Healthcare and Social Assistance Program
Burden, Need and Impact
Over 21 million workers were employed in private and public sector industries covered by the Healthcare and Social Assistance (HCSA) program in 2017. While employing 13.8% of the workforce, these industries experienced more than 679,900 occupational injuries and illnesses, 19.9% of the total for all industries.1 Although injuries and illnesses are challenging to track and are frequently undercounted, this is the best estimate available at this time.2 Work-related fatalities are not as common in HCSA compared to other industries. Nevertheless, in 2017, industries covered by the HCSA program had 2.9% of the fatalities among all workers in the U.S.1 Data related to some of these health outcomes may be available in the NIOSH Worker Health Charts (WHC). WHC is a web application
that uses data from various sources to visualize worker health data that may be difficult to find or not charted elsewhere. Note that some industries may not be represented in this tool due to small sample size.
NIOSH strives to maximize its impact in occupational safety and health. The HCSA Program identifies priorities to guide investments, and base those priorities on the evidence of burden, need, and impact. Below are the priority areas for this program.
Adverse health effects associated with exposure to antineoplastic drugs are well documented and include acute effects such as nausea, headache, skin and eye irritation, and hair loss, as well as long-term effects such as DNA damage, miscarriage, leukemia and other cancers.1-6 The current NIOSH list of antineoplastic and other hazardous drugs in healthcare settings comprises nearly 220 drugs and continues to grow.7 About 8 million U.S. healthcare workers are potentially exposed to hazardous drugs, including pharmacy and nursing personnel, physicians, operating room personnel, environmental services workers, workers in research laboratories, veterinary care workers, and shipping and receiving personnel.8
A recent NIOSH study found that nurses, including those who were pregnant, did not wear protective gloves and gowns while handling or administering such drugs.9 Twelve percent of nonpregnant nurses and 9% of pregnant nurses indicated that they never wore gloves and 42% of nonpregnant nurses and 38% of pregnant nurses reported never using a gown. Protective gloves and gowns are considered the minimum protective equipment when handling and administering such drugs.
NIOSH found over 400 healthcare workers reported acute illnesses or injuries related to disinfectant exposure from 2002-2007 in four states.10 Environmental services workers were the most common occupation (24%), followed by nursing and medical assistants (16%), technicians (15%), and nurses (11%). Healthcare workers account for about 16% of all occupational asthma cases and that up to 24% of these cases are due to exposure to cleaning agents.11 Healthcare workers have one of the highest prevalences of occupational asthma at 8.8%, compared to 7.2% among all workers.11-12
Other respiratory hazards for healthcare workers include surgical smoke and waste anesthetic gases. Smoke generated from lasers or electrosurgical devices during surgery have been found to be toxic, mutagenic and potentially infectious.13-15 The Occupational Safety and Health Administration estimates that 500,000 workers are exposed to surgical smoke each year.16 Anesthetic or analgesic gases and vapors that escape during dental and medical procedures have been associated with cognition, manual dexterity and adverse reproductive outcomes.17-18 An estimated 250,000 U.S. healthcare workers may be exposed to these waste anesthetic gases and at risk of developing adverse health effects.19
While national guidelines exist for the safe handling of antineoplastic drugs, information is lacking on adherence to these guidelines by healthcare workers and employers. A NIOSH survey conducted among members of professional healthcare organizations including oncology nurses, pharmacists, and pharmacy technicians found that 47% of pharmacy practitioners who compounded antineoplastic drugs in the seven days prior to the survey did not always wear the recommended two pairs of chemotherapy gloves, and 10% did not wear even a single pair.20 The same survey found that 12% of oncology nurses and others who administer antineoplastic drugs took home potentially contaminated clothing.21 Disuse of protective gloves and gowns during administration of antineoplastic drugs was also reported by pregnant and nonpregnant nurses who participated in the Nurses’ Health Study 3.9 Findings from these studies underscored the need for education and training to ensure both employers and healthcare practitioners understand the risks involved and know what measures to take to minimize exposure.
There is a need to develop measurement methods for cleaning and disinfecting exposures related to respiratory and dermal health effects.22 Surveillance is also needed to better understand potential barriers to reporting illness related to cleaning and disinfection products in HCSA workplaces.23
Exposure controls exist to minimize exposure to waste anesthetic gases. However, a NIOSH survey of healthcare workers found that precautionary work practices were not always implemented, putting workers at risk of exposure.24 Similarly, local exhaust ventilation is recommended to control surgical smoke. Yet, the same survey found that less than half (47%) of healthcare workers present during laser surgery and 14% of healthcare workers present during electrosurgery reported always using local exhaust ventilation.25 A better understanding of the barriers to using recommended exposure controls is needed to address these occupational risks.
In early 2018, NIOSH investigators reported on a cluster of idiopathic pulmonary fibrosis (IPF) among dental personnel in Virginia.26 IPF is a chronic, progressive lung disease of unknown etiology and associated with a poor prognosis. This cluster was the first reported among dental personnel. The investigators recommended additional studies to more fully understand occupational exposures of dental personnel and the association between these exposures and the risk for developing IPF so that prevention strategies can be developed.
The number of hazardous drugs and chemicals in the HCSA sector continues to grow as advances are made in chemical engineering and pharmaceutical manufacturing. Likewise, pressure on facilities to manage infectious disease risks has introduced stronger and more toxic cleaning products into the HCSA sector. NIOSH protects workers in the HCSA sector by publishing a list of hazardous drugs and sharing research and information on preventing occupational exposures. The potential impact of this prevention is not insignificant – the HCSA sector will account for nearly a third of the projected job growth from 2016 to 2026, more than any other industry sector.27
1Valanis BG, Vollmer WM, Labuhn KT, Glass AG . Association of antineoplastic drug handling with acute adverse effects in pharmacy personnel. Am J Hosp Pharm 50(3):455–462.
2Villarini M, Dominici L, Piccinini R, Fatigoni C, Ambrogi M, Curti G, Morucci P, Muzi G, Monarca S, Moretti M . Assessment of primary, oxidative and excision repaired DNA damage in hospital personnel handling antineoplastic drugs. Mutagenesis 26(3):359-69.
3Valanis BG, Vollmer WM, Labuhn KT, Glass AG . Acute symptoms associated with antineoplastic drug handling among nurses. Cancer Nurs 16(4):288–295.
4Skov T, Maarup B, Olsen J, Rorth M, Winthereik J, Lynge E . Leukaemia and reproductive outcome among nurses handling antineoplastic drugs. Br J Ind Med 49(12):855–861.
5Lawson CC, Rocheleau CM, Whelan EA, Hibert EN, Grajewski B, Spiegelman D, Rich-Edwards JW . Occupational exposures among nurses and risk of spontaneous abortion. Am J Obstet Gynecol 206(4):327.e1-9.
6Richardson DB, Cardis E, Daniels RD, Gillies M, O’Hagan JA, Hamra GB, Haylock R, Laurier D, Leuraud K, Moissonnier M, Schubauer-Berigan MK . Risk of cancer from occupational exposure to ionising radiation: retrospective cohort study of workers in France, the United Kingdom, and the United States (INWORKS). BMJ 351:h5359
7NIOSH . NIOSH list of antineoplastic and other hazardous drugs in healthcare settings, 2016. Cincinnati, OH; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2016-161, https://www.cdc.gov/niosh/docs/2016-161/default.html
8NIOSH . Personal protective equipment for health care workers who work with hazardous drugs. Cincinnati, OH; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No.2009-10, https://www.cdc.gov/niosh/docs/wp-solutions/2009-106/.
9Lawson CC, Johnson CY, Nassan FL, Connor TH, Boiano JM, Rocheleau CM, Chavarro JE, Rich-Edwards JW  Antineoplastic drug administration by pregnant and nonpregnant nurses: and exploration of the use of protective gloves and gowns. Am J Nurs 119(1):28-35.
10CDC . Acute antimicrobial pesticide-related illnesses among workers in health-care facilities – California, Louisiana, Michigan, and Texas, 2002-2007. MMWR 59(18):551–556.
11NIOSH . Current asthma: Estimated prevalence by industry and sex, U.S. working adults aged ≥18 years, NHIS 2004–2011. Work-Related Lung Disease Surveillance System (eWoRLD). Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Current_asthma_Estimated_prevalence_by_industry_and_sex_US_working_adults_aged_18_years_NHIS_20042011/866
12NIOSH . Prevalence of current asthma among US adults who have worked in the past 12 months by the Healthcare and Social Assistance Sector. Occupational Health Supplement. National Health Interview Survey. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, https://www.cdc.gov/niosh/topics/nhis/healthcareind/hcindfig4.html
13Barrett WL, Garber SM . Surgical smoke: a review of the literature. Surg Endosc 17(6): 979-87.
14Hensman C, Newman EL, Shimi SM, Cuschieri A . Cytotoxicity of electro-surgical smoke produced in an anoxic environment. Am J Surg 175(3):240-1.
15Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A . Surgical smoke and infection control. J Hosp Infect 62(1):1-518.
16OSHA . Laser/Electosurgery plume: Overview. Safety and Health Topics. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, https://www.osha.gov/SLTC/laserelectrosurgeryplume/index.htmlexternal icon
17Rowland AS, Baird DD, Weinberg CR, Shore DL, Shy CM, Wilcox AJ . Reduced fertility among women employed as dental assistants exposed to high levels of nitrous oxide. N Engl J Med 327:993–997.
18NIOSH . Controlling exposures to nitrous oxide during anesthetic administration. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 94-110, http://www.cdc.gov/niosh/docs/94-100/
19OSHA . Waste anesthetic gases. Safety and health topics. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, https://www.osha.gov/SLTC/wasteanestheticgases/index.htmlexternal icon
20Boiano JM, Steege AL, Sweeney MH . Adherence to precautionary guidelines for compounding antineoplastic drugs: a survey of nurses and pharmacy practitioners. J Occup Environ Hyg 12(9): 588–602
21Boiano JM, Steege AL, Sweeney MH . Adherence to safe handling guidelines by healthcare workers who administer antineoplastic drugs. J Occup Environ Hyg 11(11):728-740.
22NIOSH . Prevalence of dermatitis in the past 12 months among US adults who have worked in the past 12 months by the Healthcare and Social Assistance Sector, 2010. Occupational Health Supplement. National Health Interview Survey. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, https://www.cdc.gov/niosh/topics/nhis/healthcareind/hcindfig2.html
23Quinn MM, Henneberger PK, Braun B, Delclos GL, Fagan K, Huang V, Knaack JL, Kusek L, Lee SJ, Le Moual N, Maher KA . Cleaning and disinfecting environmental surfaces in health care: toward an integrated framework for infection and occupational illness prevention. Am J Infect Control 43(5):424-34.
24Boiano JM, Steege AL . Precautionary practices for administering anesthetic gases: A survey of physician anesthesiologists, nurse anesthetists and anesthesiologist assistants. J Occup Environ Hyg 13(10):782-793.
25Steege AL, Boiano JM, Sweeney MH . Secondhand smoke in the operating room? Precautionary practices lacking for surgical smoke. Am J Ind Med 59(11):1020-1031.
26Nett RJ, Cummings KJ, Cannon B, Cox-Ganser J, Nathan SD . Dental personnel treated for idiopathic pulmonary fibrosis at a tertiary care center – Virginia, 2000-2015. MMWR 67(9):270-273.
27BLS . Economic News Release Employment Projections: 2016-2026. Washington, DC: Department of Labor, Bureau of Labor statistics, https://www.bls.gov/news.release/ecopro.nr0.htmexternal icon
Infectious diseases are an ongoing concern among healthcare and social assistance workers. Sharps injuries are important risk factors for transmission of bloodborne pathogens such as HIV, Hepatitis B and C. The World Health Organization estimates that 37.6% of Hepatitis B, 39% of Hepatitis C and 4.4% of HIV/AIDS in healthcare workers around the world are due to needlestick injuries.1 In 2009, it was estimated that there were about 385,000 percutaneous injuries in U.S. hospital-based HCSA workers each year.2
Several well-known emerging infectious diseases affecting healthcare workers in recent years have included 2009 H1N1 pandemic influenza, Ebola, and Middle Eastern Respiratory Syndrome (MERS). Multi-drug resistant organisms present a growing challenge for workers in the HCSA sector, with 88 cases of multidrug resistant TB and one case of extensively drug-resistant TB identified in the U.S. in 2015.3
Occupational infectious diseases are also an important hazard for veterinary medicine/animal care (VM/AC) workers, who face the hazard of zoonotic (animal-to-human) transmission of infectious diseases such as brucellosis, rabies and other zoonotic diseases.
Prevention of bloodborne disease transmission in HCSA workers depends on stopping sharps injuries and other blood and body fluid exposures. Unfortunately, surveillance for this issue is fragmented and only limited data is available to estimate the full burden of needlestick injuries. NIOSH estimates that half or more of sharps injuries go unreported.4 While safety syringe/needle devices have been shown to reduce the risk of sharps injury by 43-100%, this control has not been universally adopted.5 Research is needed to develop surveillance methods to document the burden of infectious disease transmission in veterinary and animal care workers.
Known infection control practices, such as handwashing, vaccinations and personal protective equipment, are not universally accepted, poorly implemented or incorrectly utilized. For example, research indicates that vaccination rates workers in long-term care facilities, nursing assistants and aids, and childcare workers are lower than other healthcare and assistance occupations.6-7 Research is needed to identify and eliminate barriers to adopting these existing interventions. Much is also unknown about emerging infectious diseases.
Addressing infectious disease threats in the HCSA sector will require a multifaceted approach driven by evidence-based practices, thoughtful occupational health research and comprehensive surveillance. In addition to increasing worker health and safety, these efforts can also reduce costs. Vaccinating employees for influenza and reducing influenza-related absenteeism can save U.S. employers $2.58 for every dollar invested in a vaccination program.8 NIOSH protects workers in the HCSA sector by developing and evaluating personal protective equipment and sharing research and information for workers on emerging infectious diseases. The potential impact is not insignificant – the HCSA sector will account for nearly a third of the projected job growth from 2016 to 2026, more than any other industry sector.9
1WHO . Ebola Situation Report – 23 September 2015. Geneva, Switzerland: World Health Organization, http://apps.who.int/ebola/current-situation/ebola-situation-report-23-september-2015external icon
2NIOSH . Bloodborne pathogens and sharps injuries. In: State of the Sector: Healthcare and Social Assistance. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2009-139, https://www.cdc.gov/niosh/docs/2009-139/pdfs/2009-139.pdfpdf icon
3CDC . Tuberculosis — United States, 2016. MMWR 66:289–294
4NIOSH . Stop Sticks Campaign. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, https://www.cdc.gov/niosh/stopsticks/default.html.
5Tuma S, Sepkowitz KA . Efficacy of safety-engineered device implementation in the prevention of percutaneous injuries: a review of published studies. Clin Infect Dis 42(8):1159–1170.
6CDC . Influenza vaccination coverage among health care personnel – United States, 2016-17 Influenza Season. MMWR 66(38):1009-1015.
7De Perio MA, Wiegand DM, Evans SM . Low influenza vaccination rates among child care workers in the United States: assessing knowledge, attitudes, and behaviors. J Com Health 37(2):272-81.
8Campbell DS, Rumley MH . Cost-effectiveness of the influenza vaccine in a healthy, working-age population. J Occup Environ Med 39:408–414.
9BLS . Economic News Release Employment Projections: 2016-2026 Summary. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/news.release/ecopro.nr0.htmexternal icon.
The Bureau of Labor Statistics last reported on incidence rates and number of cases of musculoskeletal disorders (MSDs) for industries and occupations in 2015. MSDs are injuries that are due in large part to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures. In the HCSA sector, the incidence rate of MSDs in 2015 was 42.9 cases per 10,000 FTEs ranking second among all other industries and 44% higher than the average for all private industry establishments.1 The incidence rate for MSDs were even higher in HCSA state and local government establishments, 210% and 37% respectively.1
Some occupations within HCSA have higher MSD rates than others, such as nurses, nursing assistants and home health aides who are often involved in patient handling activities. In 2015, nursing assistants had the second highest number of cases (19,360) and third highest incidence rate (180.5) of MSDs among all occupations across all ownerships (i.e., total private, state and local government).2 Veterinary workers are at increased risk of developing MSDs as a result of their work. A survey of Minnesota veterinary personnel showed that 31% and 45% of those who work with small and large animals, respectively, reported an MSD.3
Apart from patient movement and handling activities, other risk factors for MSDs include performing repetitive procedures or performing procedures in ergonomically compromised positions which is not uncommon among gastrointestinal endoscopists, surgeons and dentists.4-6
Despite the fact that safe patient handling and mobility (SPHM) interventions (e.g., patient lifts) have been shown to significantly reduce injuries7 and produce savings from injury cost reductions that surpass program costs within three years on average,8 comprehensive SPHM programs and interventions have not been implemented in many U.S. healthcare settings.9 Research is needed to identify and address barriers to implementation of effective interventions to prevent MSDs, identify key components of intervention sustainability, and disseminate best practices to prevent MSDs in workplaces covered by the HCSA program. Although much of the work regarding MSDs has been done in acute healthcare settings, MSD risk factors are also prevalent in many other work settings covered by the HCSA program (e.g., home health, veterinary medicine and animal care) and need to be studied.
Several evaluation studies are needed to measure the effectiveness (usefulness and unexpected results) of innovative approaches to reduce risk for MSDs and to reduce the return-to-work time among HCSA workers with MSDs. Such studies are also needed to evaluate the effectiveness of safe patient handling policies and regulations, evaluate exoskeletons and other innovative approaches to reduce the risk of MSDs, and to develop and evaluate interventions for vulnerable worker populations. Finally, new approaches to better understand the burden of ergonomic impacts and chronic MSDs among HCSA workers are needed to fill in gaps in currently-available surveillance data sources.
Expanding the NIOSH effort on this goal will advance NIOSH impact on developing effective and practical strategies to prevent MSDs in HCSA, which will also impact other industrial sectors including construction, public safety, services, oil and gas, and manufacturing. NIOSH has a track record of implementing and evaluating interventions for reducing MSDs and is poised to continue such work in this sector. The Revised NIOSH Lifting Equation helps healthcare workers determine how much weight can be safely lifted without using assistive equipment. Other resources such as the Safe Lifting and Movement of Nursing Home Residents continue to provide information to employers and workers in the HCSA sector.
1BLS . News Release. Nonfatal occupational injuries and illnesses requiring days away from work, 2015. Table 1. Number, median days away from work, and incidence rate for nonfatal occupational injuries and illnesses involving days away from work by ownership, industry, musculoskeletal disorders, and event or exposure, 2015. Washington, DC: U.S Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/news.release/osh2.nr0.htmexternal icon
2BLS . News Release. Nonfatal occupational injuries and illnesses requiring days away from work, 2015. Table 9. Number, median days away from work for nonfatal occupational injuries and illnesses involving days away from work and musculoskeletal disorders by selected worker occupation and ownership, 2015. Washington, DC: U.S Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/news.release/osh2.nr0.htmexternal icon
3Fowler HN, Holzbauer SM, Smith KE, Scheftel JM. . Survey of occupational hazards in Minnesota veterinary practices in 2012. J Am Vet Med Assoc 248(2):207-218
4Moodley R, Naidoo S, Wyk JV . The prevalence of occupational health-related problems in dentistry: A review of the literature. J Occup Health 60(2):111-125.
5Stucky CC, Cromwell KD, Voss RK, Chiang YJ, Woodman K, Lee JE, Cormier JN . Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics. Ann Medicine Surg 27:1-8.
6Yung DE, Banfi T, Ciuti G, Arezzo A, Dario P, Koulaouzidis A . Musculoskeletal injuries in gastrointestinal endoscopists: a systematic review. Expert Rev Gastroenterol Hepatol 11(10):939-947.
7Teeple E, Collins JE, Shrestha S, Dennerlein JT, Losina E, Katz JN . Outcomes of safe patient handling and mobilization programs: A meta-analysis. Work 58(2):173-184. doi: 10.3233/WOR-172608.
8Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala G . Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int J Nurs Stud 43:717-733.
9Lee SJ, Lee JH, Gershon RR . Musculoskeletal Symptoms in Nurses in the Early Implementation Phase of California’s Safe Patient Handling Legislation. Res Nurs Health 38(3):183-93
Safety culture reflects the shared commitment of management and employees toward ensuring a healthy and safe work environment. There are indications that safety culture in HCSA is not as prevalent as it could be:
- Nurses consistently report the highest levels of job stress of all healthcare professionals.1
- In a 2011 survey sponsored by the American Nurses Association (ANA), nurses reported that job stress was one of their two top safety and health concerns.2
- Nurses extended work shifts are associated with negative well-being and patient measures.3
- In a survey of veterinarians, male and female respondents had a higher lifetime prevalence of depressive episodes and suicidal ideation than the general population of U.S. adults.4
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.5-9 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 contingent 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 contingent work arrangements.
Research on effective work organization interventions that reduce occupational stress and improve worker health, safety, and well-being, has high potential for adoption within the healthcare industry. For example, information about NIOSH training for nurses on shiftwork and long work hour schedules was widely disseminated by NIOSH partners (such as the ANA) and is being offered for continuing education credits at some nursing schools. It is likely that occupational stress interventions developed for the HCSA sector will have applicability for many other sectors, particularly integrative interventions that address worker health and well-being both on and off the job.
1Ilan MN, Durukan E, Taner E, Maral I, Bumin MA . Burnout and its correlates among nursing staff: Questionnaire survey. J Adv Nurs 61(1):100-106.
2ANA (American Nurses Association) . 2011 Health and Safety Survey Report. Silver Spring, MD: American Nurses Association.
3Stumpfel AW, Sloane DM, Aiken LH . The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs 31(11):2501-2509.
4CDC . Notes from the field: Prevalence of risk factors for suicide among veterinarians-United States, 2014. MMWR 64(5): 131-132.
5Clarke SP . Hospital work environments, nurse characteristics, and sharps injuries. Am J Infect Control 35:302-309.
6Hessels 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.
7Ferrie JE, Westerlund H, Virtanen M, Vahtera J, Kivimäki M . Flexible labor markets and employee health. SJWEH Suppl 6:98–110.
8Martens 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.
9Virtanen M, Kivimäki M, Joensuu M, Virtanen P, Elovainio M, Vahtera J . Temporary employment and health: a review. Int J Epidemiol 34(3):610-22.
Working directly with patients, human or animal, poses substantial risk for injury. Injuries can be caused by acts of violence (in human healthcare) or because of kicks, bites or scratches (in veterinary medicine/animal care). In human healthcare, psychiatric and substance abuse hospitals and residential mental health facilities had the two highest incidence rates for violence related injuries (181.1 and 78.0 cases per 10,000 FTE, respectively), much higher than the private industry average (4.0) and the HCSA sector average (14.7).1 Occupations with the highest incidence rate for violence-related injuries include psychiatric aides (417.4), occupational therapy aides (59.6), nursing assistants (46.1), and recreational therapists (27.9).2
In veterinary medicine and animal care, the incidence rate of violence related injuries caused by animals was highest in veterinary services (98.5 cases per 10,000 FTEs) followed by pet care services (53.5), much higher than the private industry average (4.0).1 Occupations with the highest incidence rate for violent injuries caused by animals included veterinary assistants and laboratory animal caretakers (226.9), veterinary technologists and technicians (139.8) and nonfarm animal caretakers (62.8).2 By comparison, the incidence rate for all occupations in private industry is 4.0. The figures reported for HCSA and veterinary/animal care workers likely underestimate the problem, since many violent incidents go unreported.3
In the last 10 years, the number of workers employed in temporary or non-standard work arrangements has increased.4,5 Workers in these types of work arrangements (i.e. home healthcare, nursing homes) may not have the same protections to reduce the risk of violence on the job.
Surveillance to address underreporting and misclassification of injuries related to violence is needed to better identify trends and modifiable risk factors across socio-demographic groups and within subsectors of HCSA. Specific populations of interest include workers in psychiatric and substance abuse hospitals, veterinary and animal care, home health care, nursing and residential care facilities and vulnerable demographic groups in these settings. As many workers in the HCSA sector work in non-standard work arrangements, research is needed to understand the risks involved in working in such arrangements. New or improved surveillance methods may be necessary to evaluate these groups. Research developing interventions in these settings and for these populations and evaluating their effectiveness and cost-effectiveness in reducing risk related to violence, is crucial.
NIOSH will continue its efforts developing effective and practical strategies to design out workplace violence risks, craft engineering solutions, and implement organizational interventions to reduce workplace violence incidents and prevent injuries. NIOSH has a track record of implementing and evaluating interventions for reducing workplace violence and is poised to continue such work in this sector. Over 43,000 individuals have registered for NIOSH’s online Workplace Violence Prevention Training for Nurses with over 38,000 completing the course, including over 31,000 nurses receiving continuing education credits.
1BLS . Table R8. Incidence rates for nonfatal occupational injuries and illnesses involving days away from work per 10,000 full-time workers by industry and selected events or exposures leading to injury or illness, private industry, 2017. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/iif/oshwc/osh/case/cd_r8_2017.htmexternal icon
2BLS . Table R100. Incidence rates for nonfatal occupational injuries and illnesses involving days away from work per 10,000 full-time workers by occupation and selected events or exposures leading to injury or illness, private industry, 2017. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/iif/oshwc/osh/case/cd_r100_2017.htmexternal icon
3OSHA . Inspection guidance for inpatient healthcare settings. Memorandum from deputy assistant secretary to regional administrators and state designees. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, https://www.osha.gov/dep/enforcement/inpatient_insp_06252015.htmlexternal icon
4BLS . Employment, Hours, and Earnings from the Current Employment Survey (National): Series ID- CES6056132001; Series Title-All employees, thousands, temporary help services, seasonally adjusted. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://data.bls.gov/timeseries/CES605613200external icon1
5Nicholson JR . Temporary Help Workers in the U.S. Labor Market. Washington, DC: U.S. Department of Commerce, Economics and Statistics Administration, http://www.esa.doc.gov/sites/ default/files/temporary-help-workers-in-the-us-labor-market.pdfpdf iconexternal icon
1BLS . Labor force statistics from the current population survey. Characteristics of the employed. Household data annual averages. Table 18. Employed persons by detailed industry, sex, race, and Hispanic or Latino ethnicity. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/cps/cpsaat18.pdfpdf iconexternal icon.
2BLS  Numbers of nonfatal occupational injuries and illnesses by industry and case types, 2017. Table 2. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/iif/oshwc/osh/os/summ2_00_2017.htmexternal icon.
3BLS  Fatal occupational injuries by industry and event or exposure, all United States, Table A-1. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/iif/oshwc/cfoi/cftb0313.htmexternal icon