Household-Related Hazardous Conditions With Implications for Patient Safety in the Home Health Care Sector

Classifying Studies on Workplace Violence for Visiting Nurses Using the Social-Ecological Model: A Scoping Review

PURPOSE

To prevent workplace violence (WV) against visiting nurses (VNs), understanding the influencing factors is crucial. To better comprehend potential violence prevention strategies, the U.S. Centers for Disease Control and Prevention has presented the four-level social-ecological model (SEM) at the 1) individual, 2) relationship, 3) community, and 4) societal levels. This study aims to quantify WV studies against VNs, examine the influencing factors, identify gaps based on SEM levels, and propose future research and policy directions.

DESIGN

A scoping review was conducted following the five-stage protocol proposed by Arksey and O'Malley in 2005.

METHODS

Systematic searches, including manual searches, were performed using English and Korean databases. Published journal articles including editorials on WV against VNs were included, irrespective of the publication date.

FINDINGS

Sixty journal articles were finally selected. Until the 1990s, most of the literature comprised editorials, with empirical research emerging after the 2000s. Classifying studies by SEM level, many studies have focused on individual (86.7%) and community (66.7%) factors, but fewer have addressed relationship (21.7%) and societal (16.7%) factors.

CONCLUSIONS

The study revealed that much research has focused on individual-centered training, with gaps in risk assessment tool development, training incorporating relational aspects, standardized protocols, and understanding of the impact of legal rights and policies. This article advocates a comprehensive approach that considers all SEM levels to address WV against VNs.

CLINICAL EVIDENCE

The findings confirm a research gap, which suggests the direction for future research and policies. Stakeholders should be urged to implement evidence-based strategies that contribute to safer work environments for VNs.

Occupational Violence Experienced by Care Workers in the Australian Home Care Sector When Assisting People with Dementia

BACKGROUND

People with advancing dementia may be dependent on community services from home care workers and nurses to be supported at home. However, these care workers face difficulty undertaking their roles due to challenging behaviours or occupational violence. This study aimed to explore the challenges faced by home care workers and nurses working with people diagnosed with dementia in the community, to identify job demands contributing to their vulnerability to occupational violence, and to determine ways to help manage occupational violence.

METHODS

A qualitative descriptive study was conducted by interviewing 10 homecare workers and six registered nurses from agencies in South Australia and New South Wales, Australia. Interviews were audiotaped, transcribed and inductive thematic data analysis was conducted.

RESULTS

The following themes were identified: (i) sources of threats; (ii) categories of violent, threatening or challenging behaviour; (iii) aggravating factors; (iv) early warning signs; (v) education and training; (vi) managing occupational violence, (vii) resources, (viii) outcomes associated with exposure to occupational violence.

CONCLUSION

Serious issues were identified by participants, yet very little is known about occupational violence for these community care workers. Findings can inform what aspects of work design can be improved to moderate the effects of occupational violence exposure or mitigate rates of exposure, to enable long-term services for people with dementia.

Concept analysis of patient safety in home care: a hybrid model

BACKGROUND

Patient safety in home care is a fundamental and complex concept in nursing. This concept includes a number of challenges in patient care. Studies have shown that there is no clear and uniform definition for this concept.

OBJECTIVE

The objective of the present study was to analyse patient safety in home care in Iran.

METHODS

The study was done using a hybrid model at three phases, including theoretical, field work and the final analysis. We searched valid databases including MEDLIN and CINHAL; electronic references including Web of Science, Scopus, Ovid, ProQuest, PubMed and Persian databases including Magiran, IranDoc and SID during 2008-2022, using these Persian and English keywords: Patient Safety, Safety, Home Care Service, Domiciliary Care, Home Care and Home Health Care. A total of 16 articles were searched in the theoretical phase and then analysed by content analysis. In field work phase, nine participants were interviewed (nurse, family and patient) and then the interviews were analysed by the content analysis method. In the final analysis phase, a general analysis of the previous two phases was performed and after determining the attributes, antecedents and consequences, a final definition of patient safety in home care in Iran was presented.

FINDINGS

Based on different studies, patient safety in home care is a multifaceted concept, which encompasses physical, mental, social and practical dimensions. Evaluation, prevention, participation and commitment to the safety culture are the core features of this concept. The patient care concept depends on the commitment of the involved participants, adequate resources, environmental conditions, support of the involved centres (home care agency, hospital and the insurance), self-efficacy and the ability of the caregivers (nurses).

CONCLUSION

Defining the concept of patient safety in home care provides a basis for the development of a safe patient care system at home. This concept analysis for patient safety in home care could be a guide for future studies.

Design and development of the home healthcare worker observation tool

BACKGROUND

The rapidly growing number of home healthcare workers (HHCW) are exposed to unique occupational hazards within each patient home. This article describes the development of an observation tool to document occupational hazards HHCWs encounter.

METHODS

Tool development followed three steps: determining content domain, content validity, and inter-rater agreement.

RESULTS

Expert feedback guided the revision of content domain to 636 items. Scale level content validity index (S-CVI) was 0.90. Inter-rater agreement tests resulted in percent agreement and accuracy mean of 89.5% and frequency variables resulted in standard deviations from 0 to 8.62.

CONCLUSIONS

The observation tool encompasses the diverse range of occupational hazards HHCWs encounter; inter-rater percent agreement and overall accuracy scores were acceptable. Future pilot testing of this tool among broader raters and populations is recommended to characterize its usability, internal consistency, and reliability to assess HHCW occupational hazards.

Occupational Exposures in the Homecare Environment: Piloting an Observation Tool

The population of home healthcare workers (HHCWs) is rapidly expanding. Worker tasks and the unique home care environments place the worker at increased risks of occupational exposures, injury, and illness. Previous studies focusing on occupational exposures of HHCWs are limited to self-reports and would benefit from direct observations. The purpose of this study is to describe the occupational hazards observed in the unique work environment of home healthcare. HHCWs and home care patient participants were recruited from one home care agency in the Midwest to be observed during a routine home visit. This cross-sectional study used a trained occupational health nurse for direct observation of the occupational setting. Standardized observations and data collection were completed using the Home Healthcare Worker Observation Tool. The observer followed a registered nurse and occupational therapist into 9 patient homes observing visits ranging from 22 to 58 minutes. Hazards observed outside of and within the home include uneven pavements (n = 6, 67%), stairs without railings (n = 2, 22%), throw rugs (n = 7, 78%), unrestrained animals (n = 2, 22%), dust (n = 5, 56%), and mold (n = 2, 22%). Hand hygiene was observed prior to patient care 2 times (22%) and after patient care during 5 visits (56%). Observations have identified hazards that have the potential to impact workers’ and patients’ health. The direct observations of HHCWs provided opportunities for occupational safety professionals to understand the occupational exposures and challenges HHCWs encounter in the home care environment and begin to identify ways to mitigate occupational hazards.

Homecare nurses' length of conversation and intention to remain at the workplace: A multilevel analysis

AIMS

To examine the relationship between homecare nurses' length of conversation with nurse managers and colleagues and intention to remain at the workplace.

BACKGROUND

Nurse turnover is an important issue. Previous studies focused on the perceived function of communication. However, we do not know the contribution of homecare nurses' actual conversations to nurse turnover prevention.

METHODS

We conducted a cross-sectional study in 330 homecare nurse organisations in Japan. We recruited 2,315 homecare nurses and analysed the data of 608 nurses. We used a questionnaire to investigate participants' intention to remain.

RESULTS

Nearly 68% had the intention to remain. The mean length of conversation was 34 min/day with the manager and 68 min/day with colleagues. Multilevel logistic regression analysis showed that long conversations with the nurse manager (20 min and more) and colleagues (40 min and more) were significantly related to the intention to remain.

CONCLUSIONS

Ensuring the time of conversation with a manager and colleagues may contribute to preventing potentially avoidable nurse turnover.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers should encourage homecare nurses to have daily conversations of 20 min or more with the nurse manager and 40 min or more with colleagues to continue working at their current workplace.

Home Health and Community Care Workers' Occupational Exposure to Secondhand Smoke: A Rapid Literature Review

INTRODUCTION

Although many workers are protected from exposure to secondhand tobacco smoke (SHS), home health and community care workers enter domestic settings where SHS is commonly present. Little is known about the extent of SHS exposure among this occupational group.

METHODS

A rapid review to examine the literature on home health and community care workers' exposure to SHS at work and identify research gaps. Systematic searches combining terms for SHS exposure (eg, "tobacco smoke pollution") with terms for home health and care workers, patients and settings (eg, "home health nursing") were run in CINAHL and Medline (with no date or language limitations). Web site and backward-forward citation searches identified further papers for narrative review.

RESULTS

Twenty relevant publications covering seventeen studies considered home health or community care workers' exposure to SHS either solely or as part of an assessment of other workplace hazards. Eight studies provided data on either the proportion of home care workers exposed to SHS or the frequency of exposure to SHS. No studies provided quantification of SHS concentrations experienced by this group of workers.

CONCLUSIONS

Exposure to SHS is likely to be common for workers who enter private homes to provide care. There is a need for research to understand the number of workers exposed to SHS, and the frequency, duration, and intensity of the exposure. Guidance should be developed to balance the rights and responsibilities of those requiring care alongside the need to prevent the harmful effects of SHS to workers providing care in domestic settings.

IMPLICATIONS

Very little is known about home health and community care workers' exposure to SHS. There is a need for research to quantify how many workers are exposed, how often and for how long exposure occurs, and the concentrations of SHS experienced. In many countries, home health care workers may be one of the largest working groups that experience exposure to SHS as part of their employment. The public health community needs to engage in a debate about how home health care workers can be best protected from SHS.

Home Healthcare Workers' Occupational Exposures

Home healthcare workers (HHCWs) belong to one of the fastest growing industries and have an unpredictable work environment, potentiating their risk of exposures to occupational hazards. More patients seeking care for chronic health conditions, and improvements in technology and medical advancements are allowing more complex patient care to be provided at home. A comprehensive integrative review was completed, identifying nine articles that provide an overview of the occupational hazards HHCWs face. Analysis of the articles indicates occupational hazards are similar across studies. Occupational exposures reported by HHCWs align within all the studies and include exposures to blood, saliva, dangerous conditions walking to and within the home, secondhand smoke, aggressive pets, violence, and ergonomic concerns. These studies have been methodologically limited to self-reports, including surveys, interviews, and focus groups but include quantitative and qualitative data. Future research can further describe and identify specific occupational exposures and health hazards, subsequently leading to modifications to protect the health and safety of HHCWs, personal care workers, and the informal caregivers who provide care in the home.

Critical failures in the use of home ventilation medical equipment

Home ventilation involves the use of medical devices at patient's home by personnel who are not healthcare practitioners. This implies new potential risks not fully addressed by current standards and guidelines. A methodological approach to investigate potential failures and define improvement actions to address the dangerous potential situations in HV is required.

A multidisciplinary team performed an extended version of Failure Mode, Effect and Criticality Analysis (FMECA) to analyse the home ventilation service provided by the Local Healthcare Unit of Naples (ASL NA1) that assisted 60 homebound ventilator dependent patients. The failures were identified in three risk areas: device, electrical system & fire hazard, and indoor air quality. The corrective actions were formulated with two extra steps: identification of critical failures with a threshold applied to the risk priority number and analysis of causes by means of contributory factors (Organization, Technology, Information, and Structure) based on Reason's theory of failures.

22 of 86 potential failures were identified as critical. Specific corrective actions were addressed and proposed through contributory factors to improve the overall quality of home ventilation service.

The use of this systemic approach oriented the improvements to reduce the harms caused by vulnerabilities in high-risk care service as life support home ventilation.

Safety of Care by Caregivers of Cancer Patients

OBJECTIVES

To describe common areas of threats to patient safety and quality of care when caregivers provide care. Recommendations for caregivers to enable them to provide safe care are included.

DATA SOURCES

Research-based articles and reports.

CONCLUSION

The literature is limited in discussion on home safety issues for caregivers. Non cancer-specific literature provides some direction for recommendations for nurses to guide caregivers.

IMPLICATIONS FOR NURSING PRACTICE

The home environment is an unregulated and uncontrolled site, and the safety risks families take are unknown. Professionals should assess the caregiver's knowledge and ability when providing caregiving guidance to ensure the patient is receiving safe and quality care. Nurses need to stress the importance of providing safe quality care and provide education and community resources.

Evaluating Home Healthcare Workers' Safety Hazard Detection Ability Using Virtual Simulation

Home healthcare workers (HHWs) are routinely exposed to occupational safety hazards when servicing patients in their homes that put them at risk for injury. These hazards can be broadly classified as "electric, fire and burn," "environmental," or "slip, trip, and lift" hazards. To better train HHWs regarding their potential exposure to these hazards, a home healthcare virtual simulation training system (HH-VSTS) was developed. The HH-VSTS contains three training modules, corresponding to the aforementioned hazard categories, and an assessment module. In each training module, the trainee must navigate the virtual space, via a mouse click, and identify items or conditions that represent hazards. Once an item has been clicked on, the HH-VSTS asks the user if the item or condition is a hazard. For items or conditions that are hazards, additional text boxes present material to the user as to why the item constitutes a hazard and potential remediation approaches. Thus, it is important that hazards be identified and clicked on for the trainee to receive the educational component of the training system. This article evaluated the ability of 49 HHWs to find hazards in each of the three categories. In all modules, participants found the most salient hazards (e.g., clutter on stairs, unattended candles, biohazard stains) but struggled to find some of the less salient hazards. Several less salient hazards included the pet food bowls in the path of travel, the frayed electrical cord, oxygen tube leaking into a mattress, hot water that was too hot, and elevated room temperatures. Overall, this analysis found that most of the hazards within the training modules could be found by naïve HH-VSTS users. These data suggest the need for including hints that guide users toward hazards with which they are less familiar.

Ensuring Safety When Pets Are in the Home

This article discusses safety issues involved when home healthcare clinicians visit the homes of patients with pets, particularly cats and dogs. Threats to the safety of home care clinicians are explored and concerns such as animal bites, animal scratches, and infection control are detailed in this article. Although it is acknowledged that pets can provide positive health benefits to owners, the focus is on the responsibility of the pet owners to secure pets when clinicians visit in order to keep the clinician and patient safe during the home visit. A proposed Pet Policy Agreement is presented whereby the pet owner as patient bears some responsibility for ensuring the safety of home healthcare clinicians.

Efficacy and Usability of a Virtual Simulation Training System for Health and Safety Hazards Encountered by Healthcare Workers

OBJECTIVE

This study evaluated the efficacy, usability, usefulness, and desirability (UUD) of a Home Healthcare Interactive Virtual Simulation Training System (HH-VSTS) designed to train home healthcare workers (HHWs) and healthcare students to identify and respond to health and safety hazards in client homes.

MATERIALS AND METHODS

Participants were randomly assigned to either the HH-VSTS training group or to the paper-based training group. The HH-VSTS group completed three HH-VSTS Training Modules on a laptop/desktop computer. The training modules addressed hazard identification, hazard rationale, and hazard response to electric/fire/burn, slip/trip/lift, and environmental hazards. The paper-based training group reviewed identical information in a written hard-copy format. Both groups completed an HH-VSTS Assessment module. Participants completed demographic/background and UUD questionnaires, and in-system metrics measured their performance on hazard identification, rationale, and response.

RESULTS

Participants (n = 74) were HHWs and students in health profession programs. There were no significant differences in participants' ability to correctly identify hazards, rationale, or how to address them. Participants identified over 90% of hazards, although fewer participants were able to correctly identify what makes an item a hazard or how to manage it. For those in the HH-VSTS group, over 83% found the HH-VSTS easy to use, over 94% agreed the HH-VSTS was useful, and over 80% liked it.

CONCLUSION

The HH-VSTS provided and engaging, efficacious training that was as effective as a typical paper-based training. In addition, the HH-VSTS is usable by a variety of end users, regardless of computer or gaming experience.

Occupational hazards for home care nurses across the rural-to-urban gradient in Ontario, Canada

The purpose of this paper was to describe occupational hazards for nurses working in home care (HC) and explore how they differ across the rural-to-urban gradient. Responses (n = 823) from a cross-sectional survey conducted in 2012 of HC nurses registered to practise nursing in the Province of Ontario, Canada were used. Using chi-square analysis and posthoc pairwise tests with a Bonferroni correction, 14 occupational hazards were individually tested for differences between four geographical settings (rural, town, suburban or urban areas). Our study reports that in addition to common occupational hazards that all HC nurses experience, the frequency of experiencing some hazards varies based on geographic setting. These specific hazards include exposure to: aggressive pets, environmental tobacco smoke, oxygen equipment, unsafe neighbourhoods and pests. Findings from this study suggest that a relationship exists between where a patient's home is located and the types of occupational hazards that may be experienced by HC staff. This research is useful for HC organisations in developing staff training programmes to recognise and manage occupational hazards that workers are likely to encounter. Home healthcare and policy leaders may use these findings to develop and implement educational and other strategies to reduce risk and manage exposures across the rural-to-urban gradient.

"Making Do" Decisions: How Home Healthcare Personnel Manage Their Exposure to Home Hazards

This study describes the decision-making processes home healthcare personnel (HHP) use to manage their personal health and safety when managing hazards in client homes. A professionally diverse national sample of 68 HHP participated in individual semi-structured interviews and focus group discussions, and described their decision making and strategies for hazard management in their work environments. HHP described 353 hazard management dilemmas within 394 specifically identified hazards, which were clustered within three broader categories: electrical/fire, slip/trip/lift, and environmental exposures. HHP described multiple types of "making do" decisions for hazard management solutions in which perceived and actual resource limitations constrained response options. A majority of hazard management decisions in the broader hazards categories (72.5%, 68.5%, and 63.5%, respectively) were classifiable as less than optimal. These findings stress the need for more support of HHPs, including comprehensive training, to improve HHP decision making and hazard management strategies, especially in context of resource constraints.

Environmental Health and Safety Hazards Experienced by Home Health Care Providers: A Room-by-Room Analysis

The number of personnel providing in-home health care services is increasing substantially. The unique configuration of environmental hazards in individual client homes has a significant impact on the safety and health of home health care providers (HHPs). This mixed-methods study used data from a standardized questionnaire, focus groups, and individual interviews to explore environmental health and safety hazards encountered by HHPs in client homes. The participant sample (N = 68) included nurses, aides, therapists, and owners/managers from a variety of geographic locations. The most often-reported hazards were trip/slip/lift hazards, biohazards, and hazards from poor air quality, allergens, pests and rodents, and fire and burns. Frequency of identified key hazards varied by room, that is, kitchen (e.g., throw rugs, water on floor), bathroom (e.g., tight spaces for client handling), bedroom (e.g., bed too low), living room (e.g., animal waste), and hallway (e.g., clutter). Findings indicate the need for broader training to enable HHPs to identify and address hazards they encounter in client homes.

Safety in the home healthcare sector: development of a new household safety checklist

OBJECTIVES

Unsafe household conditions could adversely affect safety and quality in home health care. However, risk identification tools and procedures that can be readily implemented in this setting are lacking. To address this need, we developed and tested a new household safety checklist and accompanying training program.

METHODS

A 50-item, photo-illustrated, multi-hazard checklist was designed as a tool to enable home healthcare paraprofessionals (HHCPs) to conduct visual safety inspections in patients' homes. The checklist focused on hazards presenting the greatest threat to the safety of seniors. A convenience sample of 57 HHCPs was recruited to participate in a 1-hour training program, followed by pilot testing of the checklist in their patients' households. Checklist data from 116 patient homes were summarized using descriptive statistics. Qualitative feedback on the inspection process was provided by HHCPs participating in a focus group.

RESULTS

Pretesting and posttesting determined that the training program was effective; participating HHCPs' ability to identify household hazards significantly improved after training (P<0.001). Using the checklist, HHCPs were able to identify unsafe conditions, including fire safety deficiencies, fall hazards, unsanitary conditions, and problems with medication management. Home healthcare paraprofessionals reported that the checklist was easy to use and that inspections were well accepted by patients. Inspections took roughly 20 minutes to conduct.

CONCLUSIONS

Home healthcare paraprofessionals can be effectively trained to identify commonplace household hazards. Using this checklist as a guide, visual household inspections were easily performed by trained HHCPS. Additional studies are needed to evaluate the reliability of the checklist and to determine if hazard identification leads to interventions that improve performance outcomes.

The human factors of home health care: a conceptual model for examining safety and quality concerns

OBJECTIVE

Increases in longevity, a growing elderly population, variation of skill and knowledge among home providers, and a steady migration of medical devices and technologies into the home are placing new demands on home heath care. The paper examines the human factors challenges associated with these converging trends.

METHODS

A growing literature base relevant to home health care is examined, and with the aid of a socio-technical systems model, the paper explores safety and quality concerns to which the converging trends are likely to give rise.

FINDINGS

The sensory, physical, and cognitive limitations of patients and their caregivers play a key role in the ability of patients to manage home health care needs. Other major components affecting successful home health care management are the nature of health care tasks undertaken, the design features of the physical environment, the medical devices and technologies used, the social and community environments, and distal but relevant external factors that shape the context of care. Home health care stakeholders can avoid foreseeable threats to safety and quality by recognizing that components need to be designed in a way that takes into account their interactions with one another and with the capabilities and limitations of patients and their providers.

CONCLUSIONS

By examining the major components and interdependencies of the home health care delivery system, a human factors perspective offers insights into ways that safety and quality can be compromised and can help pave the way for new modes of thinking in home health care policy.

Risk factors associated with patient assaults of home healthcare workers

This study used surveys from 677 home healthcare aides and nurses to explore factors associated with assaults by patients. Among respondents, 4.6% reported one or more patient assaults (being hit, kicked, pinched, shoved, or bitten) during the past year. Logistic regression analysis examined associations between several potential risk factors and assaults. Three factors were significant, including having one or more patients with dementia (OR = 4.31, 95% CI 1.47-12.67), routinely handling patients (OR = 8.48, 95% CI 1.89-37.94), and perceiving threats of violence by others in and around patients' homes (OR = 4.45, 95% CI 1.75-11.32). Assaults were not significantly associated with worker age, gender, race, job title, hours of work, or use of needles during patient care. Assaulted workers and workers who perceived threats of violence by others were significantly more likely to have shortened home care visits. More detailed research is needed to confirm these results and evaluate methods to reduce assault risk.

Evaluation of home health care nurses' practice and their employers' policies related to bloodborne pathogens

The purpose of this descriptive study was to assess home health care nurses' exposure to bloodborne pathogens, evaluate Medicare Certified Home Healthcare Agency (MCHHA) and hospice organization practices related to the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogens Standard and the Needlestick Safety and Prevention Act, and link the two to recommend safety improvements. This study evaluated the experiences of 355 home health care nurses and 30 MCHHA and hospice employers in one mid-Atlantic state regarding bloodborne pathogen programs and practices and blood and sharps contact. An index was developed to evaluate employer compliance with OSHA's Bloodborne Pathogens Standard. Employer policies and nurse practice related to the OSHA Bloodborne Pathogens Standard did not meet all requirements despite identified risk. Thirty-eight home health care nurses from 12 of the 30 employers reported needlestick injuries within the past year, yet employers reported only 18 nurse needlestick injuries within the same year. Using the bloodborne pathogen compliance index, employers can review and revise their exposure control plans to ensure compliance. This intervention should benefit both employer policies and nurse practice to improve safety and decrease the risks from bloodborne pathogens in the home health care setting.

Changing the conversation--the occupational health nurse's role in integrated HS3

Occupational health nurses have the skills and knowledge to provide a holistic perspective in advancing their company's triple bottom line, healthy people, healthy planet, and healthy profits. The HS3 model provides a road map for integrating health, safety, sustainability, and stewardship, all of which directly impact every company's triple bottom line. Occupational health nurses can use the HS3 model to promote healthy lifestyles, reduce risk and injuries, protect the natural environment, and improve resource alignment. Occupational health nurses have a unique opportunity to demonstrate the value they bring to their employers using synergistic HS3 planning that cost-effectively links work injury management, health promotion, environmental protection, safety training and surveillance, and regulatory compliance. Implementing the HS3 model requires occupational health nurses to be innovators who can change the conversation.