometimes it is easier for the charge nurse but you have to handle everyone else's sttess and that's a bit hard, especially when the workload is heavy and you don't get a break. Looking after young head injuries and seeing tiieman d their families, so much grief. It's very hard. 377
RNl. A thing that seems to ran in cycles is staff sticking diemselves with needles.There is a risk of people getting hep B and AIDS. You have to mention AIDS as it is a problem everyone worries about.We have young drag addicts who have cellulitis and you never know whether they might have AIDS. Also we have them in for investigation for yaundice, its generally obsttuctive gall bladder but could be hepatitis or anything.
Researcher: Do you have any in-service courses?
RNl. We don't have any lifting in-service but we have had fire drill and evacuation of patients.On this ward most of the heavy lifting is done by the wardsmen. Although it is probable that most staff don't report accidents when they have an accident. People just don't like to make a fuss, they are more likely to report an accident when it concems a patient that when they are involved.
RNl. The most common form of accident with patients is patients falling out of bed. Mostiy the elderly and the disoriented that is, head injuries. They also fall over in the corridor, occasionally and incident where they slip in the shower.
End of interview as interview taken on the ward and RN very busy. 378
INTERVIEW: RN2 IN THE RENAL UNTT
SATURDAY, 26 th July,1986, 3.15pm
RN2. The most common accident we have in the renal unit are needlepricks. Slipping over on wet floors is another I fell over and hurt my knees. Another one is formalin sprays into eyes and formalin spiUages in the unit and that has effects on your lungs. The last accident that I had was when I slipped on the wet floor and hurt my knees.
Researcher: Did you report the accident ?
RN2. No there was no time. I did not report the one before that either. I felt it was 1/2 my fault and I felt a bit stupid.I have never been on compensation, never needed to. I've been very lucky I've never hurt my back.Generally I think that RN'S have not reported things but they are becoming more miUtant.
Researcher: Can you tell me a little about the type of accidents diat patients are involved in.
RN2. We don't have too many accidents v^th patients as a mle but we have had 2 major ones. One patient died a few days later I wasn't tiierebu t the patient was on a ttoUeyi n the middle of the unit, sick in pain, a problem with toes neuropathy and on dialysis the cannula became disconnected and the alarm did not go off and the patient lost a lot of blood in tiie bed. They ttansfused the patient but die patient died.
RN2, The other one involved a patient who had an oxygen cylinder on the bed the oxygen bounced onto another patient's leg who had oestomyletis.It caused extensive braising but he was okay .He talked about suing but didn't. 379
Researcher: Are there any accidents that you worry about occuring?
RN2. The one most of the staff worry about is AIDS and Hep B. Probably there is about equal fear at present,It's more likely tiiat they would get hep B more than AIDS.AU staff are encouraged to be covered with hep B injections, I've had mine at $150 a course.You need a series of three. All patients have to have them.One staff member had to as her husband had hep. B. There are 8 RNS that work in the unit there aren't any ENS
RN2. Thinking about it one of the staff split a beaker of formalin on the floor in the unit.Everyone had to be shifted out immediately that is patient and staff and the unit had to be left vacant until the formalin had gone. It's a problem using formalin to sterilise the dialysis equipment and they are ttying to find something else. When you are SteriUsing the equipment that is when you can get the formaUn in your eyes. 380
INTERVIEW: FRIDAY 7th, August,1986. (9.30 AM)
RN3 WORKE^G IN INTENSIVE CARE
RN3. The most common occurring accident or injury in the intensive care unit is back injuries from lifting, stab wounds from needles ampoules that are hard to break and when broken cut your hand. One of our staff members had to have three days off with the last injury. She had to have stiches. The most common is back injury. One of our staff members had to have extended periods of time off but did not apply for compensation. Filled out an incident form but did not proceed with compensation they recovered and came back to work.
RN3. One of the staff members took on a more administtative type of role and then took her long service leave. The other did the intensive care course became pregnant had one years' leave and then worked in recovery where there is not so much lifting.
RN3. One of the problems is the wardsmen. You have 4 on during the day for the hospital, one in the aftemoon and one at night. They are not the most obliging in the world and resent it very much if called once and they won't come back again. They think they should only have to come once and at that time they think they should be able to Uft all the patients in the unit, but when you are nursing individual patients it doesn't work that way. Even if you need to move a bed you need two men to move it but they don't see that nurses should not be moving beds etc. Night duty is a particular problem. One of the staff got an injury as she helped to put a cardiac board behind the patient's back and of course its a matter of life and death. The beds are too high for easy axcess , you can lower them but nobody does. The other problem is that when you lift you need somebody of your own height and you can't always do that.
Researcher: Do you think staff report accidents and injuries? 381
RN3. No staff don't report aU incidents its too time consummg and sometimes you don't get a favourable reaction or support from die administtative staff, often you just hope die problem wUl go away. There is an occupational health and safety committee but most nurses don't know about its existence.
RN3. To help you sometimes use a Jordan Frame for patients with a fractured pelvis, this does help as it is a hydraulic lifting machme.
Researcher: Is there an area that nurses fear getting an injury from?
RN3. Well AIDS, we needed information about it and we got plenty of uiformation and we read a lot.It is something most of the staff worry about although nobody has refused to nurse AIDS patients.
RN3. Hep B is another one the charge nurse is good and has encouraged staff to get the SERIES B injections about 1/2 have.
RN3. MRSA is another and when you are in the intensive care unit staff have to swab their own nose and if positive they canot work in the ICU until they have three consective swabs. One of the staff members had glandular fever and was not able to get rid of MRSA die union rep advised her that she must get paid leave under compensation, which she did get. Staff are very reluctant to swab their noses as then they have to ttansferr out of the unit and you get pretty close and you don't like to go to work in the wards. A medical officer got it and ttansferted to Cas then got a throat infection and didn't come back. You tteat it by putting some Betadine up your nose.
RN3. Legionafres Disease was a problem we had 2 patients that died from it and we wanted to know if staff could get it, usually you have to be ran down. 382
RN3. The use of an ether vapourisor has also caused problems, nurses got very woosy from it and had to plead to have the windows opened it was very sttessful. The unit is built like a shoebox no curtains, the noise is very loud, frs very hard to work with.We are lucky to have a good cleaner as there are no problems with wet slippery floors.
RN3. The staff report patients accidents but are not so incUnded to report thefr own.
RN3. Another problem is the electrical and oxygen outlets which stick out. There is electrical outlets on one side and Oj and suction on the other side.I hit my head on it and got a black eye. Caution stickers have been put on them. The person in charge encouraged me to write out an accident form. It really hurt and I broke my glasses, it didn't occur to me to put in for new glasses I paid for them.
RN3. Some of the minor things are like the patients beds should be earthed, there are small stools around that you walk into I still have a mark on my leg from where I bumped into one, but I didn't report it.
RN3. Took a patient to CAT scan I had the lead apron on for about 1 hour. I reported it to administtation and she just said how often is this going to happen? You can get an aUowance if you have to wear it. X-rays are a concem to us, tiiey bring tiiemobil e X-ray machine in, the radiologist just yells out to go behind die lead partition. We have been assured that we are not at risk but they don't provide us with articles on it they just say there are joumals on it and that we can go and read it ourselves. We don't wear any X-ray tags tiiat measure radioactivity. We worry because we are at chUdbearing age and it is of great concem to us. 383 INTERVIEW: RN4(RM), Matemity hospital, SH. 30 th September, 1986.
RN4. The main problem here is back injury, Ufting patients post caesarian, who are big. A wardsman is not always around. There is also a problem with epidurals, post-caesars.
Researcher. Could you teU me what is the most common type of injury that you have experienced?
RN4. Wouldn't have a clue, it has been a long time really, not in the last three years. The main thing around here is Hep. B. A lot of the gfrls are in the process of having injections. Doctors are also concemed about who has had it, but you are there with the fresh blood and that's a problem. I've had a blood test but not started injections. The other thing is active herpes and we have had a few of those. We put them in isolation in the second ward or to rooming in in the kids ward, but diey are the only two reaUy.
Researcher, Could you teU me a Uttie bit about fiUingi n injury forms ?
RN4. No real problems with filling in injury reports. Staff do report thefr injuries and we are pretty lucky here as we don't get too many injuries. 384
INTERVIEW WITH RN5. FROM OPERATING THEATRE. 1st September, 1986.
RN5. The most common accident that occurs in the OT is a sfrained back. Some say it is due to an inappropriate lift but basically it is due to lack of education in lifting techniques. You don't get enough and there is no programme in the 11 OT's I worked in. Widi POW diey offer a back care programme but it is employee wide and not just for nurses and it is ran by physiotherapists,
RN5. The next most common is punctured gloves and that happens to all sugery staff by sharp instramentation sometimes associated with nicks in the skin.
RN5. The greatest problem is tripping over electrical cords and tubing that is sucker tubing.
RN5. The next most is chemical irritants that are used as disinfecting agents or cleaners used in the OT, A number of gfrls have been put off with contact dermatitis. One had used ZOFF and did she have a live allergy. She lost about 3 days and had to give up her job due to it. Some of the chemicals are disfiguring and your hand goes brown. I don't smoke but after using some of die chemicals it looks like I am a heavy smoker as my hand goes brown.
RN5. One of the problems is that people don't take time off as you are so short of staff they don't even like to take sick leave.I don't know about the staff in a bigger theatte with 85 people say but that certainly the way RNS feel m a small theatte.
RN5. Staff are very apphrensive about filUngi n injury forms due to rettibution. One RN who pricked her finger on a HEP B case (and we tteat AIDS and HEP B the same) had to fill out a form but she didn't want to, AU the staff had to have SERIES B or gamma globulin. When you report an incident there are so many implications everyone puts the system under the microscope and that shows up short cuts and relaxation of safety measures. 385 People are very worried about AIDS due to lack of education so the RNs and public are not educated. There was a case in the paper at tiie weekend about a RN getting AIDS from a subcutaneous mjection but I don't believe it not with a SCI I don't think so.
RN5. We often had the prisoners from Prince Henry hospital and so we had very strict guidelines about HEP B and AIDS.
RN5. There are also strict conttol about gasses due to the Health Departments regulations on a clean environment but this can be compromised.
RN5. Female anaesthetists have a higher incidence of miscarriages and we experienced it at LH we had 3 cases as soon as they left the OT they were okay. But is wasn't written up in joumals.
RN5. Compensation is also something seen in a similar way to an incident report. People see it as a rebuttal to themselves and just don't like put in claims. I've seen a lot of RNs off with bad backs but the RNs just don't like to fiU out forms.
RN5. Sterilisers cause a lot of bums, minor burns on the autoclaves. They usually fix themselves up. I cricked a muscle in my neck that was the last accident I was involved in it was on an overhead light. I jerked to avoid it and hurt my neck, no time to do anything about it but I suffered for 3 days I was the only one m the OT suite experienced in anaestiietic work so I had to stay.
RN5. In regard to the patients they had a negligence case proved in the courts from POW. They do get reported due to the litagation aspects. Prof, W was negligent with his duties and that was taken to court,
RN5, The main problems with the patients is they faU off tiie OT table, or thefr limb drops. If 386 they do not have proper care for thefr pressure areas problems, bums from diathermy, problems with rings that is they are not tapped on and bums because the rings get very hot when diathermy is used. The most common is inappropriate positioning in radical major surgery. It is the responsibility of the instmment nurse to ensure correct positioning of the patient. Surgery cannot proceed with a RN. Its a good thing that we have moved to the tertiary sector as all the Diplomas and post-grad courses will make the RNs more aware of procedures and the law. There are only 23% of RNS employed in OTs that have operating theafre qualifying certificates. 387 INTERVIEW; RN6,10 YEARS NURSING (AM) 11th October, 1986.
RN6. Patient scalded herself by hopping into hot bath. She sustained 2 degree bums, mainly on arm. Unattended elderly patient. We the nurses were told by adminisfration that we were responsible even though we didn't know that she was going to have a batii, Nodiing happened,
RN6, Patient threw punches at me once a 17 year old mental retard who had a fractiu-ed femur and didn't want to use tha pan, I wasn't hurt but very frightened. We needed 2 wardsman and two nurses to care for him the whole time he was in. He was more or less unconttoUable and used to masturbate all the time. He had us all scared. Administtation were totally unsympathetic no provisions were made for his care. He was 6' 3"- a big boy, he could throw lockers about etc.
RN6,1 sttained a muscle in my back Ufting a patient with a respfratory arrest. I filledi n an incident report and saw the CEO, I didn't have any time off though but it is down on record.
RN6,1 caught glandular fever at work but they didn't accept any liability, I had 6 weeks off work and then went back had a relapse another 4 weeks off then. Matton made me feel as though it was my fault it was really rotten and I had to make up the time to finish my ttaining.
RN6. Usually the hospital was pretty good about infectious diseases- we were always told and barrier nursing was instituted. Down here (N) I nursed a query infectious hepatitis and we weren't told to barrier nurse. I couldn't understand it but it wasn't my job to question. 388 RN6.1 had a car accident on the way to work once and cas gave me valium and sent me home for the day - they were good that time. Another time when I was at B hospital tfiey were pretty nasty though and though I should have to come to work anyway.
RN6. Nursing homes are pretty bad with safety - not enough bed rails to go around - heaps of patients fall out of bed. Not enough staff, 2 sisters and 4 nurses for 100 patients, 70 of whom were bedridden and incontinent. Under those conditions patients safety is jepordised for sure.
RN6. My mother-in-law is a tea lady at a nursing home in Melboume and last week she slipped carrying a bucket of hot water on a slippery (mopped) floor. She was carrying the hot water because the dishwasher wasn't going. She cracked her knee cap and scalded her face and her hand and Matton maintains it was mums' negligence. Hospitals are pretty rough when it comes to us needing tteatment. She's been put off work for two weeks and has been threatened that she will lose her job. The nurses' report is in her favour but the administtation are powerful- she's reaUy worried. 389 INTERVIEW: RN7 AT NCH, 4TH OCTOBER, 1986. 15 YEARS NURSING,(KA) B A (Major in education and Human Geography)
RN7.1 was bitten on the breast through my uniform by a patient who was deaf/dumb and bUnd retard, drew blood. I reported it and was sent to staff medical. No time off and I didn't feel bad about reporting it. Tet toxiod given then sent back to work and I had a big braise for ages. Staff weren't overly sympathetic- these things happen- they laughed. Two nurses sent to camp with 12 kids just outside M. Moderately retarded kids. The place could not be locked. One of the children kept trying to take off and I was worried and didn't sleep for the week afraid that they would lose one of the kids. The staff were not prepared for the conditions. One of the chUdren had a fitwhUs t they were out and fell into the water and I had to dive into the river and save the patient
RN7. We had a patient that had an epileptic fiu-or; manicalled post-op but managed to break free. Attacked me when she went to take his obs and I was splattered with 500 ml of whole blood (patients' transfusion). At length with the help of other staff he was conttolled. All were injured slightly- one thrown to the floor- the incident was not reported- things like that aren't reported unless the patient is hurt. They are expected in psych, units. Everyone was unnerved but we recovered.
RN7. Once asked a patient to take his largactil elixir, he was on a large dose and he forced me to drink 50 mis - it was all over my clothes etc. Patient was angry as he had just been brought in but I knew he would settie so I wasn't frightened to see him again. Incident was reported-1 was sent home upset and drowsy. Staff were sympathetic but I did not see a MO (Medical Officer). Caught German Measles during retard kids stint. I was surprised because I got workers comp, I had to do 2nd year finals in sick bay though I had 2 weeks off but even so every one was very nice to me. They were not Barrier nursing but we all knew that they (the patients) had it. We didn't have the 390 faciUties to barrier nurse anyone anyway. They didn't worry about having us immunised or suggesting it.
RN7.1 had an accident and wrote my car off on the way to work and they were really nasty about me not going to come in as soon as I could but I was really shaking- some chest braising. Didn't see the MO didn't claim workers comp., I felt that they thought I was terrible not making it to work.
RN7, One of the patients in the pscyh ward picked up an IV and smashed a lot of glass panelling-1 kept out off the way because I was there on my own, when other staff on other wards heard the noise they came and we managed to conttol her. No incident report - this is part of the job.During pscyh ttaining we all accepted a lot of verbal abuse, it doesn't make you feel very good but I suppose we just accepted it. During my pscyh days the worst part was the thought that someone might suicide on our shift and we would be held responsible. Quite a few threw themselves out of windows things like that.One of the girls I ttained with had a patient wrap himself in toilet paper then set himself alight- he died from bums. She (the nurse) felt bad and did feel in some way responsible althought the administtation did not come down too heavy.
RN7. As a student nurse I did my back in Ufting a patient. Everyone just thought I made it up but I did report it, saw a MO and had a week off. I was still stiff and sore when I came back to work but no one ever takes back complaints seriously- you know what its like. At C they had old wards right down near the river-1 always felt really vunerable. One night someone was held up at gun point for dmgs. They usuaUy had 2 of us on nights.
RN7. When I was lecturing PTS a young gfrl started and she was sick a few times- we sent her off without thinking too much about it, we just thought she was homesick. She 391 went to cas and saw a resident- given panadol. She got worse and eventually rang her mother. When she finished getting some tteatment she had a sttangulated bowel with gangrene she was away for months. The hospital did take some action hi that thereafter all staff had to be seen by an experienced MO as the resident had just taken the matter lightiy tteating her as though she was just after a "sickle".
RN7. I think that I have always been expected to go to work even with a bad cold or something like that. No one seems to care that the patients may catch it- but its always been that way, hasn't it. A patient was injured once through staff ignorance they had applied copper sulphate without any knowledge of how to use it. The poor man was quite bumt and was most uncomfortable for a few days at least.
RN7. I nursed a seram hepatitis case and felt anxious about it but we did take some precautions there including a blood test so we were fafrly well looked after. 392
INTERVIEW; NC RNS, 14 YEARS AS A RN AT NCH,
RN8, We had a couple of suicides when I was frainingb y jumping off the balcony. There was an inquest but the hospital hasn't or didn't do anything about it. I got hepatitis B , don't know where from but I reckon it must have been from a patient, I didn't have any time off though.I was comered by a lesbian in a psych unit once, it was on night duty and I was by myself so I was pretty scaared. No incident report and staff weren't unduly surprised or sympathetic.
RN8. Heaps of medication errors throughout the years that I have been aware of but none that I've actually committed. Nothing much happens unless the patient is obviously injured. APPENDIX C
Content Analysis iRegistered Nurses' and Nursing
Students' Open-ended Responses 393
CONTENT ANALYSIS OF INTERVIEWS
Category Number of Comments tfrnes mentioned 1. Anaesthetic Gases and chemicals Gases and vapours 1 Chemical spUls 1 Teratogenic hazards 1
2. Assault Aggression by 2 patients Attacked by 2 patients "threatened by a knife at my throat" Hit 2 Kicked 2 Spat at 2 394 Category Number of Comments times mentioned
Verbal abuse 4
3. Attitudes to accidents and injuries
Feel responsible 1
Feel sick 1
Fear of repercussions 1 Fear of rettibution 1 Most people don't report accidents involving themselves 1 Most simple accidents not reported 4 395
Category Number of Comments times mentioned
4. Educational factors Lack of education
Lack of mservice Presence of Occupational Health and Safety Committee "Most nurses don't know of its existence'
5. Environmental factors Hitting head on fittings 1 Noise 1 Slipping on wet floors 6 Sfress 2 396 Category Number of Comments times mentioned
Trippmg on suction tubing etc.
6. Infections
AIDS 8 Glandular fever 1 Hepatitis B 6 Legionnafres' disease 1 MRSA 1 Tuberculosis 1 Odiers 1 (methicUlin resistant staph)
7. Lifting injuries Back injiuy "lady fell on me" (non-specific) "ttaction in hospital" "made me feel guilty"
Heavy workload PuUed muscles
8. Staff factors Need more staff Need more wardsmen 397 Category Number of Comments times mentioned
9.Trauma Braised 1
Cuts Needlesticks
10. Others Bums Ffre risk Radiation APPENDIX D
Instrument for testing Content Validity OCCUPATTONAT. HKATTH AND SAFETY FORM
EXPLANATION
Please read the items listed in this form and judge whether the statements listed represent relevant issues in the area of occupational health and safety for nurses. A scale is provided on the left hand side of the form and you i asked to respond to each item by placing a tick in the box that most closely represents your view. An example is provided:
Nurses are often exposed to infections in the course of their work.
V
Agree Disagree
If you agree with the statement place a tick in the box marked agree.
PRELIMINARY INFORMATION
Please state your nursing qualifications.
Please briefly state your post-graduate clinical experience. 360
SECTION A
Ql. Nurses should fill out an accident form every time they are involved in an accident/injury.
Agree Disagree
Q2. Nurses should report their own and patients' accident/injuries.
Agree Disagree
Q3. AU nurses should report their accidents/injuries.
Agree Disagree
Q4. Nursing students should report every accident/injury they are involved in.
Agree Disagree 361
Q5. Registered nurses make judgements regarding the seriousness of patients' accidents/injuries before deciding to report it.
Agree Disagree
Q6. Registered nurses are disinclined to report patients' trivial injuries.
Agree Disagree
Q7. Administrative staff do not always encourage staff to report their accidents/injuries.
Agree Disagree
Q8. Admmistrative staff encourage nurses to report patients' accidents/ injuries.
Agree Disagree 362
Q9. Administrative staff make decisions about the importance of nurses' accidents/injuries in the reporting process.
Agree Disagree
QIO. Nurses are often too busy to report tiieir own accidents/injuries.
Agree Disagree
Qll. Nurses make time to report patients' accidents/injuries.
Agree Disagree
Q12. Domestic staff are more inclined to report their accidents/injuries than nurses.
Agree Disagree 363
Q13. Nurses do not like to claim for compensation.
Agree Disagree
Q14. Nurses think if they take time off for accidents/injuries others will think they are malingerers.
Agree Disagree
Q15. Nurses often work when they have back pain.
Agree Disagree
Q16. Nurses often have to hft patients that are too heavy for them.
Agree Disagree 364
Q17. It is often difficult to get assistance from wardsmen/orderlies to lift heavy patients.
Agree Disagree
Q18. Mechanical devices are not always used when the patient is too heavy to lift.
Agree Disagree
Q19. Extra nursing staff are not always available to help lift heavy patient
Agree Disagree
Q20. Nurses often lift more than the prescribed safe load.
Agree Disagree 365
Q21. Nurses do not always think about the mechanics of lifting before the; lift a patient.
Agree Disagree
Q22. Back injuries are a problem for nurses.
Agree Disagree
Q23. Wardsmen/orderlies are not always happy to help nurses lift heavy patients.
Agree Disagree
Q24. Nurses' needleprick injuries often go unreported.
Agree Disagree 366
Q25. Nurses worry about contracting Hepatitis B from a needleprick injury.
Agree Disagree
Q26. Nurses worry about contracting AIDS from a needleprick injury.
Agree Disagree
Q27. Nurses are more concemed about contracting AIDS from an infectious source than Hepatitis B.
Agree Disagree
Q28. Anaesthetic gases are a source of concem to nurses while they are working in the operating room.
Agree Disagree 367
Q29. Safety procedures are designed to protect nurses from radiation hazards.
Agree Disagree
Q30. Safety procedures are not always followed during patients' radiation examinations.
Agree Disagree
Q31. Nurses do need to be concemed about the effects of radiation on thei bodies.
Agree Disagree
Q32. Teratogenic agents are a hazard to nursing personnel.
Agree Disagree 368
Q33. Chemical agents used for steriUsing methods cause accidents/injuries to nurses.
Agree Disagree
Q34. Nurses often sustain bums from sterilisers.
Agree Disagree
Q35. Dermatitis is a common occupational hazard for nurses.
Agree Disagree
Q36. Sometimes nurses are hit/kicked by patients.
Agree Disagree 369
Q37. It is not unusual for nurses to be verbaUy abused by their patients.
Agree Disagree
Q38. Slipping on wet floors cause accidents/injuries to nurses.
Agree Disagree
Q39. Nurses are often injured due to the poor design of the environment.
Agree Disagree
Comments. Please provide any additional comments you wish to make in the space below. APPENDIX E
Results of VaUdity Statements: Clinical Experts 1 2 3 4 5 %of Agreement
1 1 100%
2 1 100%
3 2 1 80%
4 1 100%
5 2 2 60%
6 2 80%
7 100%
8 2 80%
9 2 80%
10 2 2 60%
11 100%
12 100%
13 100%
14 100%
15 100%
16 100%
17 100%
18 100%
19 100%
20 100%
21 100%
22 100%
23 100%
24 100%
25 100%
26 100%
27 100%
28 100%
29 100%
30 100%
31 100%
32 100% 410
33 2 1 80%
34 2 80%
35 100%
36 100%
37 100%
100% 0 C O C O 100% APPENDIX F
Occupational Health and Safety Nursing Instmment:
Unrevised Edition OCCUPATIONAL HEALTH & SAFETY NURSING INSTRUMENT
COPYRIGHT© 1987 by Jan Pincombe. 412
OCCUPATIONAL HEALTH AND SAFETY NURSING INSTRUMENT
EXPLANATION
This form consists of four sections. In Section 1 you are asked to fUl out demographic and social data relating to your professional occupation. Section 2 requires you to supply information regarding aspects of your health and safety experiences. Section 3 requires you to rank a series of questions conceming health and safety issues. Please read aU the statement and respond to each one on the basis of your own opinion without consulting a colleague or any other person. TTie information is completel> confidential.
INSTRUCTIONS Registered nurses only are required to fill in Section lA and nursing students please fill in Section IB. Both groups are required to fill in Sections 2 and 3.
Please complete the form in the following way:
1. Place a cross in the appropriate box/es:
Example: Q4. What is the highest secondary education level you have achieved? School EH HSC O Other (Specify) Certificate (Or equivalent)
2. Q13. Please nominate your height m the most appropriate unit.
Centimeters | |
OR
Feet I I Inched I
Section 3 contains statements that require you to indicate your attitude: instmctions are printed at the commencement of that section. 413
SECTION lA
REGISTERED NURSES ONLY please fill in the following section. Nursing students go to SECTION IB.
Ql. Please indicate your position in the clinical setting in which you work. Administration D Registered Nurse 6-10 YRS. Fl Education D Registered Nurse 11-14 YRS. I I Supervisor D Registered Nursel5-19 YRS. EH Nurse Unit Manager D Registered Nurse 20-24 YRS. LJ Registered Nurse 1-5 YRS. CH Registered Nurse 25-OVER. LJ
Q2. Nominate the nursing certificates you have.
General | |
Psychiatric | |
Midwifery | |
Mothercraft I I
Other(specify) 414
Q3. What is your area of work speciality? General D Psychiatric D Midwifery D Community D Mothercraft D Operating Theatres D Other (Specifv)
Q4. Please indicate the size of the hospital you work in.
Less than 100 beds | | 101 - 200 D 201 - 300 D 301 - 400 D 401 - 500 D 500 and over n Other (Specify)
Q5. What is the highest secondary education level you have achieved?
School Certificate | |
Higher School Certificate [ |
Other (Specify) 415
Q6. What is the highest tertiary qualification you possess? Diploma D Degree D Postgraduate diploma D Masters D PHD D None of the above D Specify 416
SECTION IB
NURSING STUDENTS ONLY please fill in the following section.
Q7. Please indicate the year you are presently enrolled in. First Year [_J
Second Year | |
Third Year Q
Q8. Prior to this programme have you had any previous nursing experience? Yes O ]fl
Q9. If yes, please indicate the nature of this experience.
Enrolled Nurse | |
Ward Assistant LJ
Other (Specify) _^______417
SECTION 2.
Registered nurses and nursing students are both required to fill in this section.
QIO. Please indicate your approximate age. 17-19 YRS n 40-44 YRS Q 20-24 YRS D 45-49 YRS D 25-29 YRS n 50-54 YRS Q 30-34 YRS D 55-OVER D 35-39 YRS n
Qll. What is your gender? Female | | Malq |
Q12. Please nominate your weight in the most appropriate unit listed.
Kilograms |__| Poimds | | Stones |___| Pounds [_\
Q13. Please indicate your height in the most appropriate unit.
Centimeters |_J Inches |_J ^^^^ LJ hiches LJ
Q14. Nominate your marital status. Married | | Never married | | Divorced | | Widowed Q Other (Specify) 418
Q15. During nursing, have you ever had to fill out a personal accident/injury form?
Yes D No n
Q16. If YES indicate how many times:
In the last week l~~]
In the last month F"]
In the last year | |
Over one year | J
Q17. Please specify the type of accident(s)/injury(ies) for the following times:
In the last week
In the last month
In the last year _
Over one year
Q18. If YES indicate how many you were required to miss.
In the last week EJ Yes QJ N|O~I Other (Specify)
hi the last month QJ Yes QJ ISQ Other (Specify)
In the last year LJ Yes QJ N|O~| Other (Specify)
Over one year ^J Yes QJ EJ No Other (Specify). 419
Q19. Have you ever been physicaUy injured by a patient?
Yes • No EJ
Q20. Have you ever fiUed out an accident/injury form for a patient?
Yes EJ No O
Q21. If YES please nominate the approximate frequency within the last week [^ last month |_J last year | | over one year | |
Q22. Have you missed any work/studies due to accidents/injury in the workplace during the: last week EJ ^^^ EJ No | |
last month EJ Yes EJ No EJ
last year Q Yes EJ No Q
over one year EJ Yes | | No | |
Q23. If YES indicate how many days you were required to miss:
last week |_J
last month [_j
last year | |
over one year | | 420
Q24. Have you ever claimed compensation?
Yes EJ No EJ Other (Specify)
Q25. If YES please indicate how frequently in the: last week D cause last month D cause last year D cause over one year D cause Other (Specify) D cause
Q26. Have you been entitled to claim compensation and have not done sc Yes EJ No EJ
Q27. If YES please indicate why.
Q28. Have you attended workshops on health and safety issues since graduation as a RN?
Yes EJ No EJ NoappUcable EJ 421
Q29. If YES nominate the topics/topics Ust below.
Infectious diseases (Specify)
Lifting techniques
Safety procedures (Specify)
Other (Specify)
Q30. Are you currently immunised against
Hepatitis B [_] Yes D No D Tetanus j | Yes D No D Tuberculosis | | Yes D No D Typhoid EJ Yes D No D Other (Specify)
Q32. Does your employer/institution have an Occupational Health and Safety Unit for the staff?
Yes EJ No EJ Don't know EJ
Q33. Does your employer/institution have an occupational health and safety committee?
Yes EJ No EJ Don't know EJ 422
Q34. If YES do nursing personnel have representation on that committee?
Yes EJ No EJ Don't know EJ
Q35. When are accidents/injuries more likely to occur?
FuUy staffed D Short staffed D New staff D Relief staff D Otiier (Specify)
Q36. At what time of the shift are accidents/injuries most likely to occur
Begirming of shift EJ
Before tea break Fj
After tea break | |
Before meal break | |
After meal break ["1
End of shift Pj 423
Q37. When are accidents/injuries more likely to occur?
Day shift D Evening shift D Night shift D
Q38. Are wardsmen/orderlies available for help with heavy work in your nursing area?
Yes [J No EJ Other (Specify)
Q39. Have you performed nursing care with back pain?
Yes EJ No EJ Other (Specify) 424
SECTION 3.
In this section a series of statements are listed that require you to indicate your attitude from four possible choices, namely strongly agree (SA), agree (A), disagree (D) and strongly disagree (SD). Please choos the most appropriate response and circle that which most closely matches your opinion. Please try to avoid the middle point unless you reaUy don't know. Any other comments you would like to make can be recorded in th space provided at the end of each sub-section.
SUB-SECTION A
Q40. Nurses fill out an accident/injury form every time they are involve in an accident/injury.
SA A D SD
Q41. I always report patient's accidents/injuries but often neglect to report my own. SA A D SD
Q42. Other nurses report every personal accident/injury they are involved in. SA A D SD
Q43. Nursing students report every accident/injury they are involved m.
SA A D SD
Q44. Registered nurses make judgements regarding the seriousness of patients' accident/injuries before deciding to report it.
SA A D SD
Q45. I know some registered nurses are disinclined to report patients' trivial injuries. SA A D SD 425
Q46. Administrative staff encourage nurses to report thei accidents/injuries.
SA A D SD
Q47. Admmistrative staff encourage nurses to report patients' accident/ injuries.
SA A D SD
Q48. Administrative staff make decisions about the importance of nurse: accident/injuries in the reporting process.
SA A D SD
Q49. I am never too busy to report my own accidents/injuries.
SA A D SD
Q50. I know other nurses always have time to report their own accidents/injuries.
SA A D SD
Q51. Nurses are never too busy to report patients' accidents/injuries.
SA A D SD
Q52. Domestic staff are more inclined to report their accidents/injuries than nurses.
SA A D SD
Q53. Nurses do not like to claim compensation for accidents/injuries.
SA A D SD 426
Q54. Nurses who take time off for accidents/injuries are thought to be malingerers.
SA A D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. 427
SUB-SECTION R
Q55. Nurses often work when they have back pain.
SA A D SD
Q56. Nurses never have to lift patients that are too heavy for them.
SA A D SD
Q57. You can always get extra help from wardsmen/orderlies to lift heavy patients.
SA A D SD
Q58. Mechanical devices are always used if die patient is too heavy to hi
SA A D SD
Q59. Extra nursing staff are always available to help lift heavy patients.
SA A D SD
Q60. Nurses often lift more than the prescribed load.
SA A D SD
Q61. Nurses always think first about the mechanics of lifting before the) lift a patient.
SA A D SD
Q62. Back injuries are not a problem for nurses.
SA A D SD 428
Q63. Wardsmen/orderUes are always wiUing to help nurses lift heavy patients.
SA A D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. 429
SUB-SECTION C
Q64. Needle-prick injuries often go unreported.
SA A D SD
Q65. Nurses worry about contracting hepatitis B from a needle-prick injury.
SA A D SD
Q66. Nurses worry about contracting AIDS from a needle-prick injury.
SA A D SD
Q67. Nurses are more concemed about contracting AIDS from an infectious source than hepatitis B.
SA A D SD
Q68. Legionnaire's Disease is an occupational health risk for nurses.
SA A D SD
Q69. Anaesthetic gases are not a source of concem to nurses while they are working in the operating room.
SA A D SD
Q70. Safety procedures protect nurses from radiation hazards.
SA A D SD
Q71. Safety procedures for nurses are always followed during patients' X-ray examinations.
SA A D SD 430
Q72. Nurses have no need to be concemed about the effects of radiation on their bodies.
SA A D SD
Q73. Tetragenic agents are a hazard to nursing personnel.
SA A D SD
Q74. Chemical agents used for sterilising methods do not cause accidents/injury to nurses.
SA A D SD
Q75. Nurses often sustain bums from sterihsers.
SA A D SD
Q76. Dermatitis is not a common occupational hazard for nurses.
SA A D SD
Q77. R.S.I, is not a common occupational problem for nurses.
SA A D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. 431
SUB-SECTION D
Q78. Nurses are never hit/kicked by patients.
SA A D SD
Q79. Sometimes nurses are physicaUy assaulted by their patients.
SA A D SD
Q80. Nurses understand that being hit/kicked by a patient is a fact of Ufe
SA A D SD
Q81. It is not unusual for nurses to be verbaUy abused by their patients.
SA A D SD
Q82. Slipping on wet floors cause accidents/uijuries to nurses.
SA A D SD
Q83. Nurses are often injured due to the poor design of the environment
SA A D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. APPENDIX G
Raw Data: Pilot Study 432
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1
40 4 4 3 3 3 4 3 4 3 3 2 1 3 1 3 3 3 41 1 2 1 1 2 4 1 1 1 3 4 2 2 4 2 2 2
42 4 4 2 3 3 4 4 4 3 3 2 1 4 2 3 3 3
43 3 3 2 1 4 4 3 4 3 3 3 1 3 2 3 2 3 44 3 3 4 4 1 4 2 2 3 3 4 3 4 3 2 2 2
45 3 3 2 3 1 4 1 1 4 3 3 2 4 3 2 2 2 46 3 3 2 2 2 4 1 4 3 2 3 3 1 2 3 4 4 47 3 3 2 2 2 4 1 1 1 4 2 1 1 1 2 4 1 48 2 2 2 3 2 4 2 1 2 2 2 2 2 2 2 1 2 49 3 4 3 4 4 4 3 4 3 2 2 3 4 3 3 3 4
50 3 3 3 4 4 4 4 4 3 3 4 4 4 3 3 3 3
51 3 4 2 4 3 1 3 2 3 3 1 3 4 2 3 3 2 52 1 1 1 1 1 2 2 2 2 3 1 1 1 2 2 1 2
53 1 1 2 2 2 4 2 2 1 3 1 1 1 2 2 2 1 54 1 1 1 1 1 1 2 2 2 2 2 1 1 2 2 1 2
55 1 1 3 1 2 1 2 4 1 2 3 1 1 2 2 1 2
56 4 4 4 4 4 4 3 4 4 4 2 4 4 4 4 4 4
57 4 4 4 3 1 - 4 4 4 4 3 4 4 3 3 3 3
58 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 3
59 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 3
60 1 1 1 1 1 1 1 1 1 2 2 1 1 2 1 1 1
61 4 4 4 3 4 4 3 4 3 3 3 2 2 3 3 3 3
62 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3
63 4 4 3 1 1 1 3 1 3 3 3 1 1 1 2 2 3 64 2 1 4 1 1 1 1 1 2 2 1 1 1 2 1 2 1
65 2 4 2 1 4 - 2 2 2 3 2 2 1 1 2 3 2
66 2 3 2 1 2 - 1 1 1 2 2 2 2 2 2 2 1 67 2 2 3 3 2 2 1 2 1 2 2 2 4 3 3 2 1
68 2 2 2 2 3 2 4 3 1 2 2 2 1 2 3 2 2 1 433
69 4 4 3 3 3 4 4 DK 2 3 3 3 4 3 2 3 3
70 4 4 2 2 3 3 2 DK 2 4 3 3 4 2 3 3 2
71 4 4 3 3 3 DK 2 DK DK 3 DK 2 3 2 3 3 3
72 4 4 4 4 4 4 4 4 4 4 2 4 4 4 4 3
73 1 1 2 1 2 DK 2 2 3 2 2 2 2 2
74 4 4 3 3 4 4 4 3 2 3 3 4 4 3 4 3
75 4 2 3 1 2 1 1 1 3 2 3 2 1 3 2 2
76 4 4 4 4 4 4 4 1 4 4 3 4 4 3 4 4 4
77 4 4 2 2 2 4 3 2 3 3 4 4 4 4 4 - 3
78 4 4 4 4 4 4 4 4 4 3 3 4 4 4 4 4 4
79 1 1 1 1 1 1 1 2 2 1 1 1 1 2 1 1
80 2 2 2 2 4 4 4 3 3 2 2 3 2 2 2
81 1 1 2 1 1 1 1 2 1 2 1 1 1 1 1 2
82 1 1 1 2 2 1 1 2 2 2 1 1 2 2 2 1
83 1 1 1 1 2 1 1 3 2 2 2 1 2 2 1 1 434
17 18 19 20 21
3 2 4 4 3
2 2 1 1 1
3 3 4 2 3
3 3 2 4 3
2 2 4 4 3
2 2 2 2 2
3 1 3 3 3 3
1 2 1 2 2
2 3 1 2 3
4 2 4 4 3
3 2 2 4 3
2 4 3 1 2
1 2 1 2 2
2 2 1 2 2
2 1 2 2 3
2 1 2 2 1
4 4 4 4 4
3 ^ 4 3 3 4
3 4 3 3 4
3 4 4 4 4
1 1 1 1 1
3 4 3 2 4
3 4 4 4 4
4 3 1 4 4
1 2 1 1 1
2 4 4 3 1
1 4 1 2 1
1 4 1 2 1 2 1 4 3 U-- 435
3 2 2 2 3
2 4 2 2 4
3 2 3 2 2
3 4 3 3 4
3 2 3 3 2
3 4 2 3 4
2 2 3 2 3
4 4 2 4 4
3 2 3 2 3
4 4 4 4 4
1 1 1 2 1
2 2 2 2 2
2 1 2 1 1
1 1 1 1 1 436
1 2 3 4 5 6 7 8 9 10 11 12
40 2 3 1 2 3 2 2 3 1 2 DK 1
41 2 2 2 3 DK 3 3 2 DK 3 2 3
42 3 3 3 2 3 2 2 DK DK 3 DK 3
43 2 3 3 3 2 2 2 3 2 2 3 2
44 2 2 3 DK 3 2 3 2 2 2 DK 2
45 3 2 2 3 3 3 2 DK 2 2 1 2
46 2 3 3 3 2 2 2 DK 1 DK DK 2
47 2 2 2 2 2 2 2 DK 1 1 DK 2
48 2 2 2 1 3 3 2 DK DK 3 DK 2
49 3 2 3 2 3 3 2 3 DK 3 DK 2
50 3 3 3 3 3 3 3 DK DK 2 DK 2
51 1 2 2 2 3 2 2 DK DK 2 DK 2
52 3 3 3 2 3 2 2 2 1 2 3 2
53 3 2 3 2 3 3 3 3 1 3 2 2
54 4 2 2 2 3 3 3 2 4 3 DK 3
55 2 2 2 2 2 2 2 2 4 2 2 2
56 2 2 2 3 3 3 4 4 2 4 4 2
57 1 2 2 2 3 3 3 3 4 3 4 2
58 3 2 3 3 3 3 4 3 3 3 4 2
59 3 2 3 3 3 3 3 3 3 3 4 2
60 2 2 2 2 2 2 2 1 3 1 1 2
61 3 2 2 3 3 3 3 3 2 2 3 3
62 4 3 4 1 4 3 4 4 4 4 4 3
63 2 1 2 1 2 2 3 2 3 2 4 3
64 2 2 2 2 2 2 2 2 2 2 2 2
65 2 3 3 3 3 2 2 DK DK 2 3 2
66 2 3 2 3 2 2 2 2 1 2 2 3
67 3 1 1 4 2 2 3 3 1 3 1 3
68 4 2 3 3 3 3 3 2 3 3 2 2 437
69 3 2 3 2 4 3 2 DK 2 DK DK 2
70 2 2 2 3 3 2 2 2 4 2 DK 2
71 2 2 3 2 3 2 3 3 4 2 DK 2
72 4 4 4 4 4 3 4 4 3 4 4 3
73 DK 3 DK 3 3 3 2 2 DK 2 2 DK
74 3 3 3 2 3 2 3 3 4 4 3 2
75 3 3 2 4 2 3 3 2 2 DK DK 3
76 4 4 4 2 4 3 4 3 4 3 4 3
77 3 2 2 2 2 2 4 3 2 2 DK 3
78 3 4 3 3 3 3 4 3 4 3 4 2
79 2 1 2 3 2 2 1 2 2 2 1 3
80 3 2 2 2 2 3 2 2 3 2 4 1
81 2 1 2 3 2 3 2 2 1 2 1 2
82 1 1 2 2 2 2 2 2 1 2 2 1
83 2 3 2 3 3 3 2 2 1 2 1 APPENDIX H
Reliability Estimates using The Product-Moment Correlation
Coefficient:Registered Nurses 438
Corr. Coeff. Xi : Q.58 Yi : Q.59
Count: Covariance: Correlation: R-squared: |12 .273 .878 .771
Q.58 Q.59 ••X-IBM •MYII^ 1 3 3 2 2 2 3 3 3 4 3 3 5 3 3 6 3 3 7 4 3 8 3 3 9 3 3 10 3 3 n 4 4 12 2 2. APPENDIX I
Reliability Estimates using The Product-Moment Correlation
Coefficient:Nursing Students 439
Corr. Coeff. Xi : 0.58 Y-j: Q.59
Count: Covariance: Correlation: ^-squared: 12 .273 .878 .771
Q.58 Q.59 •HX-IHH ••Y1HH 1 3 3 2 2 2 3 3 3 4 3 3 5 3 3 6 3 3 7 4 3 8 3 3 9 3 3 10 3 3 11 4 4 12 2 2 APPENDIX J
Occupational Health and Safety Nursing Instmment:
Revised Edition OCCUPATIONAL HEALTH & SAFETY
NURSING INSTRUMENT
COPYRIGHT© 1987 by Jan Pincombe. 441
OCCUPATIONAL HEALTH AND SAFETY NURSING INSTRUMENT
EXPLANATION
This form consists of four sections. In Section 1 you are asked to fill out demographic and social data relating to your professional occupation. Section 2 requires you to supply information regarding aspects of your health and safety experiences. Section 3 requires you to rank a series of statements for Questions 30, 31, 32, 33 and 34. Section 4 consists of a seri of questions conceming health and safety issues. Please read all the statements and respond to each one on the basis of your own opinion without consulting a colleague or any other person. The information is completely confidential.
INSTRUCTIONS Registered nurses only are required to fill in Section lA and nursing students please fill in Section IB. Both groups are required to fill in Sections 2, 3 and 4.
Please complete the form in the following way:
1. Place a cross in the appropriate box/es:
Example: Q5. What is the highest secondary education level you have achieved? School LH HSC Q Other (Specify) Certificate (Or equivalent)
2. Q13. Please nominate your height in the most appropriate unit.
Centimeters | |
OR
Feet LJ IncheJ |
Section 3: You are required to rank your responses to the question provided.
Section 4 contains statements that require you to indicate your opinion: instmctions are printed at the commencement of that section. 442
SECTION 1A
REGISTERED NURSES ONT v please fill in the following section. Nursing students go to SECTION IB.
Ql. Please indicate your position in the clinical setting in which you work.
Administration D Registered Nurse 6-10 YRS. EH Education D Registered Nurse 11-14 YRS. [U Supervisor D Registered Nursel5-19 YRS. CU Nurse Unit Manager D Registered Nurse 20-24 YRS. LJ Registered Nurse 1-5 YRS. LH Registered Nurse 25-OVER. I I
Q2. Nominate the nursing certificates you have.
General | |
Psychiatric | |
Midwifery | |
Mothercraft I I
Other( specify) 443
Q3. What is your area of work speciality? General n Psychiatric D Midwifery D Commtmity D Mothercraft n Operating Theatres n Other (Specifv)
Q4. Please indicate the size of the hospital you work in.
Less than 100 beds | |
101 - 200 U 201 - 300 D 301 - 400 D 401 - 500 D 500 and over D Other (Specify)
Q5. What is the highest secondary education level you have achieved?
School Certificate | |
Higher School Certificate j |
Other (Specify) ^. 444
Q6. What is the highest tertiary qualification you possess? Diploma D Degree D Postgraduate diploma D Masters D PHD D None of the above D Specify 445
SECTION IR
NURSING STUDENTS ONLY please fill in the following section.
Q7. Please indicate the year you are presently enroUed in.
First Year LH
Second Year | |
Third Year LH
Q8. Prior to this programme have you had any previous nursing experience? Yes n ^0
Q9. If yes, please indicate the nature of this experience.
Enrolled Nurse | |
Ward Assistant | |
Other (Specify) 446
SECTION 2. Registered nurses and nursing students are both required to fill in this section. QIO. Please indicate your approximate age. 17-19 YRS • 40-44 YRS Q 20-24 YRS O 45-49 YRS Q 25-29 YRS LH 50-54 YRS LH 30-34 YRS n 55-OVER D 35-39 YRS O
Qll. What is your gender? Female LH Male| |
Q12. Please nominate your weight in kilograms Over 70 kgs D 66-70 D 61-65 D 55-60 D 51-54 D 45-50 D Less than 45 kgs. D (Stone lbs 447
Q13. Please indicate your height in centimeters 170-175 cms D 165-169 D 164-150 D 149-145 D 145-140 D Less than 139 cms | |
Q14. Nominate your marital status.
Married | | Never married | | Divorced | |
Widowed | | Separated | | De-facto | |
Q15. Have you ever been physicaUy injured by a patient? Yes n No n
Q16. Have you ever filled out an accident form for a patient?
Yes • No n
Q17. Have you missed any work/studies due to accident/injuries in the workplace? Yes n No n 448
Q18. If YES indicate how many you were required to miss Days 0 n 1 D 2-3 D 4-5 n 6-7 n 8-9 D 10 or over | |
Q19. Have you been entitled to claim compensation and have not done sc Yes O No LH
Q20. Have you attended any kind of training on health and safety issues since graduation as a R.N.?
Yes n No n N/A Q
Q21. If YES please nominate the topic/s Usted below:
AIDS Q
HEPB Q
Lifting techniques | |
Back care | |
Fire drill | |
Hospital fires | |
Other (Specify) 449
Q22. What in your opinion is the prescribed load for safe lifting? More than 100 kgs D 41-50 LH 91-100 D 31-40 n 81-90 D 21-30 LH 71-80 D 10-20 LH 61-70 D Less than 10 kgs | | 51-60 D
Q23. Are you currently immunized against: Hepatitis B n Yes D No D Tetanus D Yes D No D Tuberculosis D Yes D No D Typhoid n Yes D No D
Q24. Does your employer/institution have an Occupational Healtii and Safety Committee?
Yes LH No LH Don't Know LH
Q25. If YES do nursing personnel have representation on that committee?
Yes LH No LH Don't Know LH 450
Q26. Does your employer/institution have an Occupational Healtii and Safety Unit for the staff?
Yes LH No LH Don't Know LH
Q27. Have you performed nursing care when you have had back pain? Yes LH No •
Q28. If YES, why?
Q29. In your opinion what is the cause(s) of injuries/accidents in your work environment? 451
SECTION 3.
Please r^nk in order of importance the following questions by placing the number 1 next to the statement you believe is the most important, or the most common occurring, the number 2 next to your second choice and so on.
Q30. Rank in order tiie most common type of accident(s)/injuiy(ies) thai you have sustained, (however minor). 1. Back injury I I
2. Stabbed by a "sharp" Q
3. Kicked by a patient []]
4. Motor Vehicle Accident (while on duty) [~]
5. Motor Vehicle Accident (on tiie way to work/studies) Ll
6. Motor Vehicle Accident (on the way home) F"!
7. Slipping over while at work LH
8. Eye injury LH
9. Bum injury | |
10. Injury caused by a patient | |
11. Strain injury | |
Q31. Please rank when accident/injuries are more likely to occur:
1. When the ward is fuUy staffed I I
2. When new staff are working in the area |_J
3. Relief staff have been seconded to your ward | |
4. The ward is short staffed | | 452
Q32. Again, please rank when accidents/injuries are more likely to occur: 1. At tiie beginning of tiie shift LH
2. At an early moming start LH
3. Before tea break LH
4. After tea break LH
5. Before meal break |__|
6. After meal break I |
7. Towards tiie end of shift I I
Q33. Please rank the shift in which accidents/injuries are most likely to occur:
1. Day shift LH 2. Evening shift | | 3. Night shift LH
Q34. Please rank the reasons why nursing staff may be disinclined to claim compensation:
1. No encouraged by administration staff I 1
2. The claimant has too much paper work to fill in F"!
3. It takes too long to receive compensation payment r~|
4. The claimant is too busy to fiU out the claim forms F"!
5. Because the injury was caused by a patient LH
6. The injury was not serious enought to warrant compensation! | 453
SECTION 4.
In this section a series of statements are listed that require you to indicate your opinion from five possible choices, namely strongly agree (SA), agree (A), undecided (UD), disagree (D) and strongly disagree (SD). Please choose the most appropriate response and circle that which most closely matches your opinion. Please try to avoid the middle point unless you reaUy don't know. Any other comments you would like to mak can be recorded in the space provided at the end of each sub-section.
SUB-SECTION A
Q35. Needle-prick injuries often go unreported.
SA A UD D SD
Q36. Nurses worry about contracting hepatitis B from a needle-prick injury. SA A UD D SD
Q37. Nurses worry about contracting AIDS from a needle-prick injury.
SA A UD D SD
Q38. Nurses are more concemed about contracting AIDS from an infectious source than hepatitis B. SA A UD D SD
Q39. Legionnaire's Disease is an occupational health risk for nurses.
SA A UD D SD
Q40. Anaestiietic gases are not a source of concem to nurses while they are working in the operating room.
SA A UD D SD 454
Q41. Safety procedures protect nurses from radiation hazards.
SA A UD D SD
Q42. Safety procedures for nurses are always followed during patients' X-ray examinations.
SA A UD D SD
Q43. Nurses have no need to be concemed about the effects of radiation on their bodies.
SA A UD D SD
Q44. Teratogenic agents are a hazard to nursing personnel.
SA A UD D SD
Q45. Chemical agents used for sterilising methods do not cause accidents injury to nurses.
SA A UD D SD
Q46. Nurses often sustain bums from sterihsers.
SA A UD D SD
Q47. Dermatitis is not a common occupational hazard for nurses.
SA A UD D SD
Q48. R.S.I, is not a common occupational problem for nurses.
SA A UD D SD 455
COMMENTS; Please provide any comments about the above su section in the space provided below. 456
SUB-SECTION R
Q49. Nurses are hardly ever hit/kicked by patients.
SA A UD D SD
Q50. Sometimes nurses are physicaUy assaulted by their patients.
SA A UD D SD
Q51. Nurses understand tiiat being hit/kicked by a patient is a fact of life although tiiey do not condone it.
SA A UD D SD
Q52. It is not unusual for nurses to be verbaUy abused by their patients.
SA A UD D SD
Q53. Slipping on wet floors cause accidents/mjuries to nurses.
SA A UD D SD
Q54. Nurses are often injured due to the poor design of the environmeni
SA A UD D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. 457
SUB-SECTION C
Q55. Nurses often work when they have back pain.
SA A UD D SD
Q56. Nurses never have to lift patients that are too heavy for tiiem.
SA A UD D SD
Q57. You can usually get extra help from wardspersons to lift heavy patients.
SA A UD D SD
Q58. Mechanical devices are available to help lift heavy patients.
SA A UD D SD
Q59. Mechanical devices are always used if the patient is too heavy to hi
SA A UD D SD
Q60. Extra nursing staff are always available to help lift heavy patients.
SA A UD D SD
Q61. Nurses often lift more than the prescribed load.
SA A UD D SD
Q62. Nurses always thmk first about the mechanics of lifting before the) lift a patient.
SA A UD D SD 458
Q63. Back injuries are not a problem for nurses.
SA A UD D SD
Q64. Wardspersons are usuaUy wiUing to help nurses lift heavy patients
SA A UD D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. 459
SUB-SECTION D
Q65. Nurses fiU out an accident/injury form every time they are involve in an accident/injury.
SA A UD D SD
Q66. I always report patients' accident(s)/injury(ies) however trivial.
SA A UD D SD
Q67. I often neglect to report my own accidents/injuries.
SA A UD D SD
Q68. Other nurses report every personal accident/injury they are involved in.
SA A UD D SD
Q69. Nursing students report every accident/injury they are involved in.
SA A UD D SD
Q70. Registered nurses make judgements regarding the seriousness of patients' accident/injuries before deciding to report it.
SA A UD D SD
Q71. I know some registered nurses are disinclined to report patients' trivial injuries.
SA A UD D SD 460
Q72. Admmistrative staff encourage nurses to report tiieir accidents/ injuries.
SA A UD D SD
Q73. Administrative staff encourage nurses to report patients' accident/ injuries.
SA A UD D SD
Q74. Administrative staff make decisions about the importance of nurses accidents/injuries in the reporting process.
SA A UD D SD
Q75. I am never too busy to report my own accidents/injuries.
SA A UD D SD
Q76. I know other nurses always have time to report their own accidents injuries.
SA A UD D SD
Q77. Nurses always report patients' accidents/injuries.
SA A UD D SD
Q78. Domestic staff are more inclined to report their accidents/injuries than nurses.
SA A UD D SD
Q79. Nurses do not like to claim compensation for accidents/injuries.
SA A UD D SD 461
Q80. Nurses who take time off for accidents/injuries are thought to be malingerers.
SA A UD D SD
COMMENTS: Please provide any comments about the above su section in the space provided below. APPENDIX K
Causation Interview Instmment 462
CAUSATION INTERVIEW
Nursing position Clinical setting _ Age Gender Years as a registered nurse Nursing qualifications
Time of injury Type of injury
Describe in your own words what happened.
What were the principle causes? 463
INTERVIEW
Educational Factors Have you attended occupational health and safety courses connected with the injury you have sustained?
Have you participated in in-service courses in the type of injury you have sustained?
Yes No Uncertain
Have you participated in in-service courses in coping with aggressive patients?
Have you had any instruction or re-inforcement in the use of mechanical aids?
If yes, when?
If yes, how recentiy?
Are there any "lack of education" factors you believe contributed to your injury? 464
Management Factors
Are there occupational health and safety policies in your area of work connected with the injury you sustained?
Yes No Uncertain
Environmental Factors
Do you think the design of the physical environment contributed to your injury*;
Yes No Uncertain Not relevant
If yes, in what way?
Did inadequate maintenance of equipment contribute to your injury?
Are you concemed about the risk of acquiring an infection due to the injury you sustained?
Yes No Uncertain Not relevant
If yes, what type of infection do you believe you are at risk of acquiring? 465
Social Factors
In your opinion do you consider you were obliged to "carry on" regardless of the risk to yourself?
Yes No Uncertain Not relevant
Do you believe patient needs influenced you in attending to tiieir needs first ratiier tiian your own?
Yes No Uncertain Not relevant
Are there any other social factors you believe contributed to your injury?
Client Demands
Did you find yourself in the "helper" role to the patient at the timeo f the injury?
Yes No Uncertain Not relevant
Did you find tiie patient (or other patients) at the time of your innury demanding?
Yes No Uncertain Not relevant
Do you believe there were otiier contributing nursing factors requiring your attention at the time of your injury?
Yes No Uncertain Not relevant 466
Organisational Demands
Was it your role to be responsible for "harmony" in tiiewar d at tiie time of your injury?
Yes No Uncertain Not relevant
At tiie timeo f your injury do you believe you were required to make decisions hastily due to patients' needs?
Yes No Uncertain Not relevant
Was the ward adequately staffed with registered nurses at the time of your injury?
Yes No Uncertain Not relevant
Was the ward adequately staffed with support staff at tiie time of your injury?
Yes No Uncertain Not relevant
Was there sufficient serviceable equipment at the time of your injury?
Yes No Uncertain Not relevant
Do you tiiinkther e were other organisational factors that contributed to your injury?
Yes No Uncertain Not relevant
If yes, please state what those factors were? 467
Nursing Processes
Did you believe at the timeo f tiie injury you were risking your healtii?
Yes No Uncertain Not relevant
Do you believe at the time of the injury you riskedinjur y because of pressing demands on your time?
Yes No Uncertain Not relevant
Do you think you sustained the injury because you were in a "hurry"?
Yes No Uncertain Not relevant
Are there other factors in your role as a nurse that conttibuted to your injury?
Yes No Uncertain Not relevant
If yes, please state what those factors were.