Nursing is a vocation rife with occupational hazards. On a daily basis, nurses come into contact with sick patients, infectious agents, teratogenic chemicals, and radiation, to name a few environmental risks. Additionally, nurses are constantly on their feet, walking several thousand steps per shift. They are expected to help lift, move, and transfer patients several times per day, and face many potential musculoskeletal injuries from strenuous physical labor.
It is not surprising, then, that many nurses worry about the risks inherent in their daily job descriptions once they are expecting. Many nurses are women of childbearing age, and a pregnant nurse has to take certain precautions to keep herself and her growing baby safe. Below are some of the hazards pregnant nurses may face and suggestions for mitigating those risks.
Infection. Perhaps one of the most obvious risks to a pregnant woman and her fetus is infection. A nurse in the emergency department (ED), for example, may encounter patients sick with potential pathogens, from strep throat to tuberculosis to the flu. A pregnant nurse should follow standard precautions with all patients, and may also wish to wear a surgical mask around patients with a fever or suspected respiratory illness. A pregnant ED nurse may also wish to limit exposure to pathogens by reducing time spent in triage, if possible. Pregnant nurses may wish to avoid taking care of patients with active shingles or varicella zoster infections, as well as patients on airborne precautions.
Pregnant nurses should be immunized against influenza; the vaccine is safe for women in all stages of pregnancy. The live attenuated flu vaccine is unsafe for pregnant women. As an added benefit, flu antibodies are also passed to the fetus. If a pregnant nurse cares for a patient with influenza and later suspects she may have contracted the flu, she should speak with occupational health at her hospital to possibly receive a prescription for Tamiflu. Tamiflu works best when taken within 48 hours of symptom onset.
Drugs and chemotherapeutic agents. Because several drugs and pharmaceutical agents have known fetotoxicity, great care should be taken by the pregnant nurse when administering those and any medications to patients. Medication preparation is risky, and pregnant nurses may be exposed to hazardous drugs through skin absorption, inhalation, accidental contact, or needle-stick injuries. Sometimes while drawing up medication, the liquid can splash or make contact with the skin. Nurses should at the very least wear gloves while drawing up any medications or handling drugs, and at the most, should avoid handling known chemotherapeutic agents such as methotrexate.
Nurses should also weigh the risks and benefits of continuing their particular field of nursing while pregnant. Cancer treatment drugs, for example, have known effects of infertility, miscarriage, birth defects, and low birth weights.
Ionizing radiation. Radiation for diagnostic imaging is common in nearly all hospital departments, and nurses are at risk not just of background radiation but also of direct ionizing radiation. Nuclear medicine departments in particular are of high risk to a pregnant woman. Effects of radiation on a fetus depend in part on the dosage of radiation and on the baby’s gestational age. The thresholds of safe exposures are not well investigated, but research has demonstrated an “all or none” effect; that is, significant exposures cause either no effect or a fetal loss. Although dosimeters are used in areas where high radiation exposure is expected, other areas of high ionizing radiation (e.g., the emergency department) are rarely monitored. Expectant nurses should be very aware of their surroundings.
Stress, physical labor, and shift work. It may be necessary for nurses later in pregnancy to modify their shift schedule or behaviors to help accommodate their needs. Nursing is already a physically rigorous vocation, but add in the fatigue of pregnancy and it can be extremely physiologically demanding. In the first trimester, many women experience morning sickness, which to the pregnant nurse can be debilitating. Later in pregnancy, back pain and sciatica can also interfere with nurses’ ability to continue working until their baby is full term. Additionally, the 12-hour shifts typical for most hospital nurses become more taxing later in pregnancy, and it may be necessary for the pregnant nurse to request a modification to shorter shifts or part-time hours. The best solutions for pregnant nurses are to enlist colleagues for help when possible, to always use safe-lift equipment when available, and to speak up when requiring assistance.
If you are pregnant and struggling to perform your duties, certain pregnancy complications are covered by the Pregnancy Discrimination Act. Pregnant nurses should also be familiar with their state and employer’s Family Medical Leave Act policies and eligibility requirements.
For more information about the hazards to pregnant health care workers, you can browse the National Institute for Occupational Safety and Health’s website about the effects of workplace hazards on female reproductive health.
On February 15, 2018, the newest safe nurse staffing bill was introduced to the U.S. Congress. The bill (H.R.5052 and S.2446) has bipartisan support, and is championed by Reps. David Joyce (R-OH), Suzan DelBene (D-WA), Suzanne Bonamici (D-OR), and Tulsi Gabbard (D-HI), as well as Sen. Jeff Merkley (D-OR).
In the past, several safe staffing bills have been presented in previous Congresses but have failed to pass committee. This bill, the Safe Staffing for Nurse and Patient Safety Act of 2018, is slightly different than previous iterations. Under this staffing legislation, Medicare-participating hospitals would be required to form committees that would create and implement unit specific, nurse-to-patient ratio staffing plans. At least half of each committee must comprise direct care nurses.
“It is so important for nurses on the front lines to be able to have a say in what they believe is safe staffing,” says Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, the president of the American Nurses Association (ANA). “This bill benefits bedside nurses by giving them decision-making power, control, and the ability to influence the delivery of safe care,” Cipriano continues.
A committee made of staff nurses—who would make staffing decisions that directly affect their own units—is so important because it is nurses who can best assess patient needs and the resources required to provide safe patient care. Staffing committees would be able to address the unique needs of specific units and patient populations by involving specialty nurses in the decisions, and would have the ability to modify the hospital safety plans as needed.
Overwhelmingly, research supports adequate nurse staffing. Over the last several decades, literature has demonstrated a decrease in patient morbidity and mortality and an increase in patient safety when units are well staffed. “With adequate amounts of staffing we see mortality go down and patient complications can be prevented or diminished,” Cipriano says. “It is important for nurses to have sufficient resources to care for patients, because nurses experience moral distress when they cannot provide the care they know a patient needs.”
Short-changing patients also contributes to nurse burnout, and low nursing retention is expensive. Additionally, adequate nurse staffing leads to reduced health care costs, as a result of fewer hospital readmissions, hospital-acquired infections, medical errors, and other significant measurable patient outcomes. “Patients deserve to have the right care,” Cipriano says. “They need to be kept safe, and the best way to prevent problems and complications is to have the right nurse staffing.”
Is there hope that this bill will pass, when so many previous iterations have not? “It may be difficult to pass the legislation, even this time around,” Cipriano admits. “But the most important impact is that every time we have an opportunity to have this legislation discussed, it’s another opportunity to educate another decision maker. Whether it is congresspeople, their staff, or other leaders in their communities, it gives us the opportunity to continue to reinforce why it is so important to have the right nursing care.”
It is ethically challenging when a nurse is asked to take staffing assignments that do not feel safe. On many units, nurses are expected to care for several acute and critically ill patients at a time, and are given patient loads that stretch them far beyond their reasonable care delivery capabilities. What should a nurse do when faced with an unsafe assignment? Nurses should raise immediate concerns by following the chain of command, and talking with immediate supervisors to express that they believe the situation is unsafe. “The first obligation is to make sure that no patient is left uncared for,” Cipriano says. “Short term, use the chain of command and do everything you can within in your power to make sure that you’re providing at least the minimum care the patient needs.” Longer-term, if nurses truly believe that their organization is not supporting the right staffing ratios, the ANA encourages an active dialogue with leadership, such as a conversation with responsible nursing leaders, quality directors, or patient care committees or councils to focus attention to the issue.
“Nursing care is like a medication,” Cipriano says. “You wouldn’t withhold a life-saving medication, so why would you withhold the right amount or right dose of nursing care?”
If you are passionate about safe staffing laws, consider calling or writing your congressperson and encourage them to support the Safe Staffing for Nurse and Patient Safety Act of 2018.
As most nurses certainly are aware, this year’s flu season is exceptional. It has surged earlier than in previous years and as of mid-January is widespread across all 50 states. There has been a significant wave of flu cases in doctor’s offices and hospitals across the country, affecting everyone from children to the elderly. Emergency rooms (ERs) are inundated with flu patients, and in many cases patients line the hallways in overcrowded facilities without space or beds available due to additional patient volume. Patients are boarding and holding for inpatient beds in the ERs, which exposes additional patients, visitors, and staff to the flu.
Below are some friendly flu reminders, tips, and tricks to keeping yourself and your patients healthy and safe this season and beyond.
Hand hygiene is the most effective way to stop the transmission of the flu. Flu spreads via droplets coughed or sneezed by infected persons onto shared surfaces. Washing your hands thoroughly and frequently and using alcohol-based gel sanitizers is an effective way to prevent flu. But one thing we often forget about is our patients’ hands. Especially when I work in triage, I’ve started asking my patients and their visitors to use hand sanitizer before triage and before they enter their patient rooms as well.
If your hands are feeling the burn after so much vigorous washing and sanitizing, reach out to your infectious disease department to see if it can provide some hospital-approved pump-style lotions for your cracked hands. At home, try using Bag Balm or deep healing lotions and placing mittens on before bed to help salves and creams absorb overnight.
If you have flu symptoms, you should stay home from work. Not all employers have the same regulations regarding sick leave and doctor’s notes, and some are certainly more rigid than others. But the best thing you can do for yourself, your patients, and your colleagues when feeling under the weather is to stay home. This doesn’t just help you get better faster, but also prevents you from endangering your fellow nurses. The flu can spread so rapidly through a department that it can quickly decimate staff numbers and leave no one else to care for other ill patients.
You should feel empowered to communicate with visitors about the flu. It is imperative that nurses educate family members and patient visitors about their role in flu prevention. If your facility hasn’t already done so, consider limiting visitors to your patient rooms, especially children. It is wise to limit visitors under the age of 12 to protect this vulnerable age group from germs. You should feel empowered to ask ill-appearing visitors not to enter a patient’s room if you are concerned for their health. The safety of patients is the utmost priority.
Tamiflu is not for everyone. Most cases of the flu do not require treatment with antiviral medication such as Tamiflu. Clinical judgment will determine whether a patient fits criteria for treatment with antivirals. In most cases, treatment is most effective if given within 48 hours of symptom onset. If you have cared for influenza patients and are starting to see symptoms in yourself, reach out to your employee or occupational health department as soon as possible. In some cases it may be taken prophylactically.
It’s not too late to vaccinate. Make sure to teach patients that even though the flu vaccine has been less effective this year, it still helps save lives by reducing the severity and duration of the influenza virus. Remind patients that it is not too late to receive their flu shot. Everyone six months and older should get the flu shot, especially children, the elderly, and pregnant women.
Mask yourself, mask your patients. If you suspect someone has the flu, you should immediately begin droplet precautions. Place a mask on the patient in triage or when leaving his or her room, and keep yourself protected with a mask and gloves at all times. Remind patients to cover their coughs to help keep you safe.
Resort to basic teaching. Effective discharge teaching can help prevent repeat doctor’s office or ER visits and can help patients stay healthy. Remind patients that the best place for them to be if they are feeling sick is at home. Most people who get the flu will have a mild illness that does not require hospitalization. Fluids, rest, and over-the-counter antipyretics are effective in treating most cases of illness. People with suspected flu should stay home until at least 24 hours after their fever has gone away. Emergency symptoms that require immediate evaluation in an ER include shortness of breath, difficulty breathing, sudden dizziness or confusion, severe or persistent vomiting or diarrhea, or pain or pressure in the chest or abdomen. In children or infants, watch for signs of dehydration, fast breathing, lethargy, and rash.
Keep yourself as healthy as possible. In addition to washing your hands frequently (while at work and not), you should also try to boost your immune system by eating nutritious foods, including fruits and vegetables; staying hydrated; and getting exercise and sleep. Staying well rested and well hydrated can help keep your immune system in good shape to combat this flu season.
The alarm goes off; you groan. How can it be time to get up already? You check the clock, hit the snooze button, and decide to skip breakfast in your head. You can eat something later—there’s no time.
Now that a new year is upon us, it’s time to renew some healthy habits. Many people resolve each new year to exercise more frequently or to eat healthier. I’ve got an easy suggestion for your nursing new year’s resolution: One of the best habits you can instill in your day is simply to eat breakfast before your shift.
As nurses, we know and can recognize the symptoms of hypoglycemia in our patients. But so frequently, the symptoms of low blood sugar are manifesting in ourselves and we don’t even notice. It is so important to eat breakfast, as it helps energize your morning, stabilize your blood sugar, and set you up for clear thinking and communicating at the beginning of a 12+ hour day.
Eating something in the morning is better than eating nothing, but some choices are better than others. The best breakfast choices are usually high in protein, fiber, heart-healthy fats, and complex carbohydrates. (And no, that mug of coffee doesn’t count as breakfast!)
Especially during winter, I urge you to try a bowl of oatmeal. Quick-cook oats take just two minutes to cook in the microwave, and they are so versatile. Try adding dried mango and shredded coconut, applesauce and cinnamon, or fresh fruit and Greek yogurt. Top with some raisins or nuts for added protein. Oatmeal is filling: it contains both soluble and insoluble fiber, which helps regulate your blood sugar and reduce your cholesterol levels. Even better, oatmeal is cheap! An entire canister of oats is usually less than $4 at the grocery store.
Oatmeal can be quick and easy to make and prepare (I set mine out the night before in a microwave-safe container, so in the morning I just add water and go), and I guarantee it will keep you full longer than that cup of coffee or berry smoothie. Overnight oats are a unique twist and make prep in the morning even faster. If you aren’t into hot cereal in the morning, try an oatmeal bar, the powerful effects of the oats are still available in bar form too, although be wary of excess sugars.
Whatever you grab as you walk out the door, make sure you’re setting yourself up for the best shift you can possibly have. Our job as nurses is hard enough without doing it on an empty stomach.
The emergency department (ED) presents a set of unique challenges for patient care, not the least of which is unstable patients who are at great risk for falls. I once heard a nurse educator proclaim: “Everyone is a fall risk in an ED.” From the elderly to the acutely ill, most patients in the department are at possible risk of falling, whether due to their age, their complaint, or the medications and treatment they are receiving. Additionally, many EDs do not have bed or chair alarms available for gurneys to assist with patient falls. Fall prevention is almost solely in the hands of the busy ED nurse.
Here are six ways you can help prevent patient falls in the emergency setting.
1. Use universal falls precautions.
All patients—from the 30-year-old with abdominal pain to the 65-year-old post–total knee replacement—are at risk of falling. In your own practice, using universal falls precautions can be helpful. Treating all patients as though they have the same risk for falls is a good start. Additionally, performing individual fall risk assessments on each patient at the beginning of his or her visit is important to both assessing risk and documenting that risk in the medical record. If completing a falls risk assessment is not mandatory at your facility, consider printing out the Morse Fall Scale and attaching it to your ID badge for quick reference. A standardized tool can help you quickly quantify the risk of patient falls so you can intervene accordingly.
2. Plan your interventions.
My personal favorite fall prevention intervention is the call light. On patient care whiteboards in the ED rooms, I write my name and the phrase, “Please use your call bell for ANY reason” on the board. I orient patients to the call bell immediately and make sure that it is in reach. I explain to them why both side rails need to stay up. Additionally, you may place fall risk socks (or grippy non-skid socks) on your patient as soon as you get them undressed into a gown. Use a fall risk yellow arm band if they’re available to you.
3. Orient your patient.
“I’m going to be your nurse today, and the best way we can work together is for you to help me keep you safe.” I remind patients that even if they feel fine, that trying to get up after laying down or after receiving high-risk pain medications can cause them to feel weaker or dizzier than they might imagine. I encourage patients to use the call bell so I can help assist them out of bed for any reason, but it is also important to set expectations. “It may take me a few minutes to respond, but I will be there as soon as I can.” Try to point out IV lines and oxygen tubing to patients as well as their EKG cables and monitoring leads to remind them that they will need to stay in bed and cannot get up without assistance.
4. Active toileting.
One of the biggest reasons that patients fall is because they have to use the bathroom. For male patients I always place “just in case” urinals at the bedside, and I encourage female patients to use the call bell as soon as they think they have to use the restroom. It is also recommended that you offer toileting as frequently as possible so that you are able to prevent the “have to go right now” urge that draws patients out of their beds.
5. Teamwork works.
It would be impossible for a nurse to be able to be in all of his or her patients rooms at all times, especially within the environment of the ED. If you have a patient who is a high fall risk, who perhaps has dementia or is uncooperative, notify your charge nurse and your colleagues on the unit. Try to move the patient to a room in sight of the nurses’ station or near a hallway. Keep the curtains to the room open if possible to allow as much sight as possible from passersby. If staffing allows, perhaps you could request a safety sitter to help watch the patient to keep them safe.
6. Speak up.
If there are conditions on your unit that continually put patients at risk for falls, report them to your manager and supervisors. It is everyone’s responsibility to help prevent patient falls.