Healthcare and Social Assistance
Participating core and specialty programs: Center for Motor Vehicle Safety, National Center for Productive Aging and Work, Prevention through Design, Surveillance and Translation Research.
Employers, workers, professional and labor organizations, medical educators and accrediting bodies use NIOSH information to improve occupational safety and health through work design in the healthcare and social assistance sector.
NOTE: Goals in bold in the table below are priorities for extramural research.
|Health Outcome||Research Focus||Worker Population*||Research Type|
|A||Adverse stress-induced physical & mental health outcomes (e.g., anxiety, depression, fatigue, burnout, suicide & substance use disorders)||Prevention of stress & related adverse health outcomes due to suboptimal work organization||All healthcare & social assistance workers, including veterinary medicine/animal care (VM/AC) workers; special emphasis on vulnerable workers & those affected by disparities||Intervention Translation|
|B||Adverse stress-induced physical & mental health outcomes (e.g., anxiety, depression, fatigue, burnout, suicide & substance use disorders)||Improved surveillance on work practices, work factors (e.g., psychosocial and safety climate), & health outcomes||All healthcare & social assistance workers, including VM/AC workers; special emphasis on vulnerable workers and those affected by disparities||Surveillance research|
|C||Fatal & non-fatal injuries||Fatigue, stress, work organization as risk factors for traumatic injuries such as sharps injuries, motor vehicle crashes, & suicide||Residents, interns, & home healthcare workers; others with long hours / irregular schedules||Intervention Translation|
|D||Adverse stress-induced physical & mental health outcomes (e.g., anxiety, depression, fatigue, burnout, suicide & substance use disorders)||Stressful social, interpersonal, and situational aspects of work environment (esp. bullying, violence, interpersonal interactions, dealing with traumatic situations such as those involving death & dying, injury, illness, anger, grief, loss)||Healthcare and social assistance workers who directly interact with patients/families, VM/AC workers, small businesses||Intervention|
|E||Infectious diseases, Blood borne pathogen infection||Safety culture/safety climate/safety leadership||Mid-to-small healthcare settings, nursing aides, home healthcare workers, management, VM/AC, other settings where poor adherence to safe practice has been documented||Intervention Translation|
|F||Non-standard work arrangements||Healthcare workers||Intervention
Activity Goal 7.2.1 (Intervention Research): Conduct intervention studies to develop and assess the effectiveness of work design and well-being interventions to reduce injuries and illness, including adverse mental health outcomes, among healthcare workers.
Activity Goal 7.2.2 (Translation Research): Conduct translation research to understand barriers and aids to implementing effective work design and well-being interventions among healthcare workers.
Activity Goal 7.2.3 (Surveillance Research): Conduct surveillance research to better track work practices, work factors (psychosocial and safety climate), and health and safety outcomes among healthcare workers and VM/AC workers , including those in contingent work arrangements.
Work in healthcare (human and animal) and social assistance is often associated with high levels of stress resulting in multiple adverse health and safety outcomes and burnout. The American Nurses Association surveyed 4,614 nurses in 2011 and found that 74% had concerns about the effects of stress and overwork, 24% cited the risk of a fatigue-related crash after a shift as one of their top 3 safety and health concerns, and 53% worked some mandatory or unplanned overtime each month [ANA 2011]. The COVID-19 pandemic has had a negative impact on the mental health of many healthcare professionals. A National Nurses United survey found that 38% of nurses felt more anxious and 29% felt depressed more often than before the pandemic [NNU 2020]. A mortality study identified veterinarians who specialized in food animal medicine and mixed animal medicine as being 2.2 times and 3.2 times more likely, respectively, to die from motor vehicle injuries compared with the general population [Tomasi, in press]. In one survey of veterinary personnel, 35% consider their job dangerous, 34% reported adverse effects from workplace stress, and 42% of veterinarians experienced or witnessed workplace abuse [Fowler 2016]. Veterinarians are also estimated to be at higher risk for suicide compared with the general population, with male veterinarians being 2.1 times as likely and female veterinarians being 3.5 times as likely to die from suicide compared with the general population [Bartram and Baldwin 2010; Platt B 2012; Tomasi 2019]. A survey of 7,288 physicians found that 12.9% of male physicians and 21.4% of female physicians met diagnostic criteria for alcohol abuse or dependence, and alcohol abuse or dependence was associated with burnout, depression, and lower career satisfaction [Oreskovich 2015]. Suboptimal work organization issues have been associated with increased exposure to blood and body fluids and increased risk of needlestick injuries among healthcare workers [Clarke 2007; Hessels 2016]. Temporary, contract, as-needed (pro re nata or PRN), on-call and other non-standard job arrangements are common in healthcare. These work arrangements have been associated with adverse psychological outcomes and performance [Ferrie 2008; Martens 1999; Virtanen 2005].
Since the drafting of the NIOSH Strategic goals in 2017, the Nation has faced a global pandemic of COVID-19 which has put tremendous strain on workers in the Healthcare and Social Assistance Sector. In response to the pandemic, Congress promulgated the American Rescue Plan Act of 2021. The Rescue Plan charges NIOSH with the responsibility of taking actions to prevent mental health conditions and substance use disorders among healthcare professionals [U.S. House of Representatives 2021]. The relationship between suboptimal organization of work and resulting work-related fatigue and stress with depression, anxiety, cognitive impairment, suicide and other related health and safety outcomes among workers in the healthcare and social assistance sector is not fully understood. Research to better characterize how these organizational factors impact health, and interventions to address these organizational factors, is necessary. This may include surveillance on work practices, work factors (psychosocial and safety climate), and health outcomes among healthcare workers. Innovative surveillance approaches are especially needed for certain groups such as those in non-standard work arrangements. Work organization interventions from other healthcare settings such as hospitals and clinics could be translated to workers in nursing homes, homes, veterinary/animal care environments and non-standard work arrangements. Translation research is also extremely important, and the Rescue Plan calls on NIOSH to carry out a national evidence-based education and awareness campaign to address mental health and substance use disorders that is directed at health care professionals and first responders and their employers.
NOTE: Goals in bold in the table below are priorities for extramural research.[/vc_column_text]
|Health Outcome||Research Focus||Worker Population||Research Type|
|A||Illnesses, non-fatal injuries, adverse mental health outcomes (e.g., anxiety, depression, fatigue, burnout, suicide & substance use disorders)||Work & non-work factors that contribute to worker safety, health, & well-being (i.e. Total Worker Health [TWH] approach) (e.g., musculoskeletal health, shift scheduling & control, well-being, & utilization of support services & treatment)||Healthcare workers, especially low-wage healthcare support occupations (e.g., home health aides, dental assistants, pharmacy aides, veterinary assistants & laboratory animal caretakers).||Intervention|
|B||Illnesses, non-fatal injuries, adverse mental health outcomes (e.g., anxiety, depression, fatigue, burnout, suicide & substance use disorders)||Indicators for use of TWH approaches & adverse outcomes that might be improved by TWH||Healthcare workers, especially low-wage healthcare support occupations (e.g., home health aides, dental assistants, pharmacy aides, veterinary assistants & laboratory animal caretakers).||Surveillance research|
|C||Illnesses, non-fatal injuries, adverse mental health outcomes (e.g., anxiety, depression, fatigue, burnout, suicide & substance use disorders)||Barriers & facilitators to implementing TWH research findings||Healthcare workers, especially low-wage healthcare support occupations (e.g., home health aides, dental assistants, pharmacy aides, veterinary assistants & laboratory animal caretakers).||Translation|
|D||Evaluate effectiveness & adoption TWH polices, practices and programs||Intervention Translation
Activity Goal 7.12.1 (Intervention Research): Conduct intervention studies to develop and assess the effectiveness of work design and well-being interventions that integrate protection from work-related safety and health hazards (mental and physical) with promotion of injury and illness prevention efforts including utilization of support and treatment services, to advance worker well-being in Healthcare and Social Assistance workplaces.
Activity Goal 7.12.2 (Translation Research): Conduct translation research to understand barriers and aids to implementing policies, programs, and practices that integrate protection from work-related safety and health hazards (mental and physical) with promotion of injury and illness prevention efforts including utilization of support and treatment services in Healthcare and Social Assistance workplaces.
Activity Goal 7.12.3 (Surveillance Research): Conduct surveillance research to better track risks to worker safety, mental and physical health and well-being in Healthcare and Social Assistance workplaces.
In 2019, the healthcare and social assistance sector experienced the highest number of nonfatal occupational injuries and illnesses (575,200 cases) and the fourth highest incidence rate (3.8 per 100 full-time equivalent workers) of any private industry sector [BLS 2019a]. The highest incidence rate of nonfatal injuries and illnesses was in state-operated nursing and residential care facilities (11.5 per 100 FTE workers), followed by veterinary services (10.7 per 100 FTE workers). Other industries covered by the HCSA program with high incidence rates include -operated hospitals (8.1), local government-operated nursing and residential care facilities (7.6), and psychiatric and substance abuse hospitals (7.2) [BLS 2019b]. . In 2020, healthcare support occupations accounted for over 6.4 million jobs in the HCSA sector [BLS 2020]. Of these, home health aides and personal care aides accounted for approximately half of jobs [BLS 2020]. Low wage healthcare support occupations are at risk of injury due to overexertion, falls, suboptimal work organization and violence. Over one-fifth of home care aides reported at least one incident of verbal abuse by clients and client’s family members in the past 12 months [Karlsson et al 2019]. For veterinarians, suicide is of particular concern. Poisoning was identified as the most common mechanism of suicide, and pentobarbital, the drug used in animal euthanasia, was the most common drug involved in poisonings [Witte et al. 2019]. The COVID-19 pandemic has placed additional strains on healthcare and social assistance workers. A study of 90 healthcare professionals (HCPs) and 90 age-matched controls in the United States during COVID-19 found significantly higher levels of depressive symptoms, current anxiety, concern about their health, and tiredness, but lower levels of proactive coping in HCPs compared to non-HCPs [Pearman et al. 2020].
Systemic changes to our economy and socio-demographic workforce factors are rendering some past approaches to protecting workers ineffective. Increasingly, employers face tighter profit margins, demanding timelines and global completion. Workers and employers must navigate new types of work arrangements, the aging of the workforce, high levels of work-related stress, and the growing challenges of both work and home life. Many enterprises continue to confront the legacy hazards of the traditional workplace, such as traumatic injury associated with manual lifting and falls, chemical exposures, and shift work. At the same time, scientific evidence now supports what many safety and health professionals, as well as workers themselves, have long suspected—that risk factors in the workplace can contribute to common health problems previously considered unrelated to work.
Since the drafting of the NIOSH Strategic goals in 2017, the Nation has faced a global pandemic of COVID-19 which has put tremendous strain on workers in the Healthcare and Social Assistance Sector. In response to the pandemic, Congress promulgated the American Rescue Plan Act of 2021. The Rescue Plan charges NIOSH with the responsibility to take actions to prevent mental health conditions and substance use disorders among healthcare professionals [U.S. House of Representatives 2021]. Total Worker Health promotes the integration of occupational safety and health (OSH) protection with workplace policies, programs, and practices to prevent injury and illness and advance overall health and well-being through research, interventions, partnerships, and capacity-building to meet the needs of the 21st century workforce. The healthcare and social assistance industry sector faces unique challenges and opportunities in promoting worker health as it relates to patient safety. For healthcare workers, patient-care issues often take precedence over personal safety [DeJoy, Murphy, & Gershon, 1995]. However, many opportunities exist where both worker safety and patient safety can be improved [The Joint Commission, 2012]. Evidence suggests that integrating occupational safety and health protection program activities with health promotion program activities may be more effective for safeguarding worker safety, health, and well-being than either of these programmatic activities on their own [Sorensen et al. 2013; NIOSH 2012; DeJoy 1993; Sauter 2013]. Despite these developments, there is need for continued research to better understand the benefits of integrated approaches to prevention and to promote more comprehensive intervention, especially among certain occupations and industries. Promotion of Total Worker Health is especially relevant to parts of the Rescue Plan that call on NIOSH to carry out a national evidence-based education and awareness campaign to address mental health and substance use disorders that is directed at health care professionals and first responders and their employers.
American Nurses Association . Health & safety survey reportexternal icon. American Nurses Association,
Bartram DJ, Baldwin DS . Veterinary surgeons and suicide: a structured review of possible influences on increased risk. Vet Rec 166:388–397.
BLS [2019a]. 2018 survey of occupational injuries and illnesses. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/iif/soii-chart-data-2018.htmexternal icon
BLS [2019b]. Supplemental news release tables. Table SNR01. Highest rates for total cases – injuries and illnesses. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/iif/soii-data.htmexternal icon
BLS . Occupation employment and wages, May 2020. 31-0000 healthcare support occupations Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/oes/current/oes310000.htmexternal icon
Clarke SP . Hospital work environments, nurse characteristics, and sharps injuries. Am J Infect Control 35:302-309.
DeJoy D, Southern D . An integrative perspective on work-site health promotion. J Occup Med 35:1221–1230.
DeJoy D M, Murphy LR, Gershon R . Safety climate in health care settings. In: Bitter A, ed, Advances in industrial ergonomics and safety VII). New York: Taylor & Francis.
Ferrie JE, Westerlund H, Virtanen M, Vahtera J, Kivimäki M . Flexible labor markets and employee health. SJWEH Suppl 6:98–110.
Fowler HN, Holzbauer SM, Smith KE, Scheftel JM . Survey of occupational hazards in Minnesota veterinary practices in 2012. JAVMA 248:207-218.
Hessels AJ, Larson EL . Relationship between patient safety climate and standard precaution adherence: a systematic review of the literature. J Hosp Infect 92(4):349-62.
Karlsson ND, Markkanen PK, Kriebel D, Gore RJ, Galligan CJ Sama SR, Quinn MM . Home care aides’ experiences of verbal abuse: a survey of characteristics and risk factors. Occup Envir Med 76:448-454.
Martens MJ, Nijhuis FN, Van Boxtel MJ, Knottnerus JA . Flexible work schedules and mental and physical health. A study of a working population with non-traditional working hours. J Organiz Behav 20: 35–46.
National Nurses United (NNU) . National nurse survey reveals devastating impact of reopening too soon. Silver Spring, MD: National Nurses United. https://www.nationalnursesunited.org/press/national-nurse-survey-reveals-devastating-impact-reopening-too-soonexternal icon
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Oreskovich MR, Shanafelt T, Dyrbye LN, Tan L, Sotile W, Satele D, West CP, Sloan J, Boone S  The prevalence of substance use disorders in American physicians. Am J Addict 24(1):30-8.
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Sauter SL . Integrative approaches to safeguarding the health and safety of workers. Ind Health 51: 559–561
Sorensen G, McLellan D, Dennerlein JT, Pronk NP, Allen JD, Boden LI, Okechukwu CA, Hashimoto D, Stoddard A, Wagner GR  Integration of health protection and health promotion: Rationale, indicators, and metrics. J Occup Environ Med 55(12 Suppl.): S12–S18..
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Tomasi SE, Fechter-Leggett ED, Edwards NT, Reddish AD, Crosby AE, Nett RJ  Suicide among veterinarians in the United States from 1979 through 2015. J Am Vet Med Assoc 254(1):104-112. https://doi.org/10.2460/javma.254.1.104external icon
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Virtanen M, Kivimäki M, Joensuu M, Virtanen P, Elovainio M, Vahtera J . Temporary employment and health: a review. Int J Epidemiol 34(3):610-22.
Witte TK, Spitzer EG, Edwards N, Fowler KA, Nett RJ . Suicides and deaths of undetermined intent among veterinary professionals from 2003 through 2014. J Am Vet Med Assoc 255(5):595-608
Note: Goal 7.12 was added in October 2019.