Nurses Working Conditions Implications for Infectious

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Nurses Working Conditions and Infectious Disease, elevates hospital costs increases the fragmentation of country n 14 538 Many concerns exist about clinical. health care and discourages longer term proactive solu competencies cultural sensitivity and ethics of the prac. tions to staffing shortages that would improve the morale tice of importing nurses 13 While international recruit. of the permanent staff as well as the quality of patient care ment can be a solution in one country it can create addi. services 8 Extended work shifts and overtime for nurses tional shortages in others. have also escalated however nurses report making more. errors when working shifts 12 hours working overtime Nursing and Healthcare associated Infections. or working 40 hours per week 9 A recent evidence based practice report sponsored by. To increase the overall supply of nurses many coun the Agency for Healthcare Quality and Research conclud. tries are increasingly relying on international recruitment ed that a relationship exists between lower levels of nurse. and migration 10 The percentage of foreign trained staffing and higher incidence of adverse patient outcomes. nurses in the United States is 4 compared to 8 in the 14 Nurses working conditions have been associated. United Kingdom and 23 in New Zealand 11 However with medication errors and falls increased deaths and. the actual number of foreign trained nurses in the United spread of infection 15 30 Table RN staffing levels. States is 90 000 which compares to 42 000 in the United have been associated with the spread of disease during out. Kingdom 12 In 2002 for the first time more foreign breaks 17 22 23 25 28 However increasing nurse to. trained nurses n 16 155 were newly registered in patient ratios alone is not adequate more complex staffing. Britain than were those who had been educated within the issues appear to be at work Many studies have found that. Emerging Infectious Diseases www cdc gov eid Vol 10 No 11 November 2004 1985. INTERNATIONAL CONFERENCE ON WOMEN AND INFECTIOUS DISEASES. the times of higher ratios of pool staff i e nursing staff. who were members of the hospital pool service or agency. nurses to regular staff i e nurses permanently, assigned to the unit were independently associated with. healthcare associated infections 16 17 21 27 The skill. mix of the staff that is the ratio of RNs to total nursing. personnel RNs plus nurses aides is also related to. healthcare associated infections increased RN skill mix. decreases the incidence of healthcare associated infections. 20 29 30 In a recent comprehensive review of the litera. ture the authors concluded that evidence of the relation. ship between nurses working environment and patient. safety outcomes including healthcare associated infec. tions is growing They also concluded that stability skill. mix and experience of the nurse workforce in specific set. tings are emerging as important factors in that relationship Figure Blood and body fluids exposure by personnel category. Source National Institute for Occupational Safety and Health 34. Nurses Work and Occupational working conditions In a cross sectional study of 1 500. Exposure to Infectious Disease nurses employed on 40 units in 20 hospitals poor organi. All healthcare workers face a wide range of hazards on zational climate and high workloads were associated with. the job including blood and body fluid exposure as well as 50 to 200 increases in the likelihood of needlestick. musculoskeletal injuries related to ergonomic hazards injuries and near misses among hospital nurses 3. from lifting and repetitive tasks nursing personnel often Emerging infectious diseases and outbreaks of recog. experience these hazards most frequently 32 In 2001 nized contagious illnesses have highlighted other concerns. U S hospitals reported 293 600 nonfatal occupational about the safety of healthcare workers For example much. injuries and illnesses among their personnel Among the of the worldwide severe acute respiratory syndrome. eight private U S industries with 100 000 injuries and ill SARS outbreak was hospital based and healthcare. nesses annually the number of cases of nonfatal injury or workers made up a large proportion of cases accounting. illness in hospitals is the second highest and the incidence for 37 to 63 of suspected SARS patients in highly. rate of injuries and illnesses per 100 fulltime workers affected countries 35 In many countries nurses were the. employed in nursing and personal care facilities is 13 5 by largest single group affected by SARS 36 During the. contrast the national average is 1 8 In 2001 nursing aides Toronto outbreak patient care activities commonly con. and orderlies reported the highest number of occupational ducted by critical care nurses such as manipulating oxy. injuries that resulted in days away from work of any serv gen masks and suctioning infected patients were signifi. ice industry 70 300 RNs had the second highest number cantly associated with SARS infection 37 In the event of. 24 400 33 an influenza pandemic healthcare workers would be sus. Work acquired infectious diseases are among the risks ceptible During an outbreak of parainfluenza in a interme. all healthcare workers face and bloodborne pathogens fig diate care nursery 16 25 of 65 staff members reported. ure prominently among these Occupational exposure to symptoms of respiratory illness 38 These threats to safe. blood and body fluids is well documented among health ty of the nurse and other essential healthcare workers are. care workers Annual exposure prevalence rates range of concern for many reasons. from 10 to 44 depending on the occupational sub First a trained qualified healthcare workforce is neces. group 34 Every year approximately 600 000 800 000 sary to respond and care for the public in the event of an. occupational needlestick injuries occur in the United States outbreak Staffing issues and hospital organization prob. 34 In a study of 60 U S hospitals in a 4 year period lems are believed to have complicated the containment of. nurses were the most likely to experience a blood or body the SARS crisis in Toronto Staffing shortages especially. fluid exposure Figure 34 Most exposures involve per of nurses have been identified as one of the major factors. cutaneous injuries e g needlesticks although mucocuta expected to constrain hospitals ability to deal with possi. neous e g spray or splashes to the eyes or mouth and ble future threats 4 Without adequate numbers of trained. direct contact of infected blood with nonintact skin are also hospital employees to implement effective infection con. routes of exposure These potential infections like health trol procedures such as hand hygiene and proper isolation. care associated infections also appear to be tied to nurses procedures emergency departments and hospital wards. 1986 Emerging Infectious Diseases www cdc gov eid Vol 10 No 11 November 2004. Nurses Working Conditions and Infectious Disease, can easily become the venues where the spread of epi include costs related to training recruitment and retention. demics occurs need to be conducted, Second the perception of unsafe working conditions. both for the patient and the worker may actually hinder Implications for Policy. recruitment and retention of qualified staff In a American Policy solutions for nurse staffing fall into two general. Nurses Association survey of RNs N 7 353 88 of categories 1 incentives and funding for various parties to. respondents reported health and safety concerns related to increase the supply of nurses and 2 employer and hospital. work 75 felt the quality of nursing care had declined in regulatory approaches Although scholarships loan for. their work setting in the past 2 years and 92 of those giveness schemes and funding of new nursing school stu. respondents related these concerns to inadequate staffing dent slots may be helpful these policies are unlikely to. Furthermore 70 of respondents indicated concerns overcome the long standing complex nature of the diffi. about the acute and chronic effects of work stress and culties in recruiting sufficient newcomers to the nursing. overwork concerns about a disabling back injury 60 profession and then retaining a qualified workforce. and fear of contracting HIV or hepatitis from a needlestick In the United States regulatory approaches by the. injury 45 Nurses reported that these health and safety states have included prohibiting mandatory overtime for. concerns influence their decision to continue working in nurses nine states with regulations holding hospitals. the field of nursing and the kind of nursing work they accountable for developing and implementing valid. choose to perform Because of these concerns nearly 55 staffing plans seven states and setting minimum staffing. of the nurses surveyed would not recommend the nursing ratios one state Regulating minimum nurse patient ratios. profession as a career for their children or friends has received much attention despite critiques from the. Although the results of this survey may not be generaliz hospital industry that insufficient data exist to credibly set. able to all nursing personnel because of the nonprobability minimum safe staffing levels California was the first state. sampling method and inclusion of only RNs the results to implement hospitalwide minimum nurse patient ratios. suggest that concern over safety may be contributing to The effects of this regulation need to be carefully exam. hospital personnel shortages and hindering recruitment ined Although nursing services are positively correlated. efforts Dissatisfaction burnout and concerns about qual with patient outcomes controversy exists over what con. ity of care are reportedly common among hospital nurses stitutes an optimal staffing ratio and little empirical evi. in five other industrialized countries 39 dence is available on which to base these decisions. Staffing levels for bedside nurses are not the only criti. Gaps in Current Knowledge cal resource involved in decreasing risks for healthcare. Barring unprecedented growth in the nursing workforce associated infections occupational injuries and infections. or unforeseen new forces in health care that intervene to Also important is determining the critical mass of infection. reduce burden of care in society the numbers of nurses control and occupational health professionals needed for. will not keep pace with the demand for services In the surveillance identification of departures from sound prac. coming decades we face the prospect of fewer profession tices and ongoing education of healthcare workers. als and more unlicensed workers in the healthcare work Policies aimed at ensuring the availability of training pro. force Decisions will have to be made about how hospitals grams on all aspects of patient and worker safety are need. will safely adapt to this situation At this time little evi ed as is the availability of appropriate supplies to prevent. dence exists on what constitutes a safe and efficient labor unnecessary infections among patients and nurses. force mix Therefore the general impact of nurse working. conditions needs to be examined First longitudinal stud Conclusions. ies that track change in infection rates and other untoward Nursing is a predominately female occupation in which. incidents over time under different working conditions the working conditions are often poor Such conditions. and with different staffing models are essential Second contribute to recruitment and retention problems Together. researchers need to study how the actual care received by with demographic changes the result is a shortage of qual. patients varies under different staffing conditions at the ified nurses Mounting evidence demonstrates that the lack. bedside so that a better understanding of the impact of of an adequate supply of qualified nurses is a global pub. work environments at the point of care can be gained lic safety issue that may require a multipronged policy. Finally since costs of care increase when patients have approach Monitoring and improving the working condi. adverse outcomes 40 and nurses working conditions tions of nurses are likely to improve the quality of health. affect outcomes better working conditions could arguably care by decreasing the incidence of many infectious dis. save the healthcare system money However the cost ben eases assisting in retaining qualified nurses and encour. efit ratio is not known and economic analyses which aging men and women to enter the profession Further. Emerging Infectious Diseases www cdc gov eid Vol 10 No 11 November 2004 1987. INTERNATIONAL CONFERENCE ON WOMEN AND INFECTIOUS DISEASES. research is needed to understand how best to protect the 16 Alonso Echanove J Edwards JR Richards MJ Brennan P Venezia. patient as well as the healthcare worker Changes in the RA Keen J et al Effect of nurse staffing and antimicrobial impreg. nated central venous catheters on the risk for bloodstream infections. workforce will have implications for infectious disease in intensive care units Infect Control Hosp Epidemiol. infection control and occupational health professionals 2003 24 916 25. with a need for much more thorough training of nonprofes 17 Andersen BM Lindemann R Bergh R Nesheim B Syversen G. sionals in critical practices Solheim N et al Spread of methicillin resistant Staphylococcus. aureus in a neonatal intensive unit associated with understaffing. overcrowding and mixing of patients J Hosp Infect 2002 50 18 24. Staffing patterns and nurses working conditions are risk factors for healthcare associated infections as well as occupational injuries and infections Staffing shortages especially of nurses have been identified as one of the major factors expected to constrain hospitals ability to deal with future outbreaks of emerging infections These prob lems are compounded by a global nursing

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