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| REVIEW ARTICLE |
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| Year : 2016 | Volume
: 21
| Issue : 1 | Page : 19-24 |
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Health hazards among health care personnel
Shakuntala Amirchand Chhabra
Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences; Kasturba Health Society, Sevagram, Wardha; Mahatma Gandhi Adiwasi Dawakhana, Mata Va Shishu Rugnalaya, Utawali, Dharni, Amravati, Maharashtra, India
| Date of Web Publication | 4-Mar-2016 |
Correspondence Address:
Shakuntala Amirchand Chhabra
Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-9903.178074
While providing health services, (preventive, curative, rehabilitative), health care personnel (HCP) face hazards. Developments in medical science provide some safety, still modern technology has made health care very complex with many hazards. Biological (viruses, bacteria, and parasites) and chemical (disinfectants, drugs, and diagnostics) therapeutic modalities in health delivery are leading to many disorders in HCP. Needle prick injuries, radiation exposure, violence, psychiatric disorders, stalking by patients, and suicides are common. HCP are at high risk for musculoskeletal disorders, due to patient handling, compounded by increasing number of obese patients. With increase in workload because of human immunodeficiency virus, hardships have increased. Despite potential for exposure to hazards, many HCP lack awareness about prevention. Also the system is not conducive, policies of prevention not clear, inaccessibile, or there is attitude problem. Hence, HCP continue to suffer, more in developing countries. Health managers need to ensure that health care is geared toward assessment of hazards suffered by HCP, there reasons, and do everything possible for prevention. Keywords: Hazards, health care personnel, health services
How to cite this article:
Chhabra SA. Health hazards among health care personnel. J Mahatma Gandhi Inst Med Sci 2016;21:19-24 |
| Introduction | |  |
Health services require a broad range of workers-doctors, nurses, technicians, laboratory workers, social workers, responders at various levels, maintenance, security administration, food services, housekeeping, mortuary and so on. [1] Health care personnel (HCP) refers to all persons, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces or contaminated air. Also, health services are provided at variety of settings, small/large, outpatient, inpatient, birthing places, operation theaters, emergency care, clinics, nursing homes, and at home also. Hazardous elements also include blood borne pathogens (biological), chemicals, drugs, anesthetic gases, laser, workplace violence, those associated with laboratories, radioactive material, X-ray waste, ergonomic, lifting, and repetitive tasks. Some of the potential hazardous chemicals include formaldehyde (used for preservation of tissue, organs) and numerous other chemicals used in laboratories. [2],[3]
While trying to ensure health of patients and public, HCP face a wide range of hazards to their own health due to injuries (needle prick, musculoskeletal, allergens), infections (viruses, bacteria, parasities), violence, and so on. HCP have the potential to get exposed to infectious material, including body substances, contaminated medical supplies, environment around including air and anesthetic gases, radiation equipment etc.
Chances of hazards in health facilities are highly variable depending on type of health facility. Women represent 80% of the health workforce, so they are major sufferers, with effect on their reproductive health also. Nonfatal injuries and illnesses among the HCP are the highest of any industry. Even, agriculture and construction industries have become safer than health facilities. Prevention of infections, injuries, and violence all needs to be in place at health facilities. [4] HCP are also the segment of society who are in need of guidance for prevention of substance use and therapy of substance abuse. [5]
Chemical exposure can occur from sterilants, disinfectants, cleaning compounds, hazardous drugs, mercury, anesthetic gases, latex etc. Biological hazardous items include viruses (hepatitis B and C viruses [HBV and HCV] human immunodeficiency virus [HIV], etc), bacteria, and parasites. Others injuries are ionizing and nonionizing radiation. Ergonomic injuries can occur from patient handling, lifting, shifting, lifting heavy equipment, and static postures. Psychological and work organization, shift work, stress, burnout, and the workplace violence especially gender related are other hazards. [6]
| Types of Hazards | | |
Physical
The Centers for Disease Control and Prevention [6] report that more than 40% of the needlestick injuries (NSIs) are suffered by nursing personnel even in developed countries. The circumstances in which most NSIs occur involve manipulating a needle (26%), sharp disposal (21%), collision with a worker or sharp (10%), clean-up (9%), and recapping needles (5%) or surgery. Computer workstations, hand held devices, laboratories, minimally invasive surgery, patient handling, slips, trips, and falls due to wet floors of stairways, ramps or due to cables and cords, lighting, and spills also lead to various injuries.
Orji et al. [7] investigated occupational health hazards among health-care workers in an obstetrics and gynecology unit. The common occupational health hazards were work-related stress (83.3%), needle-stick injuries (75.6%), bloodstains on skin (73.1%), sleep disturbance (42.3%), skin reactions (37.2%) assault from patients (24.3%), and hepatitis (8.9%).
In a study by Ndejjo et al., [8] overall, 50.0% of respondents reported experiencing an occupational health hazard. Among these, 39.5% experienced biological hazards while 31.5% experienced nonbiological hazards. In biological hazards, sharp related injuries (such as needle sticks) were 21.5%, cuts and wounds were 17%, direct contact with contaminated specimens/bio-hazardous materials were 10.5%, airborne diseases were 19.0%, infectious diseases and/or infections were 7.5%, and others (blood borne pathogens, vector borne diseases, and bioterrorism) were 7.5%. In nonbiological hazards, health care providers with stress were 21.5%; physical, psychological, sexual, and/or verbal abuse were 10.5%; musculoskeletal injuries were 10.5%; slips, trips, and/or falls were 6.0%; fractures were 15.0%; and others (chemical spills, noise, burns, and radiations) were 10.0%.
Major injuries are musculoskeletal disorders (MSDs), [9],[10],[11] in all HCP, seen highest in nurses, [12] and orderlies. It is seen more than 7 times of other industries, due to patient handling, positioning, lifting, bed making in extremely awkward postures, transferring to bed, chair, toilet, for diagnostics and therapy. These problems are compounded by increasing number of obese patients. Ergonomic exposures include the use of excessive force, as in lifting, pushing, or pulling in awkward, constrained postures. [13] Back, neck, shoulder, and knee problems are the most common complaints among medical, dental, and nursing personnel. [14],[15],[16] Tinubu et al. [16] report a high proportion of Nigerian nurses having MSDs during their occupational lives, low backache being the most common. Munabi et al. [17] also found the same in more than 80% of nursing professionals in Uganda. Work-related MSDs may impact presenteeism. [18] The Occupational Safety and Health Administration [19] reports that 20% nurses leave patient care positions because of such risks. In 2012, injuries reported in residential care nurses were significantly higher than those in construction, and 2-3 times higher than in retail or manufacturing. [20] Sprains, strains are reported very often. Shoulders, low back, calf muscles, and hand muscles are most affected body parts. A study revealed specialty-related MSDs afflicting dental professionals since very early stage of their careers. [21]
Biological
HCP are exposed to a variety of infectious diseases. The primary routes of getting affected are direct contact, droplets, and airborne. Droplets containing infectious agents are generated through cough, sneeze, talking, or certain medical procedures, such as suction or endotracheal intubation. [1] Latent tuberculosis in HCP varies from 20% in the developed world, [22] 40% in Russia, [23] and about 70% in the developing world. [24] The annual rate of tuberculosis among HCP varies from 0.1% to 2% in unexposed hospital personnel compared to 1-10% among highly exposed HCP. Influenza, measles, rhinovirus, varicella, and severe acute respiratory syndrome viruses can all be transmitted in healthcare settings by the airborne route. [6]
The most common bloodborne risks are of HBV, HCV, and HIV. The World Health Organization (WHO) estimates that in 2003 approximately 16,000 HCV infections, 66,000 HBV infections and 1000 HIV infections occurred in HCP worldwide from NSI. [25],[26] About one million annual accidental NSI have been reported every year in China, translating into one HCP getting an NSI every 30 s. [27]
Chemical hazards
HCP are exposed to a variety of chemical hazards including cleaning agents used for housekeeping (excluding sterilization and disinfection of surgical or medical instruments), on floors, windows, washrooms, carpets, and other surfaces throughout the hospital and waiting areas. The primary routes of exposure to cleaning agents are inhalation of aerosolized droplets or vapors and skin exposure with the risk of skin, eye irritation. [28]
Ethylene Oxide is used to sterilize medical equipment that cannot be exposed to heat, moisture, and abrasive chemicals such as opticals, rubber items, plastic instruments and devices, [6] Formaldehyde is primarily used as tissue preservative in operation theater, laboratories and autopsy suites, Glutaraldehyde is used as a cold high-level disinfectant for heat-sensitive medical equipment, primarily endoscopes. Mercury is mainly used in thermometers and blood pressure (BP) apparatus but is also found in dental clinics, in medical devices used in the digestive tract, and in eye surgery, in laboratory chemicals, in pharmaceutical products, etc. Many hospitals around the world are phasing out the mercury use in thermometers and BP apparatus.
All these chemicals lead to irritation of the eyes, respiratory airways (causing sore throat, cough, and nasal irritation) and prolonged exposure may result in pneumonitis more permanent damage causing asthma and hypersensitivity. Direct contact with the skin may result in itching, burning, redness, swelling, and cracking. Over exposure to Methyl methacrylate can result in headache, drowsiness, nausea, weakness, fatigue, irritability, dizziness, loss of appetite, and sleeplessness. Gaseous by-products "surgical smoke" produced with or without a heating process, during electrocautery, laser surgery or the use of ultrasonic scalpels, contain bio-aerosols with viable and nonviable cellular material consisting of a mixed variety of gases, carbon monoxide, acrylonitrile, hydrogen cyanide, and benzene particulates that cause irritation to the lungs leading to acute and chronic inflammatory changes which can damage the lungs and respiratory tract. [6],[29] Handling of many medications including antineoplastic and other drugs is hazardous as this can cause skin rashes, and cancer. [30]
Radiation
Ionizing radiation from X-ray machines, fluoroscopes, and computed tomography used for diagnostic and therapeutic procedures, image-guided procedures, cardiac catheterization, angiograms, pain management, and others are hazardous. Nonionizing electromagnetic radiation has less energy and, therefore, is not powerful enough to cause ionization (or removal of electrons) of molecules. [6]
Violence
Another hazard is violence of different forms to all categories of health providers specially women HCP. WHO [31] reports that workplace violence, a phenomenon affecting every country, every workplace and every professional group, is such a common problem that it can be characterized as an epidemic. In all health care areas, employees face the risk of being a victim of violence. According to occupational health researchers, workplace violence is one of the most complex and dangerous hazard faced by resident doctors/nurses, helpers. [32] In healthcare, there is an increased anticipation of violence due to several factors, a patient population specially under the influence of intoxicants such as drugs and alcohol, metabolic disorders, trauma, psychosis, or personality disorders. It may also be due to increased stress levels in patients and relatives, long waiting hours, nonavailability of money and drugs on a 24 h basis, unrestricted visitor access, overcrowding and so on. Workplace violence can have a negative impact on both HCP as well as patients and leads to negative consequences of violence like loss of professional self-esteem, loss of job satisfaction, trauma, disability, increased litigation costs, and staff absenteeism.
Reproductive health
Exposure to reproductive hazards in the workplace is an increasing health concern. Earlier studies focused on possible effects only on the fetus and not reproductive health in general. Later, it was realized that reproductive toxins may also induce hormonal alterations which might affect other aspects of reproductive health such as menstruation, ovulation, fertility, and quality life. Attention is now shifting from concern for the pregnant woman and the foetus, to the entire spectrum of health hazards in the reproductive system of both genders. [33] Reproductive hazards may cause infertility, miscarriage, and birth defects. Potential health effects also include development disorders in children. [21] Agents which cause reproductive hazards include lead (chemical), radiation (physical) and viruses (biological). Workers may be exposed to reproductive hazards by inhalation or by contact with skin and by swallowing also.
Stress disorders
Gorman et al. [6] reported that workplace stress is a condition, if left unresolved, can result in various disorders and in extreme circumstances, death also. Burn out syndrome of emotional exhaustion, depersonalization toward patients, and reduced sense of personal accomplishment is not uncommon. Some psychiatrists consider burn out to be a clinical form of depression. In the study of Martin et al., [34] the prevalence of depression and burn out were very close, 17.1% and 15.7% among the women, 19.4% and 22% among the men, but 6.5% of the women and 9.4% of the men were both depressive and burn out.
Stalking of health professionals is a common hazard, yet it remains under-researched and underreported. It can lead to significant distress and psychiatric morbidity. A study revealed that 11% health professionals had been stalked, and in 90% cases the stalker was a patient under the direct care of the clinician. [35] When Sandberg and colleagues [36] surveyed all clinical staff employed in an urban, university-based psychiatric inpatient unit, 53% reported having been the target of stalking, threatened by hazardous behavior. Professional exhaustion caused by aggression or other factors can reflect a deterioration in the HCP relationships. [37] As such HCP are also experiencing increase in workload because of HIV AIDS, which adds to stress.
| Possibilities of Prevention/Reduction of Hazards | | |
Controlling and minimizing hazards to HCP in health care system present a unique challenge because the health and well-being of patients/relatives/friends must also be considered. Health management system, technology, industry must work in synergy to control exposure in a way that does not interfere with safe patient care. Despite potential for exposure to hazardous elements, workplace policies are many times inaccessible to HCP who also lack awareness. [38] Health facilities need to be geared toward knowing hazards, their causes, use of appropriate measures for prevention/reductio. Also, following traditional concept, called the "hierarchy of controls," is that exposure controls are most effective at the source and least effective at the level of workers; may be beneficial. Solutions vary according to local situations such as types of patients, treatment options, building, climate, and access to resources such as water, power, and basic supplies. Front-line workers often can identify problems and most practical approach and solutions (exp in resource limited settings) that managers and supervisors may overlook. [6]
Administrative measures are critical to reduce the risks from persons with suspected or confirmed tuberculosis or other airborne illnesses. [39] These measures include a written infection control plan, prompt detection and isolation of suspected cases as per the situation, training of staff, rapid reporting of diagnostic test results, education of patients and increasing awareness among HCP. [40]
Environmental controls by effective, low-cost intervention in high-risk situations in developing countries are also important lines of defense to prevent airborne infections, provided that there is adequate mixing of room air. [40] It is important that the ultraviolet lights are not placed lower in the room where exposure to the eyes of occupants of room can take place, even for seconds as it, can cause eye injury. [41] Employers need to establish surveillance program to protect workers who handle hazardous drugs. [30] Radiation control in hospitals generally falls under the supervision of specially trained professionals known as health physicists, medical health physicists, or radiation safety officers and needs to be taken care.
Immunization for healthcare-associated infections is advocated, be it Influenza, West Nile virus exposure, or others as per the need. Safe use of glutaraldehyde, mercury and quick appropriate smoke clearance from laser/electric surgical procedures in operation theater and other places is essential. It is essential to minimize leakage of anesthetic gases into the work environment, and exposure to these agents. Other preventive steps include prevention of fire and malfunction resulting from inappropriate use of cleaning and disinfecting liquids on electronic medical equipment. The NIOSH and the U.S. Food And Drug Administration have published a joint public health notification to alert HCP and the public about potential hazards associated with the improper use of oxygen regulator gaskets. [42] Evaluation of the effectiveness of comprehensive program for reducing slip, trip, and fall, awareness of the risk factors for violence in hospitals and strategies for reducing exposure to these factors is essential. Education programs for prevention and coping strategies for everyone are recommended.
It is essential to follow job safety and injury prevention practices, follow infection control guidelines, learn the right way to lift heavy objects with or without newer equipment and find ways to manage stress to reduce the risk of health problems. Shift duties, provision, for daytime sleep are essential components. [43]
Violence prevention focuses on hospital organization, control over the physical environment, staff education and development. Some of the measures that can contribute to the prevention of violence include avoiding overcrowding, enforcing visiting hours, adequate staffing at the "Accident and Emergency unit," staff training in handling violent persons. [44] Consultants' mental health need to be taken care by maintaining or enhancing job satisfaction and by providing training in communication and management skills.
Health Care and Social Assistance sector is for elimination of occupational diseases, injuries, and fatalities among individuals working in this sector through a focused program of research and prevention in place. [45] Although it is not possible to prevent all the hazards, they can definitely be reduced, so prevention has a definite place. Globalization is putting the social cohesion of many countries under stress. Health systems are key constituents of the architecture of contemporary societies and are not performing as well as they could and they should. People are increasingly impatient with the inability of health systems to meet the expected/demanded needs. Health systems need to respond better and faster to the challenges of a changing world. [31] When this does not happen, violence, physical mental stress become unavoidable and injuries to HCP seem to be common and time has come to take action in right direction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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