Celebrating Nurses

Could there be a more fitting year to honor nurses?  As 2020 comes to a close, so does our blog series celebrating the Year of the Nurse.  The COVID-19 pandemic has tested our healthcare system and, in some cases, pushed it to the brink. Nurses and other healthcare professionals are working tirelessly and sacrificing much while caring for patients during this pandemic. As of December 14, 2020, CDC reports 273,233 cases of COVID-19 and 915 deaths in healthcare workers. These figures likely underestimate the true effect on healthcare workers.

Thanks to our healthcare workers we have learned how to better care for patients with COVID-19. As we find ourselves at another milestone with this pandemic, our healthcare workers continue to battle on the front lines. As vaccines become available, nurses will play a critical role in administering the vaccines. Our country is forever indebted to our healthcare heroes.

We would like to thank the many contributors to this blog series who helped us honor nurses with posts covering various topics relevant to the field of nursing.

• • Year of the Nurse LCDR Megan Casey, RN, BSN, MPH
  • Managing Fatigue During Times of Crisis: Guidance for Nurses, Managers, and Other Healthcare Workers  Beverly M. Hittle, PhD, RN, Imelda S. Wong, PhD and Claire C. Caruso, PhD, RN, FAAN
  • Nurses’ and Other Health Professionals’ Wellness and Safety Resource Update Ruth Francis, MPH, MCHES and Holly Carpenter, BSN, RN
  • Surgical Smoke Inhalation: Dangerous Consequences for the Surgical Team  Mary J. Ogg, MSN, RN, CNOR
  • Safety Culture and Health Care  Bonnie Rogers, DrPH, COHN-S, FAAN, LNCC
  • Work Ability among Older Nurses  Amy Witkoski Stimpfel, PhD, RN
  • The Unique Occupational Environment of the Home Healthcare Worker  Elizabeth Bien, PhD, MSN, RN, and Ron Smith, AIA, ACHA, ACHE, LEED AP
  • Can Exoskeletons Reduce Musculoskeletal Disorders in Healthcare Workers? Liying Zheng, PhD
  • Preventing Needlesticks and Sharps Injuries: Reflecting on the 20th Anniversary of the Needlestick Safety and Prevention Act Amber Hogan Mitchell, DrPH, MPH, CPH

Many of these contributors are nurses who conduct research, develop guidance, and create tools and interventions to support workplace health and safety programs. Nurses also contribute to workplace safety and health through the field of occupational health nursing. This specialty delivers health and safety programs and services to workers, worker populations, and community groups. The practice focuses on promotion and restoration of health, prevention of illness and injury, and protection from work-related and environmental hazards.[1]

Nurses play an important role at the National Institute for Occupational Safety and Health (NIOSH). Many NIOSH nurses are United States Public Health Service Nurses in the Commissioned Corps of the U.S. Public Health Service. In addition to their primary responsibilities, many have deployed to assist with the COVID-19 response and other emergencies. Their research and work in the field are an important part of the NIOSH mission to protect America’s workers. Examples of their research and prevention activities are described below.

Preventing Workplace Violence in Healthcare

In 2016, a total of 11,830 nonfatal workplace violence–related injuries requiring time off from work were reported in the Health Care and Social Assistance sector, accounting for 70% of this type of injury across all industries.[2] Further, incidents of workplace violence directed toward health care workers continue to be underreported.[3],[4],[5] To address the issue of violence in healthcare, NIOSH researchers, including CAPT Marilyn Ridenour, MPH, MBA, BSN, who is a United States Public Health Service Nurse in the Division of Safety Research at NIOSH in Morgantown, West Virginia, developed an online workplace violence prevention course for nurses. As a nurse epidemiologist, CAPT Ridenour developed an online course to raise awareness of workplace violence among nurses and to help in the development of prevention strategies. Each month, over 600 healthcare professionals complete the NIOSH Workplace Violence Prevention for Nurses Online Training Course. The training contains units on what constitutes workplace violence, consequences of workplace violence for nurses and employers, and risk factors for both patient-on-worker violence and employee-on-employee violence. It also provides strategies nurses and organizations can use to prevent violence in their facilities.

A survey of course participants revealed that 94% of respondents indicated they had experienced verbal workplace violence in the past 12 months—two-thirds perpetrated by patients (34%) and family members (33%), and the remaining third perpetrated by supervisors (16%) and coworkers (14%). Nearly 18% of participants said they had experienced physical workplace violence in the past 12 months—three-fourths (74%) perpetrated by patients, 12% by patients’ family members, and 14% by coworkers (8%) and supervisors (6%). After taking the course, 96% of participants felt the course was a good introduction to the topic and met the stated learning objectives, and 90% of participants felt they could take steps to implement a comprehensive violence prevention program in their workplace.

Making Shiftwork Safer/Managing Fatigue

To meet the 24/7 demand for healthcare, nurses often work 12 hours at a time and may need to work at night during traditional sleeping hours. Research has shown that shift work and long work hours are associated with: declines in brain function (thinking, remembering); reduced job performance, injuries , and medical errors; negative impact on health behaviors (obesity, smoking); increased short-term and long-term health risks including cancer, cardiovascular disease, and diabetes; and negative impacts to patients, families, employers, and the community. Claire Caruso, PhD, RN, FAAN is a research health scientist and leader of the American Academy of Nursing workgroup on nurse fatigue. She spearheaded the development of a free online course to train nurses and their managers on the risks of shift work and long work hours, and the strategies to reduce these risks including strategies at the personal and management levels. NIOSH Training for Nurses on Shift Work and Long Work Hours is divided into two courses and offers continuing education certificates for completing these. The training provides nurses and managers information on:

• How shift work and long hours are linked to a wide range of health and safety risks by reducing time for sleep, disturbing circadian rhythms, and disrupting family and non-work responsibilities
• What vital functions occur during sleep and the relevant physiologic processes that determine the timing of sleep and the development of fatigue
• Good sleep practices and other coping strategies nurses working shift work and long work hours can adopt in their personal lives to reduce risks
• Work organization strategies for employers to reduce risks associated with shift work and long work hours

Dr. Caruso leads 14 Fellows in the American Academy of Nursing whose mission is to promote progress on this workplace hazard across healthcare settings. They published an Academy position statement in 2017 and an Academy policy brief in 2019.

During a crisis it can be difficult to step away when the healthcare system is flooded with people needing care. During these periods, fatigue among healthcare workers may be impossible to avoid. For more information on how to balance the high demands for health care with the need to protect workers from fatigue, see the blogs: Managing Fatigue During Times of Crisis: Guidance for Nurses, Managers, and Other Healthcare Workers and Improve Sleep: Tips to Improve Your Sleep When Times Are Tough.

Serving 9/11 Responders and Survivors

The World Trade Center Health Program (WTCHP) is a limited federal health benefit plan which provides coverage of healthcare services for over 104,000 responders and survivors who developed health conditions from their toxic exposure during the 9/11 terrorist attacks in New York City, Washington DC, and Shanksville, Pennsylvania.

LCDR Hannah Dupont, MPH, BSN, RN, PHNA-BC, CPH is a U.S. Public Health Service nurse. She serves as the Chief of Medical Benefits and Certifications for the World Trade Center Health Program. With 10 years of nursing experience and a Master of Public Health, LCDR Dupont applies her public health, occupational health, and health benefits expertise through a clinical nursing lens in order to have an effective impact on the WTCHP member population. She supervises a team of 17 medical professionals and has direct oversight over medical benefits, interdisciplinary clinical collaboration, medical benefit policy and coverage determinations, case management, quality assurance, medical coding, claims, utilization management, provider network management, and complex member care.

On and after 9/11/2001, thousands of individuals were exposed to toxins due to their occupation as a Ground Zero/9-11 responder, or due to living, working, or going to school in the New York City Disaster Area. In her job as a NIOSH nurse, LCDR Dupont applies her clinical knowledge and nursing skills to occupational health as it relates to the terrorist attacks on 9/11, and feels it is a privilege to be able to serve the 9/11 community every day. In addition to her role within the World Trade Center Health Program, LCDR Dupont has deployed three times for the COVID-19 response where she conducted tele-health consultations with nursing homes nationwide, staffed a COVID-19 Medical-Surgical unit at a local Hawai’i hospital, and served as a quarantine medical officer for airport quarantine station consultations.

CDR Pattama Ulrich, RN, MPH (PhD student)is a senior nurse consultant program manager at the World Trade Center Health Program (WTCHP) providing services to first responders and survivors from the 9/11 terrorist attacks. CDR Ulrich has been deployed three times for COVID-19 since May. She feels her deployments were humbling experiences that allowed her to advocate for worker safety and health during COVID-19. In her first deployment, CDR Ulrich served as the Chief Nurse Officer working to ensure the safety and health of the Commissioned Corps officers and the hospital staff they worked alongside in a COVID-19 unit. She supported the hospital’s nursing leadership team with appropriate use of personal protective equipment (PPE) and clarified the PPE protocols.

In another deployment, she contributed to community and school guidance to keep the environment safe. When deployed at a skilled nursing facility, CDR Ulrich worked alongside nursing staff as they suddenly transitioned their response to caring for newly diagnosed COVID-19 infections in nursing home patients. She supported their increased workload and helped set up PPE donning and doffing areas and manage workflow in the newly configured space. This work helped the facility receive a “no deficiencies” rating during an unplanned Centers for Medicare & Medicaid Services infection control inspection, and supported recovery of 44 COVID-19 patients with only two cases remaining in treatment status. CDR Ulrich notes that being part of NIOSH allows her to share the NIOSH mission of protecting worker safety and health with the community.

Investigating Workplace Hazards

NIOSH’s Health Hazard Evaluation (HHE) Program helps employees, unions, and employers determine if hazardous conditions are present at their workplace and recommends ways to protect workers. LCDR Laura Reynolds, MPH, BSN, RN, CPH, COHN-S, is a United States Public Health Service Nurse in the Division of Field Studies and Engineering at NIOSH in Cincinnati, OH. As a nurse epidemiologist in the HHE program, she collects data and administers medical surveys to identify, control, and prevent occupational health hazards in a variety of work settings. She works closely with industrial hygienists and engineers to make recommendations on how to reduce or eliminate occupational hazards. For example, one particularly interesting HHE evaluated zoo staff exposed to elephants with tuberculosis. Although she no longer sees patients in a clinical setting, she finds this position very rewarding because she can go into the field, talk with workers, and use epidemiology to address their occupational health concerns.

During the COVID-19 pandemic, she helped Federal Emergency Management Agency (FEMA) by consulting on PPE preservation methods and coordinating with mental health experts to create a factsheet and develop prevention strategies related to healthcare worker burnout and stress during the pandemic.  She tracked the activities of CDC /NIOSH staff deployed both virtually and in the field to assist with the pandemic. These staff assisted more than 100 workplaces and more than 60,000 workers across 13 industries throughout 25 states and 2 tribal nations.

Improving Personal Protective Equipment

Several NIOSH nurses support the National Personal Protective Technology Laboratory (NPPTL). This NIOSH Division is responsible for the approval of respirators used in U.S. workplaces and conducts testing and evaluation of PPE.

CAPT Harold L. Boyles, MHA, BSN, RN is a United States Public Health Service Officer with 26 years of active duty in NPPTL in Morgantown, West Virginia. He is the Deputy Chief currently serving as the acting Chief of the Research Branch. CAPT Boyles helps protect worker safety and health by providing leadership to the Research Branch which is dedicated and committed to research of personal protective technology. CAPT Boyles also provides leadership and support to the World Trade Center Health Program as a Federal Official for appeals. Lastly, CAPT Boyles has completed several deployments as a Commissioned Corps Nurse Officer most recently for Ebola and the current COVID-19 pandemic.

LCDR Adam Hornbeck, MSN, APRN, FNP-BC, FNP-C is a United States Public Health Service Nurse Practitioner in NPPTL in Pittsburgh, Pennsylvania. LCDR Hornbeck protects worker safety and health through medical monitoring for both the Research Branch and Evaluation and Testing Branch that is part of the respirator approval program for NIOSH. He is also currently helping with research on reusable elastomeric respirators in hospital settings so healthcare workers can have information available for alternative respirator options to use during pandemics to remain safe and healthy. LCDR Hornbeck helped to author two science blogs in 2020, The Physiological Burden of Prolonged PPE Use on Healthcare Workers during Long Shifts and Skin Irritation from Prolonged Use of Tight-Fitting Respirators.

LCDR Megan Casey, RN, BSN, MPH, CIC is a nurse epidemiologist and Team Lead supervising a group of NPPTL health communication specialists and researchers developing PPE communication tools, resources, and interventions. LCDR Casey also coordinates NIOSH research related to the healthcare and social assistance industry sector. She has provided infection control and data management support for public health events including 2018 Family Reunifications at the U.S. Border, 2017 Hurricanes Irma and Maria, 2016 Zika Virus, 2014 Ebola Virus, 2012 Fungal Meningitis, 2009 H1N1 Influenza, and the 2009 G20 Summit. Her most recent work has been focused on supporting NIOSH’s response to COVID-19 related PPE shortages. LCDR Casey supervised the response process for over 5,000 public inquiries regarding PPE and personally responded to over 600 inquiries as CDC’s COVID-19 PPE Unit Deputy Lead. She also provided PPE supply chain expertise during meetings with the White House’s Coronavirus Task Force. LCDR Casey helped to author two PPE-related blogs Respiratory Protection vs. Source Control – What’s the difference? and The Need for Fit Testing During Emerging Infectious Disease Outbreaks

Enhancing Occupational Health Data

Electronic health records (EHRs) often do not contain information about patients’ work history or hazards encountered in their workplace. To improve surveillance for occupational illness and injury, NIOSH develops best practices to support work information in EHRs. LCDR Lauren Brewer, MPH, BSN, advocates for and supports the collection of standardized occupation and industry data in EHRs for use in patient care, population health and public health. This work will protect workers by allowing medical providers and public health officials to use occupational data in health care decisions and surveillance. NIOSH will also use this occupational data for research. An article describing the recommended way to collect occupation and industry was published in the Journal of the American Medical Informatics Association in 2020, “Opportunities at the intersection of work and health: Developing the occupational data for health information model”.

In support of the COVID-19 response, LCDR Brewer has worked with the Repatriation Mission bringing US citizens back from Wuhan, China; the Bureau of Prisons mission where she was involved with COVID-19 testing, infection control and patient movement; and is currently deployed as a COVID-19 Quarantine Medical Officer on call for airports.

NIOSH and the country are fortunate that these nurses have dedicated their careers to protecting America’s workers.

John Howard, MD, Director, National Institute for Occupational Safety and Health

For more information on occupational health nursing

American Association of Occupational Health Nursing (AAOHN)

Commissioned Corps of the U.S. Public Health Service

For NIOSH research on protecting healthcare workers

Healthcare Worker Topic Page

Healthcare and Social Assistance Program

The National Occupational Research Agenda (NORA) for the Healthcare and Social Assistance Sector

References

[1] American Association of Occupational Health Nurses website. http://aaohn.org/. Accessed 17 November 2020.

[2] Bureau of Labor Statistics. Injuries, illnesses, and fatalities. Case and demographic characteristics for work-related injuries and illnesses involving days away from work: calendar year 2016 survey results. U.S. Department of Labor. 2018. https://www.bls.gov/iif/oshcdnew2016.htm.

[3] Friedman RA. Violence and mental illness—how strong is the link? N Engl J Med 2006;355(20):2064-6.

[4] Gillespie GL, et al. Workplace violence in healthcare settings:risk factors and protective strategies. Rehabil Nurs 2010; 35(5):177-84.

[5] Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. Washington, DC; 2016. OSHA 3148-06R 2016. https://www.osha.gov/Publications/osha3148.pdf.