Journal of Nursing Management, 2015, 23, 803–812
Work hazards for an aging nursing workforce JENNAN A. PHILLIPS
PhD, RN
1
and REBECCA MILTNER
PhD, RN, CNL, NEA-BC
2
1
Assistant Professor and Director, Occupational Health Nursing Program and 2Assistant Professor, Community Health, Outcomes & Systems Department, School of Nursing University of Alabama at Birmingham, AL, USA
Correspondence Jennan A. Phillips NB 316 1720 2nd Avenue South Birmingham Alabama 35294-1210 USA E-mail: [email protected]
(2015) Journal of Nursing Management 23, 803–812. Work hazards for an aging nursing workforce
PHILLIPS J.A. & MILTNER R.
Aim To discuss selected work hazards and safety concerns for aging nurses. Background Greater numbers of older nurses remain in the workforce. Projections suggest that one-third of the nursing workforce will be over age 50 years by 2015. Employers will struggle to find ways to protect the health and safety of their aging workforce and prevent a massive loss of intellectual and human resources when these experienced nurses exit the workforce. Evaluation Review of recent relevant literature in English language journals. Key issues Repetitive motion injuries, fatigue and slips, trips and falls are three major work hazards older nurses face. We discuss several factors for each hazard, including: the normal physiological aging effects of diminished strength, hearing and vision; workplace variables of work schedules, noise and clutter; and personal characteristics of sleep disturbances, overexertion and fatigue. Conclusions Inconclusive evidence exists to guide best practices for designing safe workplace environments and shift patterns for nursing work. Implications for nursing management There are at least two areas administrators can reduce work hazards for older workers: (1) modification of the workplace, and (2) creating the infrastructure to support the aging workforce to encourage healthy behaviours. Keywords: aging nurses, aging workers, older nurses, older workers, work hazards Accepted for publication: 23 December 2013
Introduction The aging workforce is a great concern for all employers (Healthy Aging for a Sustainable Workforce 2009, Bureau of Labor Statistics 2013), yet few companies are actively investing in programs to build a sustainable workforce (Hill 2011). Chronological aging occurs at the same rate for everyone, but noticeable effects depend on genetics, health habits, lifestyle choices, illnesses, environmental exposures and work processes (Naumanen 2006). These differences preclude a precise definition of aging workers (between 45 and 55 years or older is often used). Generally, older workers have some physical difficulties such as weakened work ability, stiff and slow movements and DOI: 10.1111/jonm.12217 ª 2014 John Wiley & Sons Ltd
more fatigue or exhaustion. Older workers with psychological limits also may exhibit rigid behaviour, boredom and memory or learning problems (Naumanen 2006). Nurse managers should be concerned about protecting the health and safety of their employees. The nursing role is physically, cognitively and psychologically demanding (Healthy Aging for a Sustainable Workforce 2009), yet the median age of registered nurses (RNs) is now 46 years (US Department of Health & Human Services 2010). A web-based search using PubMED and CINAHL for literature published between 2000 and 2013 in English language journals was conducted to obtain a broad overview of job hazards for aging workers and nurses. Key terms included
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occupational injury, aging workers, older workers, older nurses, aging nurses and shiftwork. The aims of this paper are to: (1) address work hazards for an aging nursing population; (2) discuss selected health and safety concerns; and (3) describe implications for nursing managers.
Background There are now more workers in the USA over age 55 years than ever before (Bureau of Labor Statistics 2013). Increased life span, rising health care costs and shrinking retirement portfolio values all contribute to these record numbers (Johnson 2008, Soto 2009). Nearly one million US workers aged 55 years and older were hired during the recent slow economic recovery (Bureau of Labor Statistics 2011). These increased hires were probably because of low birth rates after the 1960s creating a diminished worker pool. Other highly developed countries face similar concerns (Geipel 2003). To maintain a viable workforce in light of a dearth of workers born between 1965 and 1978, strategies are needed to protect the health and safety of aging workers to retain their services and expertise (Fragar & Depczynski 2011). This has also had an impact on the health care industry. In 2003, just over 15% of all health care workers were aged over 55 years; by 2010, that number increased to over 21% of the workforce (Fogg & Harrington 2011). The average age for all RNs working in the USA is now in the mid-forties (US Department of Health & Human Services 2010). Buerhaus et al. (2000, 2009a,b) have closely monitored the nursing workforce and work environment and project that the number of nurses aged 50 years and above will peak in 2015 at just over 36% of the workforce. Large numbers of nurses nearing retirement age raise concerns about the availability of nurses with sufficient knowledge and clinical expertise to care for an aged population. All employers recognise the need to retain older workers because there simply are not enough younger experienced workers to fill vacated positions at retirement or to assume leadership roles and support the economy in developed countries (Fragar & Depczynski 2011). Therefore, strategies are needed to attract younger workers. Millennials – workers entering the workforce since 2000 – will account for the majority of workers by 2020 (Long Range Policy Committee 2010). Although there are generational differences across age groups, there are advantages to a robust multigenerational workforce. Older workers can 804
model their wisdom and expertise while younger workers bring enthusiasm, energy and technological capabilities. According to Cahill and Sedrak (2012) restructuring the work environment to account for the different needs and preferences of this multigenerational workforce will improve overall organisational effectiveness and create an energised, creative workplace. The future viability of health care systems is dependent on this multigenerational nursing workforce. Nursing is ranked among the top 10 physically demanding occupations for older females; workers in physically demanding jobs may be unable to work until retirement age (Rho 2010). Unhealthy lifestyles, highly stressful jobs, and heavy physical work has a negative impact on workers over 45 years of age (Naumanen 2006). Further, physiological variations occur during aging which affect older workers’ ability to work safely. Although older nurses may use excellent coping and injury avoidance strategies, demanding workload and normal physiological changes contribute to increased work hazards.
Key Issues The literature revealed five major work hazards for older nurses: (1) fatigue, (2) needle-stick injuries, (3) repetitive motion injuries, (4) stress-related health problems and (5) slips, trips and falls. Factors from normal aging, personal habits and the work environment for each hazard were delineated. Figure 1 presents a schematic representation from an occupational health nursing perspective of potential relationships between contributing factors, work hazards and adverse outcomes among an aging nursing workforce. It is beyond the scope of this paper to address each work hazard and the discussion will focus primarily on fatigue, repetitive motion injuries and slips, trips and falls. Best evidence suggests managers must consider normal aging outcomes on job performance when assigning job responsibilities (Ilmarinen 2001). The decreased cardiovascular function associated with increasing age could overload some workers, negatively impacting on health. Among aging Europeans, health care workers suffer specific and often acute problems similar to those of high-risk workers in unskilled manual jobs (Vendramin & Valenduc 2012). High-risk workers typically perform jobs in painful positions at high speeds with little social support or discretion in decision-making about their jobs. These role strains contribute to declining health for aging ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
Work hazards
* Work Environment * Job Tasks/Roles * Shift Pattern * Work/Life Imbalance * Family/Personal Relationships * Personal Finances
Stress Related Health Problems * Work Schedule * Strenuous Work * Circadian Disruption * Family/Other Responsibilities * Sleep Disturbances
OUTCOMES Fatigue
* Diminished Vision * Fatigue * Unsafe Equipment * Unsafe Work Habits * Inadequate Training
Chronic Health Problems Increased Lost Work Time Increased Presenteeism Increased Absenteeism Increased Medical Costs Increased Operating Costs
Needle Stick & Sharps Injuries
Cumulative Motion Injuries
Slips, Trips & Falls
* Decreased Strength & Flexibility * Abnormal Postures * Repeated Actions * Overexertion
* Diminished Balance * Vision Changes * Corrective Lens * Workplace Spills * Cluttered Walkways * Hearing Loss
Figure 1 Phillips’ aging nursing workforce model.
workers and increase the prevalence of back problems and sleep disorders. Although the majority of health care workers over the age of 50 years reported satisfactory general health in the preceding year, nearly 60% had back problems and 25% experienced sleep disorders. Similarly, there were complaints of back problems and sleep disorders in younger health care workers (Vendramin & Valenduc 2012). Among older female nurses with at least 28 years’ experience who worked over 9 hours/day and 36 hours/week during the preceding 5 years, 36% reported a work-related health problem and nearly one-fourth (23%) were injured at work (Levtak 2005). Perhaps these health conditions signal warnings that force workers to question their ability to continue working long hours. Nearly half of health care workers over 50 years prefer to work fewer hours (Vendramin & Valenduc 2012). The physical workload of jobs, especially among the aging female population, should ideally be reduced as workers age (Ilmarinen 2001). Concerns mount that normal aging effects combined with strenuous work processes and occupational exposures may adversely affect health care workers’ quality ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
of life and health (Healthy Aging for a Sustainable Workforce 2009). As nurses work into older age to address workforce shortages, those with chronic diseases may be more vulnerable to musculoskeletal injuries. More complex work tasks and health care delivery organisations have intensified physical and emotional demands for workers. Jobs with inadequate numbers of workers owing to high staffing ratios and an older, sicker more obese patient population may force workers to engage in dangerous and risky practices. Workers may reach a point where they can no longer perform job tasks simply because of age-related limitations (Healthy Aging for a Sustainable Workforce 2009).
Fatigue and safety risks Fatigue in sleep-deprived shift workers also affects job performance. Nearly 60% of hospital nurses work 12hour shifts; less than 25% work a straight 8-hour day shift (American Nurses Association 2013a). Generally, working shift patterns contribute to high turnover rates (Peters et al. 2009); replacement costs are 805
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approximately $88 000 per nurse (Li & Jones 2013). Nurses working longer than 8–9 hours per shift report more burnout and greater job dissatisfaction, and are more likely to resign (Stimpfel et al. 2012). No distinct difference in the work schedule is evident based on age. Older health care workers have similar schedules to those of their younger counterparts; many work more than 8 hours/day and 40 hours/week, including successive night and weekend shifts (Healthy Aging for a Sustainable Workforce 2009). Concerns among shift workers remaining in the workforce include safety risks associated with the shift pattern. There is a clear link between fatigue and safety risks (Price 2011). Substituting shifts of 10–12 hours for traditional 8-hour shifts increases fatigue and may affect occupational injury rates for nurses (Hopcia et al. 2012). In 2009, hospitals reported 248 200 non-fatal occupational injuries and illnesses among workers (Bureau of Labor Statistics 2012). The incidence rate was 6.9 injuries and illnesses per 100 fulltime workers compared with rates for industry as a whole of 3.7 injuries and illnesses per 100 full-time workers. Recent data revealed injury incidence rates of 125.1 per 10 000 full-time RNs; median absence rates were 7 days per injury (Bureau of Labor Statistics 2012). Among older workers, the risk of incidents and resultant injury is higher on evening shifts than on morning shifts and highest on the night shift (Folkard 2008). Other injury trends include: (1) night workers have longer recovery periods; (2) injury risks increase as night shift progresses and overall alertness and performance levels decline; (3) injury risk increases on each successive night shift; and (4) the greatest injury risk occurs on the fourth consecutive night worked (Folkard 2008). Hopcia et al. (2012) also reported increased injury risk with consecutive workdays and 12-hour shifts. While not limited to any age group, concern over fatigue-related nursing errors from long work shifts prompted a recommendation that shift work patterns be evaluated (Joint Commission 2011). Hospitals were prompted to monitor fatigue-causing factors such as length of time between shifts and the number of consecutive shifts worked, and to involve nursing staff in designing work schedules to reduce fatigue risks. These recommendations were significant as older nurses need longer to recover from night shifts or overtime work (Fragar & Depczynski 2011). Older workers may be unable to sustain the same level of performance over the entire shift or cope with multiple successive night shifts (Folkard 2008). 806
Injuries and work performance Although fatigue and shiftwork increase work hazards, older workers generally have excellent safety records. However, their injuries are more pronounced and require longer recovery times (Folkard 2008, Farrow & Reynolds 2012). The number of days off work after an injury increases substantially based on age; median days off for all workers was 7 but increased to 12 for those aged 55–65 years, and to 16 for those aged 65 years and older. Older workers have more disabling conditions, such as fractures and multiple injuries (Healthy Aging for a Sustainable Workforce 2009). Work performance, or functional capacity, begins to decline at age 45 years (Soer et al. 2012). Lifting and the ability to carrying objects, hand and finger strength and coordination are most affected. Regardless of age, between 20% and 35% of women in professions such as nursing have insufficient capacity to meet work demands for occasional lifting, pulling and pushing loads of 50 pounds (22.7 kg) or less (Soer et al. 2012). Moving and lifting patients along with squatting, bending or maintaining postures for long periods are difficult and physically challenging with obese and debilitated aging patient populations (Fragar & Depczynski 2011). In addition, physically demanding jobs require highly coordinated body movements and balance to work safely and reduce injury risks. Coordination and balance are affected by muscle strength; male workers are always stronger and start losing their strength earlier, but once women begin losing theirs, around age 41 years, weakening progresses rapidly (Danneskiold-Samsøe et al. 2009). Balance is a complicated skill, perhaps protected in firefighting and construction because workers regularly climb ladders to work at heights (Punakallio 2003). Both of these worker categories demonstrated better functional balance than nursing staff and home-health workers. However, balance abilities declined for all workers as they grew older regardless of gender or job (Punakallio 2003). Other factors also increase risk of injuries. A noisy workplace coupled with age-related hearing loss increases the risk of injury incidents, particularly slips, trips and falls (Picard et al. 2008). Excessive noise may increase fatigue leading to decreased concentration and increased mental mistakes (Picard et al. 2008). Psychomotor performance also affects job safety. Nurses with fewer hours of sleep experienced worse psychomotor performance regardless of their longevity in nursing or experience working a particular unit or night shift (Johnson et al. 2010). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
Journal of Nursing Management, 2015, 23, 803–812
Work hazards for an aging nursing workforce JENNAN A. PHILLIPS
PhD, RN
1
and REBECCA MILTNER
PhD, RN, CNL, NEA-BC
2
1
Assistant Professor and Director, Occupational Health Nursing Program and 2Assistant Professor, Community Health, Outcomes & Systems Department, School of Nursing University of Alabama at Birmingham, AL, USA
Correspondence Jennan A. Phillips NB 316 1720 2nd Avenue South Birmingham Alabama 35294-1210 USA E-mail: [email protected]
(2015) Journal of Nursing Management 23, 803–812. Work hazards for an aging nursing workforce
PHILLIPS J.A. & MILTNER R.
Aim To discuss selected work hazards and safety concerns for aging nurses. Background Greater numbers of older nurses remain in the workforce. Projections suggest that one-third of the nursing workforce will be over age 50 years by 2015. Employers will struggle to find ways to protect the health and safety of their aging workforce and prevent a massive loss of intellectual and human resources when these experienced nurses exit the workforce. Evaluation Review of recent relevant literature in English language journals. Key issues Repetitive motion injuries, fatigue and slips, trips and falls are three major work hazards older nurses face. We discuss several factors for each hazard, including: the normal physiological aging effects of diminished strength, hearing and vision; workplace variables of work schedules, noise and clutter; and personal characteristics of sleep disturbances, overexertion and fatigue. Conclusions Inconclusive evidence exists to guide best practices for designing safe workplace environments and shift patterns for nursing work. Implications for nursing management There are at least two areas administrators can reduce work hazards for older workers: (1) modification of the workplace, and (2) creating the infrastructure to support the aging workforce to encourage healthy behaviours. Keywords: aging nurses, aging workers, older nurses, older workers, work hazards Accepted for publication: 23 December 2013
Introduction The aging workforce is a great concern for all employers (Healthy Aging for a Sustainable Workforce 2009, Bureau of Labor Statistics 2013), yet few companies are actively investing in programs to build a sustainable workforce (Hill 2011). Chronological aging occurs at the same rate for everyone, but noticeable effects depend on genetics, health habits, lifestyle choices, illnesses, environmental exposures and work processes (Naumanen 2006). These differences preclude a precise definition of aging workers (between 45 and 55 years or older is often used). Generally, older workers have some physical difficulties such as weakened work ability, stiff and slow movements and DOI: 10.1111/jonm.12217 ª 2014 John Wiley & Sons Ltd
more fatigue or exhaustion. Older workers with psychological limits also may exhibit rigid behaviour, boredom and memory or learning problems (Naumanen 2006). Nurse managers should be concerned about protecting the health and safety of their employees. The nursing role is physically, cognitively and psychologically demanding (Healthy Aging for a Sustainable Workforce 2009), yet the median age of registered nurses (RNs) is now 46 years (US Department of Health & Human Services 2010). A web-based search using PubMED and CINAHL for literature published between 2000 and 2013 in English language journals was conducted to obtain a broad overview of job hazards for aging workers and nurses. Key terms included
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Visually impaired and older workers need the higher range of luminance; lights with adjustable intensity will allow all workers to have comfortable lighting. Lighting units need low-brightness lenses that control glare and evenly distribute light (Industrial Accident Prevention Association 2008). Separate lighting units for tasks, ceilings and walls will prevent shadows. Table 1 provides recommendations for controlling work hazards for aging nurses compiled from information contained in a factsheet available from a workers’ compensation division (Texas Department of Insurance 2008). Ergonomics is the science of fitting workplace conditions and job demands to the physical and cognitive capabilities of workers (US Department of Labor 2007). Organisational leaders should assess structures and equipment and match nursing tasks to worker capabilities; an ergonomically designed work environment benefits all staff regardless of age and may also promote retention of older nurses (Chosewood 2012). The functionality of new products should be evaluated not just within existing systems or patient populations, but also mindful of specific worker groups. For example, aging eyes do best with serif scripts at 12–14 font sizes in dark colours against light backgrounds. However, many computer screens in electronic health records do not meet that standard. Purchasers could
request adjustable documentation templates. Other relatively simple workplace accommodations are targeted lighting and computer screen magnifiers or other magnifying devices. Recommendations for ergonomic redesign specific to health care environments are available in eTools for hospitals (US Department of Labor 2002) and long-term care facilities (US Department of Labor 2000). Manual lifting or shifting of patients should be avoided by all nurses. Safe patient handling equipment should be readily available to all direct patient care providers, but broadly accepted standards to guide systematic development of safe handling programmes have only recently been released (American Nurses Association 2013b). At a minimum, workers need easy access to equipment that supports patient transfers, lifting and repositioning. The Department of Veterans Affairs in the USA developed a model comprehensive safe patient handling programme for its national network of health care facilities (Nelson & Baptiste 2004). The Department of Veterans Affairs’ policies, equipment information, cost benefit analyses, and other information are freely available (US Department of Veterans Affairs 2012). Task rotation is often used in office or manufacturing work to reduce repetitive motion injuries and/or static standing. Initially, rotating tasks may not seem
Table 1 Strategies to protect an aging nursing workforce Work hazard Cumulative trauma from repetitive motion injuries
Slips, trips and falls
Fatigue
Nursing management strategy Provide educational programmes that teach proper movement including avoiding a fixed posture or performing only one kind of movement, twisting with any lifting activity, repetitive tasks, and prolonged standing or sitting Provide appropriate safe patient handling equipment and/or get assistance from others when moving patients Provide anti-fatigue mats in areas that require standing for long periods Provide opportunities during work for all nurses to engage in exercise at least 20–30 minutes daily Provide strength and balance training for older nurses at the worksite Provide access to membership for fitness facilities for older nurses to participate in water exercise in reduced weight-bearing environment to improve balance Encourage older workers to have annual vision checks Provide administrative controls that require all nurses to wear appropriate well-fitted shoes with non-slip soles Maintain clutter-free workspaces Provide slip-resistant flooring; replace marble, polished wood and tile flooring Check for uneven surfaces, cracks, build-up of dirt/debris and weather hazards on exterior walkways Use bright lights and provide handrails in stairways Use non-slip surfaces on stair treads Use contrasting colours to separate different levels of surfaces like stairs Improve contrast between objects by increasing lighting Eliminate need to constantly move between brightly and dimly lit areas To reduce eye fatigue, install glare screens on computers Reduce glare by using shades, awnings and diffuse light sources, adjustable and indirect lighting Minimise background noises to accommodate hearing deficits Provide flexible work schedules and options for reduced work hours Limit consecutive 12-hour shifts to a maximum of two Allow at least one short nap break of 20 minutes during night shift Educate older workers on sleep hygiene Offer health screening for sleep apnoea/other sleep disorders
Adapted from: Aging in The Workplace Factsheet (Texas Department of Insurance 2008).
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to apply in nursing work. However, repetitive motion work such as keyboarding, working in awkward positions, sitting in poorly designed seats at non-adjusting tables with inappropriate heights as well as repetitive pulling, lifting, pushing, bending, stooping and other gross motor activities is common in nursing. Managers should consider rotating nursing assignments for patients with heavy physical care demands while also allowing self-paced work with self-directed breaks (Chosewood 2012). Patients who require intense physical exertion may need to be co-assigned with a nursing assistant or other team member to protect workers from injury. Working in teams can offset some job demands and should be encouraged.
Supportive infrastructure Infrastructure to support both aging workers and overall healthy worker behaviours is essential to a productive workforce. Administrative policies and procedures are needed that support the aging workforce in a respectful and legal way. These policies should cover a broad range of issues from the interaction with the work environment to appropriate work scheduling and health promotion and protection in all employees. Policies that change the work environment include the ergonomic issues discussed above but also more comprehensive evaluation of nursing work processes. Questions include what staffing models best protect an older workforce and whether a team approach is more effective and less hazardous to all clinical health care workers. The need exists to modify, or perhaps eliminate heavy, physically demanding work requirements. Unquestionably, more research is needed to determine the safest design for nursing work. Policies also need to address appropriate work scheduling to support the nursing workforce by allowing flexible scheduling, job sharing, part-time employment and phased retirement options (Long Range Policy Committee 2010, Chosewood 2012). Most acute care nurses work three or more 12-hour shifts each week, although the evidence suggests consecutive shifts have a negative impact on performance (Geiger-Grown & Trinkoff 2010). These scheduling patterns are very popular with nurses and eliminating them may be difficult. Fatigue during these shifts may be reduced with short 20-minute nap periods, but these break periods need support from nursing administration. Because physical changes in vision and hearing are gradual, aging workers rarely notice their own functional decline. Administrators should consider annual ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
screening for vision, hearing, and even balance and flexibility. Strategies are needed that offset work demands with age-related performance limitations. Workloads should include more mentally challenging tasks that rely more on the rich knowledge and skills of older workers. Further, organisations must evaluate the influence of their benefits and compensation policies on the financial interests of older workers. In other words, do employer policies and actions actually encourage workers to exceed their physical capabilities and functional limitations? One concern with increasing numbers of older workers is finding workplace accommodations for functional decline. As workers age, the possible risk of disability from masked limited functional capacity increases; injury may occur when the worker performs an infrequent or unusual job task (Fogg & Harrington 2011). Many job tasks of direct patient care place older nurses at higher risk of injury and disability. Proactive strategies such as modifying the workplace, as discussed, above may address many limitations of aging nurses, and reasonable accommodations and case management may speed return to work after an illness or injury (Chosewood 2012). Job training to develop worker competencies in technology-related care modalities may address declining functional capabilities associated with aging (Chosewood 2012). Changes in the physical spaces of nursing units as well as in job duties, work tasks and hours of work, including more flexible work schedules, are needed to accommodate aging workers (Fogg & Harrington 2011). Additional research in this area is therefore warranted. Ilmarinen (2001) proposed the following strategies to support an older workforce: (1) teach supervisors best practices for managing aging workers, (2) implement supportive ergonomic principles; (3) implement worksite exercise and fitness programmes; and (4) provide age-appropriate technology training for older workers. The integration of several approaches was suggested for improved results. Outcomes could be measured as improved work productivity and decreased complaints of musculoskeletal injuries along with reduced absenteeism and medical costs among nurses with chronic health conditions. Finally, support for managing the older nursing workforce must begin with the top executives and involve senior administrators from human resources and nursing with input from occupational health nurses. Ensuring a viable workforce to meet future demands requires proactive strategies to protect and promote health while creating a positive work environment for all nurses regardless of age or shift 809
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pattern. Recommendations from the Joint Commission (2011) to promote improved alertness during night shifts, including engaging in conversations, walking around the nursing unit, stretching, strategic caffeine consumption and taking short naps, may help protect nurses from occupational injuries. Administrative policies that support these practices are needed. The American Hospital Association suggested a workplace culture supportive of healthy lifestyles and recognising the value of older staff were strategies that support aging health care workers and counter the looming tight labour market (Long Range Policy Committee 2010). Box 1 contains two web-based resources useful for promoting preventive services among adults aged 50–64 years. Many large organisations offer incentives for employees who quit smoking or lose weight. However, everyone needs access to healthy foods while at work and employer-sponsored programmes for stress management, weight loss support and tobacco cessation are important even in small work settings. Further, more effort is needed to support a culture of fitness; promoting physical activity by creating standing work stations and walking spaces within the workplace may be beneficial. Workers should be encouraged to engage in regular aerobic exercise to maintain their cardiovascular system at an age-appropriate fitness level. Box 1 Promoting preventive services for adults aged 50–64 years ● In partnership with the American Association of Retired Persons (AARP) and the American Medical Association, the Centers for Disease Control and Prevention (CDC) released recommendations for health promotion among older working age adults in the document Promoting Preventive Services for Adults 50–64: Community and Clinical Partnerships available at http://www.cdc.gov/aging/pdf/promoting-preventiveservices.pdf. ● An interactive tool identifies a set of recommended preventive services and health indicators for the 50- to 64-year-old population and allows one to search by state and local metropolitan areas to monitor progress toward successful adoption of health behaviours. This eTool from the CDC is available at http://apps.nccd.cdc.gov/DACH_PPS/Default/ Default.aspx
The Healthier Worksite Initiative (Centers for Disease Control & Prevention 2010) and Total Worker HealthTM programme (Centers for Disease Control & Prevention 2013) offer useful evidence-based guidelines that any employer could use to protect and promote health. Similar information specific to health care settings is also available (Chang 2013, Centers for Disease Control & Prevention n.d.). Administrative policies and worksite programmes based on these 810
initiatives may create a work environment that supports older nurses and the international, multigenerational nursing workforce. Organisations with a robust workplace climate supportive of health and wellness will be well positioned for the future.
Conclusions As the nursing workforce continues to age, many challenges will present for nurse managers to protect the health and safety of this vulnerable worker population. There is strong evidence of the physically and mentally challenging nature of direct nursing care. Additionally, injuries among US health care workers across all ages exceed those in occupations often considered more hazardous. However, the nature of nursing work, including shift patterns for around-the-clock patient care, presents unique hazards for the international nursing community. Only recently have governments and employers begun to address the associated problems, yet few have taken the necessary actions to confront them in a comprehensive manner. Limited evidence exists to guide occupational health strategies specific to the aging nursing workforce. Further, at best there is inconclusive evidence from other worker populations to suggest potential solutions to prevent work-related injuries, burnout and early retirements in older nurses. Therefore, it is imperative that nursing leaders from health systems administration, worksite health promotion programmes and occupational health collaborate on solutions to address these issues. Strong research agendas are needed to not only determine work hazards specific to an aging nursing population but also interventions that promote and protect the health and safety of the total nursing workforce.
Sources of Funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was not required for this paper.
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with special reference to age and gender. Acta Physiologica 197 (Suppl. 673), 1–68. Available at: http://onlinelibrary.wiley.com/ doi/10.1111/j.1748–1716.2009.02022.x/pdf, accessed 16 October 2013. Farrow A. & Reynolds R. (2012) Health and safety of the older worker. Occupational Medicine 62, 4–11. Fogg N.P. & Harrington P.E. (2011) Rising demand for older workers despite the economic recession: accommodation and universal design for the new American workforce. Public Policy & Aging Report 21 (2), 11–17. Folkard S. (2008) Shift work, safety and aging. Chronobiology International 25, 183–198. Fragar L.J. & Depczynski J.C. (2011) Beyond 50. Challenges at work for older nurses and allied health workers in rural Australia: a thematic analysis of focus group discussions. BMC Health Services Research 11, 42. Available at: http://www. biomedcentral.com/1472–6963/11/42, accessed 16 October 2013. Geiger-Grown J. & Trinkoff A.M. (2010) Is it time to pull the plug on 12-hour shifts? part 1: the evidence. Journal of Nursing Administration 40 (3), 100–102. Geipel G.L. (2003) The Aging/Workforce Equation: a Framework for Understanding the Impact of Global Aging on the Supply of Labor in the More Developed World. United States Senate – Special Committee on Aging, 27 February, 2003. Available at: http://www.aging.senate.gov/events/hr94gg.pdf, accessed 6 October 2013. Healthy Aging for a Sustainable Workforce (2009) A Conference Report. Silver Spring, MD 17–18 February 2009. Available at: http://www.public-health.uiowa.edu/HWCE/researcher/ AgingWorkersWorkshopReport_11%2009_Final.pdf, accessed 10 October 2013. Hill K.S. (2011) Nursing and the aging workforce: myths and reality, what do we really know? Nursing Clinics of North America 46, 1–9. Hopcia K., Dennerlein J.T., Hasimoto D., Orechia T. & Sorensen G. (2012) Occupational injuries for consecutive and cumulative shifts among hospital registered nurses and patient care associations. Workplace Health & Safety 60, 437–444. Ilmarinen J.E. (2001) Aging workers. Occupational and Environmental Medicine 58, 546–556. Industrial Accident Prevention Association (2008) A Health and Safety Guideline for Your Workplace. Lighting at Work. Available at: http://www.iapa.ca/lightin.pdf, accessed 16 September 2013. Johnson R. (2008) Older workers and the recession: urban institute commentary. San Diego Union-Tribune. Available at: http://www.urban.org/retirement_policy/url.crm?ID=901205, accessed 4 October 2013. Johnson A.L., Brown K. & Weaver M.T. (2010) Sleep deprivation and psychomotor performance among night-shift nurses. AAOHN Journal 58, 147–154. Joint Commission (2011) Sentinel Event Alert. Joint Commission 48. Available at: http://www.jointcommission.org/assets/ 1/18/SEA_48.pdf, accessed 11 October 2013. Levtak S. (2005) Health and safety of older nurses. Nursing Outlook 53, 66–72. Li Y. & Jones C.B. (2013) A literature review of nursing turnover costs. Journal of Nursing Management 21, 405–418. Long Range Policy Committee (2010) Workforce 2015: Strategy Trumps Shortage. American Hospital Association, Chicago, IL.
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Available at: http://www.aha.org/advocacy-issues/workforce /workforce2015.shtml, accessed 11 October 2013. Melamed S., Fried Y. & Froom P. (2004) The joint effect of noise exposure and job complexity on distress and injury risk among men and women: the cardiovascular occupational risk factors determination in Israel study. Journal of Occupational and Environmental Medicine 46, 1023–1032. Naumanen P. (2006) The health promotion of aging workers from the perspective of occupational health professionals. Public Health Nursing, 23, 37–45. Nelson A. & Baptiste A. (2004) Evidence-based practices for safe patient handling and movement. Online Journal of Issues in Nursing 9 (3), Manuscript 3. Available at: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANA Periodicals/OJIN/TableofContents/Volume92004/No3Sept04/ EvidenceBasedPractices.aspx, accessed 10 October 2013. Peters V.P.J.M., de Rijk A.E., Boumans N.P.G. (2009) Nurses’ satisfaction with shiftwork and associations with work home and health characteristics: a survey in the Netherlands. Journal of Advanced Nursing 65, 2689–2700. Picard M., Girard S.A., Simard M., Larocque R., Leroux T. & Turcotte F. (2008) Association of work-related accidents with noise exposure in the workplace and noise-induced hearing loss based on the experience of some 240,000 person-years observation. Accident Analysis and Prevention 40, 1644–1652. Price M. (2011) The risks of night work. Monitor on Psychology 42, 38. Available at: http://www.apa.org/monitor/ 2011/01/night-work.aspx, accessed 16 September 2013. Punakallio A. (2003) Balance abilities of different-aged workers in physically demanding jobs. Journal of Occupational Rehabilitation 13, 33–43. Rho H.J. (2010) Hard Work? Patterns of Physically Demanding Labor Among Older Workers. Center for Economic and Policy Research, Washington, DC. Available at: http://www.cepr.net/ documents/publications/older-workers-2010–08.pdf, accessed 6 October 2013. Soer R., Brouwer S., Geertzen J.H., Vander Schans C.P., Groothoff J.W. & Reneman M.F. (2012) Decline of functional capacity in healthy aging workers. Archives of Physical Medicine and Rehabilitation 93, 2326–2332.
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Soto M. (2009) How is the Financial Crisis Affecting Retirement Savings?, Urban Institute, Washington, DC. Available at: http://www.urban.org/url.cfm?ID=411880&renderforprint=1, accessed 4 October 2013. Stimpfel A.W., Sloane D.M. & Aiken L.H. (2012) The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs 31, 112501–112509. Texas Department of Insurance (2008) Aging in the Workplace Factsheet. Texas Department of Insurance, Division of Workers Compensation Available at: http://www.tdi.texas.gov/pubs/ videoresource/fsageinwork.pdf, accessed 6 October 2013. US Department of Health and Human Services (2010) The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. Health Resources and Services Administration, Bureau of Health Professions, Rockville, MD. Available at: http://bhpr.hrsa.gov/healthworkforce/ rnsurveys/rnsurveyfinal.pdf, accessed 18 October 2013. US Department of Labor (2000) Long Term Care Facilities eTool. Occupational Safety and Health Administration, Washington, DC. Available at: http://www.osha.gov/SLTC/ etools/nursinghome/index.html, accessed 30 October 2013. US Department of Labor (2002) Hospital eTool. Occupational Safety and Health Administration, Washington, DC. Available at: http://www.osha.gov/SLTC/etools/hospital/hazards/ ergo/ergo.html, accessed 30 October 2013. US Department of Labor (2007) Ergonomics. Occupational Safety and Health Administration, Washington, DC. Available at: http://www.osha.gov/SLTC/ergonomics/, accessed 6 October 2013. US Department of Veterans Affairs (2012) Safe Patient Handling and Movement. VISN 8 Patient Safety Center of Inquiry, Tampa, FL. Available at: http://www.visn8.va.gov/ patientsafetycenter/safepthandling/, accessed 8 October 2013. Vendramin P. & Valenduc G. (2012) Occupations and Aging at Work. An Analysis of the Findings of the fifth European Working Conditions Survey. Europena Trade union Institute, Brussels. Available at: http://www.ftu-namur.org/fichiers/ETUI_ WP09_Occupations_ageing_EN.pdf, accessed 10 October 2013.
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
Work hazards for an aging nursing workforce JENNAN A. PHILLIPS
PhD, RN
1
and REBECCA MILTNER
PhD, RN, CNL, NEA-BC
2
1
Assistant Professor and Director, Occupational Health Nursing Program and 2Assistant Professor, Community Health, Outcomes & Systems Department, School of Nursing University of Alabama at Birmingham, AL, USA
Correspondence Jennan A. Phillips NB 316 1720 2nd Avenue South Birmingham Alabama 35294-1210 USA E-mail: [email protected]
(2015) Journal of Nursing Management 23, 803–812. Work hazards for an aging nursing workforce
PHILLIPS J.A. & MILTNER R.
Aim To discuss selected work hazards and safety concerns for aging nurses. Background Greater numbers of older nurses remain in the workforce. Projections suggest that one-third of the nursing workforce will be over age 50 years by 2015. Employers will struggle to find ways to protect the health and safety of their aging workforce and prevent a massive loss of intellectual and human resources when these experienced nurses exit the workforce. Evaluation Review of recent relevant literature in English language journals. Key issues Repetitive motion injuries, fatigue and slips, trips and falls are three major work hazards older nurses face. We discuss several factors for each hazard, including: the normal physiological aging effects of diminished strength, hearing and vision; workplace variables of work schedules, noise and clutter; and personal characteristics of sleep disturbances, overexertion and fatigue. Conclusions Inconclusive evidence exists to guide best practices for designing safe workplace environments and shift patterns for nursing work. Implications for nursing management There are at least two areas administrators can reduce work hazards for older workers: (1) modification of the workplace, and (2) creating the infrastructure to support the aging workforce to encourage healthy behaviours. Keywords: aging nurses, aging workers, older nurses, older workers, work hazards Accepted for publication: 23 December 2013
Introduction The aging workforce is a great concern for all employers (Healthy Aging for a Sustainable Workforce 2009, Bureau of Labor Statistics 2013), yet few companies are actively investing in programs to build a sustainable workforce (Hill 2011). Chronological aging occurs at the same rate for everyone, but noticeable effects depend on genetics, health habits, lifestyle choices, illnesses, environmental exposures and work processes (Naumanen 2006). These differences preclude a precise definition of aging workers (between 45 and 55 years or older is often used). Generally, older workers have some physical difficulties such as weakened work ability, stiff and slow movements and DOI: 10.1111/jonm.12217 ª 2014 John Wiley & Sons Ltd
more fatigue or exhaustion. Older workers with psychological limits also may exhibit rigid behaviour, boredom and memory or learning problems (Naumanen 2006). Nurse managers should be concerned about protecting the health and safety of their employees. The nursing role is physically, cognitively and psychologically demanding (Healthy Aging for a Sustainable Workforce 2009), yet the median age of registered nurses (RNs) is now 46 years (US Department of Health & Human Services 2010). A web-based search using PubMED and CINAHL for literature published between 2000 and 2013 in English language journals was conducted to obtain a broad overview of job hazards for aging workers and nurses. Key terms included
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occupational injury, aging workers, older workers, older nurses, aging nurses and shiftwork. The aims of this paper are to: (1) address work hazards for an aging nursing population; (2) discuss selected health and safety concerns; and (3) describe implications for nursing managers.
Background There are now more workers in the USA over age 55 years than ever before (Bureau of Labor Statistics 2013). Increased life span, rising health care costs and shrinking retirement portfolio values all contribute to these record numbers (Johnson 2008, Soto 2009). Nearly one million US workers aged 55 years and older were hired during the recent slow economic recovery (Bureau of Labor Statistics 2011). These increased hires were probably because of low birth rates after the 1960s creating a diminished worker pool. Other highly developed countries face similar concerns (Geipel 2003). To maintain a viable workforce in light of a dearth of workers born between 1965 and 1978, strategies are needed to protect the health and safety of aging workers to retain their services and expertise (Fragar & Depczynski 2011). This has also had an impact on the health care industry. In 2003, just over 15% of all health care workers were aged over 55 years; by 2010, that number increased to over 21% of the workforce (Fogg & Harrington 2011). The average age for all RNs working in the USA is now in the mid-forties (US Department of Health & Human Services 2010). Buerhaus et al. (2000, 2009a,b) have closely monitored the nursing workforce and work environment and project that the number of nurses aged 50 years and above will peak in 2015 at just over 36% of the workforce. Large numbers of nurses nearing retirement age raise concerns about the availability of nurses with sufficient knowledge and clinical expertise to care for an aged population. All employers recognise the need to retain older workers because there simply are not enough younger experienced workers to fill vacated positions at retirement or to assume leadership roles and support the economy in developed countries (Fragar & Depczynski 2011). Therefore, strategies are needed to attract younger workers. Millennials – workers entering the workforce since 2000 – will account for the majority of workers by 2020 (Long Range Policy Committee 2010). Although there are generational differences across age groups, there are advantages to a robust multigenerational workforce. Older workers can 804
model their wisdom and expertise while younger workers bring enthusiasm, energy and technological capabilities. According to Cahill and Sedrak (2012) restructuring the work environment to account for the different needs and preferences of this multigenerational workforce will improve overall organisational effectiveness and create an energised, creative workplace. The future viability of health care systems is dependent on this multigenerational nursing workforce. Nursing is ranked among the top 10 physically demanding occupations for older females; workers in physically demanding jobs may be unable to work until retirement age (Rho 2010). Unhealthy lifestyles, highly stressful jobs, and heavy physical work has a negative impact on workers over 45 years of age (Naumanen 2006). Further, physiological variations occur during aging which affect older workers’ ability to work safely. Although older nurses may use excellent coping and injury avoidance strategies, demanding workload and normal physiological changes contribute to increased work hazards.
Key Issues The literature revealed five major work hazards for older nurses: (1) fatigue, (2) needle-stick injuries, (3) repetitive motion injuries, (4) stress-related health problems and (5) slips, trips and falls. Factors from normal aging, personal habits and the work environment for each hazard were delineated. Figure 1 presents a schematic representation from an occupational health nursing perspective of potential relationships between contributing factors, work hazards and adverse outcomes among an aging nursing workforce. It is beyond the scope of this paper to address each work hazard and the discussion will focus primarily on fatigue, repetitive motion injuries and slips, trips and falls. Best evidence suggests managers must consider normal aging outcomes on job performance when assigning job responsibilities (Ilmarinen 2001). The decreased cardiovascular function associated with increasing age could overload some workers, negatively impacting on health. Among aging Europeans, health care workers suffer specific and often acute problems similar to those of high-risk workers in unskilled manual jobs (Vendramin & Valenduc 2012). High-risk workers typically perform jobs in painful positions at high speeds with little social support or discretion in decision-making about their jobs. These role strains contribute to declining health for aging ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
Work hazards
* Work Environment * Job Tasks/Roles * Shift Pattern * Work/Life Imbalance * Family/Personal Relationships * Personal Finances
Stress Related Health Problems * Work Schedule * Strenuous Work * Circadian Disruption * Family/Other Responsibilities * Sleep Disturbances
OUTCOMES Fatigue
* Diminished Vision * Fatigue * Unsafe Equipment * Unsafe Work Habits * Inadequate Training
Chronic Health Problems Increased Lost Work Time Increased Presenteeism Increased Absenteeism Increased Medical Costs Increased Operating Costs
Needle Stick & Sharps Injuries
Cumulative Motion Injuries
Slips, Trips & Falls
* Decreased Strength & Flexibility * Abnormal Postures * Repeated Actions * Overexertion
* Diminished Balance * Vision Changes * Corrective Lens * Workplace Spills * Cluttered Walkways * Hearing Loss
Figure 1 Phillips’ aging nursing workforce model.
workers and increase the prevalence of back problems and sleep disorders. Although the majority of health care workers over the age of 50 years reported satisfactory general health in the preceding year, nearly 60% had back problems and 25% experienced sleep disorders. Similarly, there were complaints of back problems and sleep disorders in younger health care workers (Vendramin & Valenduc 2012). Among older female nurses with at least 28 years’ experience who worked over 9 hours/day and 36 hours/week during the preceding 5 years, 36% reported a work-related health problem and nearly one-fourth (23%) were injured at work (Levtak 2005). Perhaps these health conditions signal warnings that force workers to question their ability to continue working long hours. Nearly half of health care workers over 50 years prefer to work fewer hours (Vendramin & Valenduc 2012). The physical workload of jobs, especially among the aging female population, should ideally be reduced as workers age (Ilmarinen 2001). Concerns mount that normal aging effects combined with strenuous work processes and occupational exposures may adversely affect health care workers’ quality ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
of life and health (Healthy Aging for a Sustainable Workforce 2009). As nurses work into older age to address workforce shortages, those with chronic diseases may be more vulnerable to musculoskeletal injuries. More complex work tasks and health care delivery organisations have intensified physical and emotional demands for workers. Jobs with inadequate numbers of workers owing to high staffing ratios and an older, sicker more obese patient population may force workers to engage in dangerous and risky practices. Workers may reach a point where they can no longer perform job tasks simply because of age-related limitations (Healthy Aging for a Sustainable Workforce 2009).
Fatigue and safety risks Fatigue in sleep-deprived shift workers also affects job performance. Nearly 60% of hospital nurses work 12hour shifts; less than 25% work a straight 8-hour day shift (American Nurses Association 2013a). Generally, working shift patterns contribute to high turnover rates (Peters et al. 2009); replacement costs are 805
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approximately $88 000 per nurse (Li & Jones 2013). Nurses working longer than 8–9 hours per shift report more burnout and greater job dissatisfaction, and are more likely to resign (Stimpfel et al. 2012). No distinct difference in the work schedule is evident based on age. Older health care workers have similar schedules to those of their younger counterparts; many work more than 8 hours/day and 40 hours/week, including successive night and weekend shifts (Healthy Aging for a Sustainable Workforce 2009). Concerns among shift workers remaining in the workforce include safety risks associated with the shift pattern. There is a clear link between fatigue and safety risks (Price 2011). Substituting shifts of 10–12 hours for traditional 8-hour shifts increases fatigue and may affect occupational injury rates for nurses (Hopcia et al. 2012). In 2009, hospitals reported 248 200 non-fatal occupational injuries and illnesses among workers (Bureau of Labor Statistics 2012). The incidence rate was 6.9 injuries and illnesses per 100 fulltime workers compared with rates for industry as a whole of 3.7 injuries and illnesses per 100 full-time workers. Recent data revealed injury incidence rates of 125.1 per 10 000 full-time RNs; median absence rates were 7 days per injury (Bureau of Labor Statistics 2012). Among older workers, the risk of incidents and resultant injury is higher on evening shifts than on morning shifts and highest on the night shift (Folkard 2008). Other injury trends include: (1) night workers have longer recovery periods; (2) injury risks increase as night shift progresses and overall alertness and performance levels decline; (3) injury risk increases on each successive night shift; and (4) the greatest injury risk occurs on the fourth consecutive night worked (Folkard 2008). Hopcia et al. (2012) also reported increased injury risk with consecutive workdays and 12-hour shifts. While not limited to any age group, concern over fatigue-related nursing errors from long work shifts prompted a recommendation that shift work patterns be evaluated (Joint Commission 2011). Hospitals were prompted to monitor fatigue-causing factors such as length of time between shifts and the number of consecutive shifts worked, and to involve nursing staff in designing work schedules to reduce fatigue risks. These recommendations were significant as older nurses need longer to recover from night shifts or overtime work (Fragar & Depczynski 2011). Older workers may be unable to sustain the same level of performance over the entire shift or cope with multiple successive night shifts (Folkard 2008). 806
Injuries and work performance Although fatigue and shiftwork increase work hazards, older workers generally have excellent safety records. However, their injuries are more pronounced and require longer recovery times (Folkard 2008, Farrow & Reynolds 2012). The number of days off work after an injury increases substantially based on age; median days off for all workers was 7 but increased to 12 for those aged 55–65 years, and to 16 for those aged 65 years and older. Older workers have more disabling conditions, such as fractures and multiple injuries (Healthy Aging for a Sustainable Workforce 2009). Work performance, or functional capacity, begins to decline at age 45 years (Soer et al. 2012). Lifting and the ability to carrying objects, hand and finger strength and coordination are most affected. Regardless of age, between 20% and 35% of women in professions such as nursing have insufficient capacity to meet work demands for occasional lifting, pulling and pushing loads of 50 pounds (22.7 kg) or less (Soer et al. 2012). Moving and lifting patients along with squatting, bending or maintaining postures for long periods are difficult and physically challenging with obese and debilitated aging patient populations (Fragar & Depczynski 2011). In addition, physically demanding jobs require highly coordinated body movements and balance to work safely and reduce injury risks. Coordination and balance are affected by muscle strength; male workers are always stronger and start losing their strength earlier, but once women begin losing theirs, around age 41 years, weakening progresses rapidly (Danneskiold-Samsøe et al. 2009). Balance is a complicated skill, perhaps protected in firefighting and construction because workers regularly climb ladders to work at heights (Punakallio 2003). Both of these worker categories demonstrated better functional balance than nursing staff and home-health workers. However, balance abilities declined for all workers as they grew older regardless of gender or job (Punakallio 2003). Other factors also increase risk of injuries. A noisy workplace coupled with age-related hearing loss increases the risk of injury incidents, particularly slips, trips and falls (Picard et al. 2008). Excessive noise may increase fatigue leading to decreased concentration and increased mental mistakes (Picard et al. 2008). Psychomotor performance also affects job safety. Nurses with fewer hours of sleep experienced worse psychomotor performance regardless of their longevity in nursing or experience working a particular unit or night shift (Johnson et al. 2010). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
Journal of Nursing Management, 2015, 23, 803–812
Work hazards for an aging nursing workforce JENNAN A. PHILLIPS
PhD, RN
1
and REBECCA MILTNER
PhD, RN, CNL, NEA-BC
2
1
Assistant Professor and Director, Occupational Health Nursing Program and 2Assistant Professor, Community Health, Outcomes & Systems Department, School of Nursing University of Alabama at Birmingham, AL, USA
Correspondence Jennan A. Phillips NB 316 1720 2nd Avenue South Birmingham Alabama 35294-1210 USA E-mail: [email protected]
(2015) Journal of Nursing Management 23, 803–812. Work hazards for an aging nursing workforce
PHILLIPS J.A. & MILTNER R.
Aim To discuss selected work hazards and safety concerns for aging nurses. Background Greater numbers of older nurses remain in the workforce. Projections suggest that one-third of the nursing workforce will be over age 50 years by 2015. Employers will struggle to find ways to protect the health and safety of their aging workforce and prevent a massive loss of intellectual and human resources when these experienced nurses exit the workforce. Evaluation Review of recent relevant literature in English language journals. Key issues Repetitive motion injuries, fatigue and slips, trips and falls are three major work hazards older nurses face. We discuss several factors for each hazard, including: the normal physiological aging effects of diminished strength, hearing and vision; workplace variables of work schedules, noise and clutter; and personal characteristics of sleep disturbances, overexertion and fatigue. Conclusions Inconclusive evidence exists to guide best practices for designing safe workplace environments and shift patterns for nursing work. Implications for nursing management There are at least two areas administrators can reduce work hazards for older workers: (1) modification of the workplace, and (2) creating the infrastructure to support the aging workforce to encourage healthy behaviours. Keywords: aging nurses, aging workers, older nurses, older workers, work hazards Accepted for publication: 23 December 2013
Introduction The aging workforce is a great concern for all employers (Healthy Aging for a Sustainable Workforce 2009, Bureau of Labor Statistics 2013), yet few companies are actively investing in programs to build a sustainable workforce (Hill 2011). Chronological aging occurs at the same rate for everyone, but noticeable effects depend on genetics, health habits, lifestyle choices, illnesses, environmental exposures and work processes (Naumanen 2006). These differences preclude a precise definition of aging workers (between 45 and 55 years or older is often used). Generally, older workers have some physical difficulties such as weakened work ability, stiff and slow movements and DOI: 10.1111/jonm.12217 ª 2014 John Wiley & Sons Ltd
more fatigue or exhaustion. Older workers with psychological limits also may exhibit rigid behaviour, boredom and memory or learning problems (Naumanen 2006). Nurse managers should be concerned about protecting the health and safety of their employees. The nursing role is physically, cognitively and psychologically demanding (Healthy Aging for a Sustainable Workforce 2009), yet the median age of registered nurses (RNs) is now 46 years (US Department of Health & Human Services 2010). A web-based search using PubMED and CINAHL for literature published between 2000 and 2013 in English language journals was conducted to obtain a broad overview of job hazards for aging workers and nurses. Key terms included
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Visually impaired and older workers need the higher range of luminance; lights with adjustable intensity will allow all workers to have comfortable lighting. Lighting units need low-brightness lenses that control glare and evenly distribute light (Industrial Accident Prevention Association 2008). Separate lighting units for tasks, ceilings and walls will prevent shadows. Table 1 provides recommendations for controlling work hazards for aging nurses compiled from information contained in a factsheet available from a workers’ compensation division (Texas Department of Insurance 2008). Ergonomics is the science of fitting workplace conditions and job demands to the physical and cognitive capabilities of workers (US Department of Labor 2007). Organisational leaders should assess structures and equipment and match nursing tasks to worker capabilities; an ergonomically designed work environment benefits all staff regardless of age and may also promote retention of older nurses (Chosewood 2012). The functionality of new products should be evaluated not just within existing systems or patient populations, but also mindful of specific worker groups. For example, aging eyes do best with serif scripts at 12–14 font sizes in dark colours against light backgrounds. However, many computer screens in electronic health records do not meet that standard. Purchasers could
request adjustable documentation templates. Other relatively simple workplace accommodations are targeted lighting and computer screen magnifiers or other magnifying devices. Recommendations for ergonomic redesign specific to health care environments are available in eTools for hospitals (US Department of Labor 2002) and long-term care facilities (US Department of Labor 2000). Manual lifting or shifting of patients should be avoided by all nurses. Safe patient handling equipment should be readily available to all direct patient care providers, but broadly accepted standards to guide systematic development of safe handling programmes have only recently been released (American Nurses Association 2013b). At a minimum, workers need easy access to equipment that supports patient transfers, lifting and repositioning. The Department of Veterans Affairs in the USA developed a model comprehensive safe patient handling programme for its national network of health care facilities (Nelson & Baptiste 2004). The Department of Veterans Affairs’ policies, equipment information, cost benefit analyses, and other information are freely available (US Department of Veterans Affairs 2012). Task rotation is often used in office or manufacturing work to reduce repetitive motion injuries and/or static standing. Initially, rotating tasks may not seem
Table 1 Strategies to protect an aging nursing workforce Work hazard Cumulative trauma from repetitive motion injuries
Slips, trips and falls
Fatigue
Nursing management strategy Provide educational programmes that teach proper movement including avoiding a fixed posture or performing only one kind of movement, twisting with any lifting activity, repetitive tasks, and prolonged standing or sitting Provide appropriate safe patient handling equipment and/or get assistance from others when moving patients Provide anti-fatigue mats in areas that require standing for long periods Provide opportunities during work for all nurses to engage in exercise at least 20–30 minutes daily Provide strength and balance training for older nurses at the worksite Provide access to membership for fitness facilities for older nurses to participate in water exercise in reduced weight-bearing environment to improve balance Encourage older workers to have annual vision checks Provide administrative controls that require all nurses to wear appropriate well-fitted shoes with non-slip soles Maintain clutter-free workspaces Provide slip-resistant flooring; replace marble, polished wood and tile flooring Check for uneven surfaces, cracks, build-up of dirt/debris and weather hazards on exterior walkways Use bright lights and provide handrails in stairways Use non-slip surfaces on stair treads Use contrasting colours to separate different levels of surfaces like stairs Improve contrast between objects by increasing lighting Eliminate need to constantly move between brightly and dimly lit areas To reduce eye fatigue, install glare screens on computers Reduce glare by using shades, awnings and diffuse light sources, adjustable and indirect lighting Minimise background noises to accommodate hearing deficits Provide flexible work schedules and options for reduced work hours Limit consecutive 12-hour shifts to a maximum of two Allow at least one short nap break of 20 minutes during night shift Educate older workers on sleep hygiene Offer health screening for sleep apnoea/other sleep disorders
Adapted from: Aging in The Workplace Factsheet (Texas Department of Insurance 2008).
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to apply in nursing work. However, repetitive motion work such as keyboarding, working in awkward positions, sitting in poorly designed seats at non-adjusting tables with inappropriate heights as well as repetitive pulling, lifting, pushing, bending, stooping and other gross motor activities is common in nursing. Managers should consider rotating nursing assignments for patients with heavy physical care demands while also allowing self-paced work with self-directed breaks (Chosewood 2012). Patients who require intense physical exertion may need to be co-assigned with a nursing assistant or other team member to protect workers from injury. Working in teams can offset some job demands and should be encouraged.
Supportive infrastructure Infrastructure to support both aging workers and overall healthy worker behaviours is essential to a productive workforce. Administrative policies and procedures are needed that support the aging workforce in a respectful and legal way. These policies should cover a broad range of issues from the interaction with the work environment to appropriate work scheduling and health promotion and protection in all employees. Policies that change the work environment include the ergonomic issues discussed above but also more comprehensive evaluation of nursing work processes. Questions include what staffing models best protect an older workforce and whether a team approach is more effective and less hazardous to all clinical health care workers. The need exists to modify, or perhaps eliminate heavy, physically demanding work requirements. Unquestionably, more research is needed to determine the safest design for nursing work. Policies also need to address appropriate work scheduling to support the nursing workforce by allowing flexible scheduling, job sharing, part-time employment and phased retirement options (Long Range Policy Committee 2010, Chosewood 2012). Most acute care nurses work three or more 12-hour shifts each week, although the evidence suggests consecutive shifts have a negative impact on performance (Geiger-Grown & Trinkoff 2010). These scheduling patterns are very popular with nurses and eliminating them may be difficult. Fatigue during these shifts may be reduced with short 20-minute nap periods, but these break periods need support from nursing administration. Because physical changes in vision and hearing are gradual, aging workers rarely notice their own functional decline. Administrators should consider annual ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 803–812
screening for vision, hearing, and even balance and flexibility. Strategies are needed that offset work demands with age-related performance limitations. Workloads should include more mentally challenging tasks that rely more on the rich knowledge and skills of older workers. Further, organisations must evaluate the influence of their benefits and compensation policies on the financial interests of older workers. In other words, do employer policies and actions actually encourage workers to exceed their physical capabilities and functional limitations? One concern with increasing numbers of older workers is finding workplace accommodations for functional decline. As workers age, the possible risk of disability from masked limited functional capacity increases; injury may occur when the worker performs an infrequent or unusual job task (Fogg & Harrington 2011). Many job tasks of direct patient care place older nurses at higher risk of injury and disability. Proactive strategies such as modifying the workplace, as discussed, above may address many limitations of aging nurses, and reasonable accommodations and case management may speed return to work after an illness or injury (Chosewood 2012). Job training to develop worker competencies in technology-related care modalities may address declining functional capabilities associated with aging (Chosewood 2012). Changes in the physical spaces of nursing units as well as in job duties, work tasks and hours of work, including more flexible work schedules, are needed to accommodate aging workers (Fogg & Harrington 2011). Additional research in this area is therefore warranted. Ilmarinen (2001) proposed the following strategies to support an older workforce: (1) teach supervisors best practices for managing aging workers, (2) implement supportive ergonomic principles; (3) implement worksite exercise and fitness programmes; and (4) provide age-appropriate technology training for older workers. The integration of several approaches was suggested for improved results. Outcomes could be measured as improved work productivity and decreased complaints of musculoskeletal injuries along with reduced absenteeism and medical costs among nurses with chronic health conditions. Finally, support for managing the older nursing workforce must begin with the top executives and involve senior administrators from human resources and nursing with input from occupational health nurses. Ensuring a viable workforce to meet future demands requires proactive strategies to protect and promote health while creating a positive work environment for all nurses regardless of age or shift 809
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pattern. Recommendations from the Joint Commission (2011) to promote improved alertness during night shifts, including engaging in conversations, walking around the nursing unit, stretching, strategic caffeine consumption and taking short naps, may help protect nurses from occupational injuries. Administrative policies that support these practices are needed. The American Hospital Association suggested a workplace culture supportive of healthy lifestyles and recognising the value of older staff were strategies that support aging health care workers and counter the looming tight labour market (Long Range Policy Committee 2010). Box 1 contains two web-based resources useful for promoting preventive services among adults aged 50–64 years. Many large organisations offer incentives for employees who quit smoking or lose weight. However, everyone needs access to healthy foods while at work and employer-sponsored programmes for stress management, weight loss support and tobacco cessation are important even in small work settings. Further, more effort is needed to support a culture of fitness; promoting physical activity by creating standing work stations and walking spaces within the workplace may be beneficial. Workers should be encouraged to engage in regular aerobic exercise to maintain their cardiovascular system at an age-appropriate fitness level. Box 1 Promoting preventive services for adults aged 50–64 years ● In partnership with the American Association of Retired Persons (AARP) and the American Medical Association, the Centers for Disease Control and Prevention (CDC) released recommendations for health promotion among older working age adults in the document Promoting Preventive Services for Adults 50–64: Community and Clinical Partnerships available at http://www.cdc.gov/aging/pdf/promoting-preventiveservices.pdf. ● An interactive tool identifies a set of recommended preventive services and health indicators for the 50- to 64-year-old population and allows one to search by state and local metropolitan areas to monitor progress toward successful adoption of health behaviours. This eTool from the CDC is available at http://apps.nccd.cdc.gov/DACH_PPS/Default/ Default.aspx
The Healthier Worksite Initiative (Centers for Disease Control & Prevention 2010) and Total Worker HealthTM programme (Centers for Disease Control & Prevention 2013) offer useful evidence-based guidelines that any employer could use to protect and promote health. Similar information specific to health care settings is also available (Chang 2013, Centers for Disease Control & Prevention n.d.). Administrative policies and worksite programmes based on these 810
initiatives may create a work environment that supports older nurses and the international, multigenerational nursing workforce. Organisations with a robust workplace climate supportive of health and wellness will be well positioned for the future.
Conclusions As the nursing workforce continues to age, many challenges will present for nurse managers to protect the health and safety of this vulnerable worker population. There is strong evidence of the physically and mentally challenging nature of direct nursing care. Additionally, injuries among US health care workers across all ages exceed those in occupations often considered more hazardous. However, the nature of nursing work, including shift patterns for around-the-clock patient care, presents unique hazards for the international nursing community. Only recently have governments and employers begun to address the associated problems, yet few have taken the necessary actions to confront them in a comprehensive manner. Limited evidence exists to guide occupational health strategies specific to the aging nursing workforce. Further, at best there is inconclusive evidence from other worker populations to suggest potential solutions to prevent work-related injuries, burnout and early retirements in older nurses. Therefore, it is imperative that nursing leaders from health systems administration, worksite health promotion programmes and occupational health collaborate on solutions to address these issues. Strong research agendas are needed to not only determine work hazards specific to an aging nursing population but also interventions that promote and protect the health and safety of the total nursing workforce.
Sources of Funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was not required for this paper.
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