The Home Health Worker- A Vulnerable Population
Esther Murray, RN, COHNs
The article that follows was published in AOHP Journal, Winter, 2010.
Esther Murray is the Assistant Director of Clinical Services for Prism Medical, Ltd., based in St. Louis, MO. Esther has been an Occupational Health Nurse for 24 years with 10 years focused on occupational health of the healthcare worker. The past 7 years have been devoted to the development, implementation and active consultation of safe patient handling programs in hospitals, nursing homes and home health programs. Prism Medical is a US manufacturer of patient lifts and assistive devices for safe patient handling in all healthcare settings.
The Home Health Worker - A Vulnerable Population
The growth of the home health sector is being driven by the aging of the baby boomer in the United States. The Institute of Medicine's report - Retooling for an Aging America (2008) reports that the baby boomers will begin to turn 65 by 2011, and that by 2030 will number 70 million and make up 20 percent of the U.S. population (Institute of Medicine, Nationalacademies.org).
Home healthcare is the fastest growing segment of the healthcare industry and an underexplored subpopulation of healthcare professionals (Waters, Collins, Galinsky & Caruso, 2006). The Home Healthcare Worker (HHCW) performs the duties of lifting, transferring and moving the patient alone. Often, the duties the HHCW performs are with a patient who is in a bed that is not adjustable, and in a crowded room, making the environment less than ideal for the difficult patient handling tasks (Galinsky, Waters & Malit, 2001).
The National Institute for Occupational Safety and Health (NIOSH) is evaluating and researching this vulnerable population. The home health environment is at first, a unique health care situation. Each home is different and some are safer than others. The home is the property of the patient and in essence the patient is the king of the castle. The HHCW is a guest working in their home with no control over the work environment. The underlying struggle is who is responsible for safety in the home health environment, the employer or the patient who owns the property.
The HHCW characteristics show the vulnerability of this population. Meyer (1999) reported, in the first study of HHCWs, that the bulk of the workers were women, of ethnic minorities beginning with an entry level job having minimal training. A recent study by Gong, Baron, Stock and Ayala, (2009) reported that 90% of home care workers are women, 50% are minorities, and 25% speak a language other than English at home. They are low-wage and low-status workers.
The central health issue that drew the focus of researchers over the last decade was the HHCW's risk of overexertion injuries as demonstrated by the injury rates. First, Meyer (1999) reported that despite the higher rates of injury of the nursing home worker, the HHCW had a more severe injury resulting in more lost work days. More recently, the rate of injury among the HHCW has soared. Galinsky, Waters and Malit (2001) stated that musculoskeletal injury rates have been shown to be higher in HHCWs than in many other groups studied including construction workers. These authors went on to report that the rate for HHCWs is 161injuries per 10,000 workers: this is compared to the national rate of overexertion injuries at 54 per 10,000 workers, and the general health care industry with 100 per 10,000 workers. The rate of overexertion injuries for HHCWs is three times the national rate. This rate of injury is alarming and has resulted in several other initiatives by NIOSH in researching the home health work setting. One study focused on HHCWs in California; the goal of that program was to empower the HHCWs to initiate safety changes with their clients while incorporating the cultural value of respecting elders (Gong, Baron, Stock, & Ayala, 2009). These studies, although slow and difficult to conduct, are making a difference in understanding the home health care environments. The barriers that the HHCWs face in making the environments safer for themselves as well as the client and caregiver spouse are becoming clearer and creative ways to change the workplace are being discovered.
Barriers to Safety in the Home
Gong, Baron, Stock and Ayala (2009) report several barriers that the HHCW perceived in approaching their clients and families in making safe changes (2009). Power dynamics between the patient and HHCW leaves the HHCW unwilling to communicate with the client. The HHCW face many fears; one of which is fear of losing their job, another is that the client does not demonstrate an interest in the safety of the HHCW. The client is most often an elderly patient, and is unwilling to make changes in their surroundings to promote a safer environment. Clients may also be unable to afford to make changes such as a hospital bed purchase. Multiple barriers, including power dynamics as well as physical environment issues, pose difficulties for the HHCW without the assistance of the RN supervisor.
Long term effects of musculoskeletal disorders in healthcare workers have spurred research in this general area of health care workers and their exposure to high weight limits. The rate of exposure to high weight lifts, awkward positions as well as overexertion is compounded by the psychological demands in this very personal service of home health visits. Dellve, Langerstrom and Hagberg (2003) found that the lack of time of one's own, lack of time to rest from work, and a lack of influence on decisions, can be viewed as indicators of a lack of control. The home health care sector has a high level of absence related to poor health, such as long term sick leave, disability pension and occupational disorders (Dellve, Lagerstrom & Hagberg, 2003). These factors compound the already unusual physical work load and lead to a more severe injury.
The caring nature of home health work compounds the physical nature of this area patient care in particular. The HHCW offers these services often at great personal sacrifice. The ANA conducted a survey in 2001 and found that 83% of respondents complained of back pain during work but continued working (Menzel, 2008). Health care workers avoid reporting their injuries by being very creative about rescheduling their shifts and working around the injury due to peer pressure and frustration with the workers' compensation system. The nurse is only an indicator of what the home health aide is experiencing. It is very likely that the HHCW is also concerned about taking time away from work and may believe that they could lose their job if they reported an injury. The characteristics of the HHCW reported earlier were one of a minority female with minimal training in a low wage job. This worker is trying to keep everyone happy both at work and at home.
The Family Caregiver
The family caregiver mentioned earlier is another part of the home caregiving equation. This population is under researched as well, but organizations such as the American Association of Retired Persons (AARP) are taking up the cause and giving voice to the family caregivers. Houser and Gibson (2008) estimated that the dollar value each year for family caregiving is over $365 billion (AARP.org/ppi). What does $375 billion look like? That amount is around the total sales (2007) from the largest money making machine in the world, Wal-Mart. Family caregivers estimated at 34 million go unpaid, but in harm's way to keep a family member in their home.
Suggested areas for change in the Home Health environment
Several studies have suggested areas for changes in the home health environment. Parsons, Galinsky and Waters (2006) outlined some different assistive tools that would improve the ergonomic design of the home environment. Most assistive devices that were suggested are low cost and easily adaptable to the home. Gong, Baron, Stock and Ayala (2009) studied a group of HHCW and found that assisting the focus groups with finding community resources as well as role playing to practice effective communication were creative measures that could change the home care environment for the better.
Gong, Baron, Stock and Ayala (2009) reported on several strategies to implement safety behaviors across a culturally diverse group of home healthcare workers in California. Training was given to assist the HHCW in approaching the patient about unsafe or risky situations in the home. During the training, the employees were given the opportunity to role play their reactions and possible responses to client responses. The HHCW could present the safe alternatives, a lift, assistive devices such as friction reducing devices and shows how everyone's safety would be enhanced. Family caregivers may not, at first, embrace the assistive device, but as patients and caregivers seek to remain safe at home, the resistance is lowered.
The work that is being done by health care equipment manufacturers, the application of lifts and other devices to the home care environment, is critical to keeping HHCW and family caregivers safe. Ceiling lifts and other ergonomically assistive devices such as friction reducing devices in many different styles are being promoted for use in the home environment. Traditional lift equipment, such as floor lifts, is usually too large for the home to accommodate. The chronically disabled client does not have access to the bathroom with most floor lifters. Ceiling lifts are being sought out as a useful device for patients as well as the family caregiver.
The strategies employed to reach the HHCW would be first through their employer, as the methods would need to be approved and financed with agency funding. But, safety interventions for HHCWs are challenging at best, as each home is individual and the strategies for one client may not be the same interventions that are needed for the next patient. Some strategies to promote safety can be standardized as they apply to the employee.
Home Health is a new Safe Patient Handling Frontier
The home healthcare setting is a relatively new setting for the implementation of safe lifting or safe patient handling programs. Long term care facilities have been working on safe lift programs for over a decade. Hospitals have also been implementing broad reaching safe patient handling (SPH) programs throughout their organizations for many years. However, home health agencies have only begun to recognize the need and implement the use of assistive devices for risky tasks. Due to the difficulty of mandating changes to the home environment, many agencies have been hard pressed to make the monetary investment in the devices needed to fully integrate assistive devices needed to assist with changing lifting behaviors. Family caregivers have been struggling to give care to their loved ones in the home for years. Often, the family is the one to mobilize the funds needed to bring about the changes in the home lifting environment.
The implementation of a SPH program needs to be multi-faceted. Multi-media material as well as different training styles help in familiarizing staff and family caregivers to the use of the different assistive devices. Consideration needs to be made to the language barriers as well as the potential literacy barriers to learning the skills needed to operate the equipment. Typically, the SPH training is comprised of a video, a short lecture, some discussion and at least half of the time devoted to hands on practice with the equipment so the employee is comfortable and competent with the operation.
Goals for a Home Health SPH Program
The goals of any safe patient handling program would be to decrease the injuries of the patients in transfer, while also providing a safer environment for employees and increase retention and recruitment of new employees to a safer work environment. But, before these benefits to the employee are realized, the home health care worker must recognize that there is a hazard present in the patient's home. The program culminates in the employer finding their worker's comp premiums dropping in response to the decrease in injuries to the employee. Implementing a program of safe patient handling represents a focused period of training in the classroom, and at the bedside. For the home health worker there may be an additional component of training to provide for training to introduce the equipment to the home health client. Fong, Baron, Stock and Ayala (2009) suggest that role-playing as well as social marketing be used to disseminate the information about the availability of equipment and other resources.
Several hospital systems have implemented safe patient handling programs in their home health services. The goals for each SPH program were similar. Goals for the Kaleida Health safe patient handling program for home care were listed as decreasing employee injury, increasing safety for other caregivers and increasing the safety for the client (Pless, 2008). A hospital in Wisconsin reported their safe patient handling program as a program centered on patient safety (Biese, 2007). Middlesex Hospital in Connecticut reported a 66% reduction of patient handling cases over their three year intervention, a 50% reduction of the total number of injuries, and a 75% reduction in the number of average lost work days (Smart Moves, 2007). These safe patient handling programs demonstrate that the goal of reducing employee injuries while providing for patient safety is an attainable goal.
The implementation of a SPH program in any healthcare organization should be tracked over time to prove effectiveness. The organization should celebrate incremental successes that follow the hard work of achieving positive changes (Fragala, 2003). Several outcomes can be measured fairly easily as the employee injury reports (providing that the employee reports the injury) can be tracked through the worker's compensation carrier. The number of injuries, the type of injury, the cost of the injury and lost work days all give indicators of the effectiveness of a safe patient handling program (Fragala, 2003). Additionally there are other benefits that are not so easily measured, but still need to be quantified to see the progress that is being made. These additional benefits are employee satisfaction, patient satisfaction and employee turnover (AOHP, 2006). By measuring these outcomes the effectiveness of the safe patient handling program takes shape and bolsters the confidence to continue the journey of change. Changing a deep seated habit such as manual lifting is a long process that takes consistent review, then communication of outcomes to all who will listen.
Project objectives may include reducing employee injuries by 50% over three years. Another reasonable goal could be to increase employee satisfaction as evidenced by lowering employee turnover by 25% over three years. A patient centered goal might be to decrease patient falls in transfer by 50% over three years. All attainable goals of an aggressive SPH program integrated with assistive devices. Another measurement of program effectiveness is that patient satisfaction would increase as evidenced by phone satisfaction surveys.
Sustaining a Home Health SPH program
Sustaining a safe patient handling program is a routine of auditing and communicating the results as well as training and retraining. In the home health environment, problems could present as staff are working in the field alone, and usually don't have a ready helper to work out problems with. The Middlesex Hospital presentation points out several measures taken (Smart Moves, 2007). One of the measures that points to great insight is that they paired the home health aide with an occupational therapist from time to time, especially when training on the new equipment. Second, the aide was empowered to recognize dangerous situations. Third, the licensed staff was to communicate and carry out the plan of care which included outlining the proper equipment to be used with the patients. When sustaining this process of change, auditing the small details over and over again is important. Owens and Staehler-Skalitsky (2003) reported that the nurses in their study were charged with completing a home safety assessment that led them to identify the use of assistive devices. If the home safety assessment was done, but not communicated by adding the information to the plan of care, the aide is not prepared for the need to use assistive devices. If the nurse has done the safety assessment but hasn't followed up to get the proper equipment sent out to the house, the aide arrives for the next visit and the equipment is not available.
Journey of Change
While the process of change is a long journey, there can be great joy in this program. During implementation, nursing staff have been overwhelmed at how easy assistive devices make the moving and caring for patients. In some cases, the staff has been angry that their organization has taken so long to bring them equipment that has been available for over twenty years. The joy that is experienced is balanced by the processes that have to accompany this change. Slings have to be washed separately, so they need to be separated from the other laundry. Lifts have to be made available, and as such, require a phone call or a process of funding that may need to be made in advance. Assessments must be done consistently on every new patient as well as done periodically during their time of care. RNs and therapists must learn a new skill in matching the equipment with the patient's mobility level (Owen and Staehler-Skalitsky, 2003). The change in routine is not always easy and auditing helps the manager to understand how the process of change is proceeding.
Assigning the safe patient handling program to an employee who can consistently work with the staff in problem solving, training and retraining, as well as quantify and communicate results to the administrators is essential. The care and nurturing of the program is part and parcel of training the employees to recognize risk and then match the risk with the proper assistive device. Communicating the programs goals to other staff as well as to the client and family caregiver is part of the empowerment of the staff to take an active role in their own safety. Making routine rounds to see the employees at work, and talk with clients is part of the auditing of the program. Documenting patient and family satisfaction is part of the success of a safe patient handling program.
There have been choice moments when a family caregiver will confide that they were thinking of placing the patient in a long term care center, but because of the assistive devices or addition of the ceiling lift, they are able to continue to give care with the help of the home healthcare worker. These moments represent the successes of a safe patient handling program that has reached out into the home. The family caregiver experiences the benefit of identifying the risks and meeting that risk with an assistive device, and as an outcome they stay together in the home as a family.
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