RESEARCH ARTICLES

Emergency nursing team: occupational risks and self protection

Júlia Trevisan Martins^I; Maria Cristina Cescatto Bobroff^II; Aline do Nascimento de Andrade^III; Gabriela D’Ovidio Menezes^IV

^INurse, PhD in Nursing, Adjunct Professor of the Nursing Graduation Course of the State University of Londrina.Paraná, Brazil. E-mail: jtmartins@uel.br.
^IINurse, PhD in Health Science, Adjunct Professor of the Nursing Graduation Courseof the State University of Londrina. Paraná, Brazil. E-mail: crisbob@uel.br.
^IIIStudent of the Nursing Graduation Course of the State University of Londrina. Paraná, Brazil. E-mail: lika_plain@yahoo.com.br.
^IVStudent of the Nursing Graduation Course of the State University of Londrina. Paraná, Brazil. E-mail: gabidovidio@hotmail.com.

ABSTRACT: This qualitative study aimed to reveal knowledge of workplace risks and identify self-protection measures taken by an emergency nursing team at a university hospital in Londrina, Paraná. Data were collected from March to May 2012 using semi-structured interviews and were analyzed by content analysis. Three categories were identified: living with workplace risks that materialize externally, living with risks that materialize internally, and measures for self-protection against those risks. It was concluded that the respondents understood the biological risks of care and of handling contaminated objects, because of inadequate human resources and insufficient equipment, and also the risks of exposure to physical and verbal assaults’ resulting in situations where they experience stress. They understand the importance of self-protection, but cannot always protect themselves, especially in urgent or emergency situations and for lack of time.

Keywords: Occupational risks; occupational health; nursing; emergency medical services.

INTRODUCTION

The work is an essential activity of the human beings, being responsible by the income source for survival and normally, is the reason of existence of most people. Through work, we achieve the life objectives. The work that at the beginning generates satisfaction and pleasure, it can also bring suffering, diseases and other problems, taking risk for the own worker instead of pleasure situations.

Nursing as any other occupation in health area, has different risk factors worsening with work do it in hospital institutions, since they are places with characteristics as unhealthy. The occupational risks in these health institutions are mainly physical, chemical, physiologic, biologic, psychological, ergonomic and mechanical¹.

Risk is a word of hazard English origin meaning danger, factor or risk situation. Recognition of risks at work involves several procedures for recognition of factors and/or conditions/situations offering potential for harm and evaluation of the risk “means estimating the probability and severity of the damage”^2:37.

In an emergency room (ER), there are specific requirements of the professional nursing staff with skills such as: think fast, be agile and ability to solve emerging problems. This is a working environment where time is limited, the activities are intense and the clinical status of individuals requires, in most cases, the professional performing everything quickly stop the imminent risk of death³.

An ER is one of the major areas of hospital care complexity, flow of professionals and users. It has features distinguishing it from other health services, as it requires immediate, efficient and integrated care, as well as a broad technical knowledge, professional skill and the use of technological resources. It is also compared to a health subsystem by requiring various associated services such as operating room, intensive care unit, radiology, laboratory, and others⁴.

So, these health activities demand greater productivity associated with time pressure and complexity of tasks and personal unrealizable expectations and often strained relations work. This set of psychosocial factors may be responsible for situations of stress related to work².

Nursing occupational risks were surveyed in its various aspects, however in practice, the changes directed to prevention are insignificant and do not affect the actual needs to change the situation experienced by these workers⁵.

There is few information about the knowledge of health professionals about the occupational risks, as well as the degree of adherence to rules of biosecurity. As a result, in the Brazilian health institutions, it is necessary to establish new policies on health and safety for those who care the health of the population⁶.

Given these considerations it is justified this study aimed to reveal the knowledge of risk at work by a nursing team that acts in a ER and identify the means of self-protection used by these workers.

This study is very importance to develop and enlarge this knowledge about the work environment, and from there to strategize among these workers, in order to seek alternatives and reconstruction of reality aimed at health promotion.

LITERATURE REVIEW

This study relies on social epidemiology, being part of the epidemiology that investigates the health/disease process as result of the different ways of individual´s living in society. In this type of research, it can correlate the risk factors and characteristics of the population to disease and/or health problems of the investigated sample⁷.

Thus, a risk is the possibility of a certain event occurs or immediately or remote damage that may be isolated or include different factors simultaneously^7.8.

However, there is an advance in the understanding that the risk actually exists and is inherent in certain work environments, but the process of work and life context can directly affect the onset of diseases or health problems⁹.

The workloads experienced at work can be grouped according to their nature or basic characteristics in external materiality and that change in the interaction with the body, for example, the physical, chemical, biological and mechanical and those who acquire materiality in the human body and are expressed internally through it, as the physiological and psychics⁹. In this context, the workloads have specific types that acquire meaning from the global dynamics of the labor process⁹.

In health institutions by ignorance or identifying some risk situations, the worker takes actions without proper protection, which may favor the occurrence of occupational accidents, occupational diseases or health problems¹⁰.

Thus, it is essential to discuss in the universe of the professional training, aiming an awakening to the health of workers as well as managers of health institutions to prioritize the promotion of health, prevention of diseases and health problems arising from the lack of adequate protection to risks that health workers are exposed¹¹.

METHODOLOGY

Descriptive research with a qualitative approach performed in the ER of a university hospital in Londrina, Paraná, Brazil. Members of the nursing staff who worked for at least 6 months in this area were included and excluded those who were on vacation, on leave or who declined to participate in the sample.

Data collection was from March to May 2012. All professionals of this team were invited to participate, and there was no refusal. They were randomly selected, speeches were kept until the repetition of the speeches, when enough convergence occurred to visualize the phenomenon and the sample reached 12 professional, covering all three shifts. With data saturation, the professionals not interviewed were dismissed.

Semi-structured, recorded interviews were used and conducted based on the guiding questions: Tell me what do you know about risk at work? What do you do for your self-care at work? To preserve the anonymity of participants the letter I was given for each numbered (I1, I2, I3, ...). The average length of the interviews was 30 minutes. An instrument with questions on socio-demographic characteristics was applied (gender, age, marital status, religion, profession, workload, time of work in ER and training time).

For the interpretation and discussion of data, content analysis was used. This technique is applied when it is needed to go beyond the simple reading of the meanings of the real, to test hypotheses and discover what is implied in the content. To that end, transcription of the speeches in full was performed and then the pre-analysis, a comprehensive examination of the material with repeated readings of the speeches and the analysis of results by inference and interpretation¹².

The pre-analysis phase is performed through initial reading of the collected material, using the completeness, representativeness, consistency, relevance and uniqueness, so the material is organized, becoming operational. During the exploitation phase of the material, the categories are built, as classes that meet elements of common characteristics and finally, the treatment of the results, through inference and interpretation of them¹².

At the end of the speeches categories and analytical subcategories were built, through associations of ideas and analysis of differences, revealing the constituent elements of the concept that the research subjects have about risk at work¹².

The research project was approved by the Ethics Committee of the State University of Londrina, in the opinion paragraph 062-09. Once informed, the participants signed a consent form and received a copy of it.

RESULTS AND DISCUSSION

Among the 12 professionals interviewed (auxiliary, technical and nurses), most of them were females between 28 and 47 years old. The workload was 36 hours per week, with 3-6 years of experience in ER and 8-27 years of service time.

After the speech analysis, three categories were found with their respective analytical subcategories as presented below.

Category 1 - Experiencing the risks in the work of external materiality

This category included four subcategories presented and discussed below.

Subcategory - Exhibition on patient care

Here is the statement:

Exposed to take care of patients, the ER is a gateway, arriving people who has a shotgun, stabbed, with a lot of blood, secretions, vomiting, and other things of urgency. (I8)

Participants are aware of risks when caring without even knowing the diagnosis of patients. Workers potentially at risk need to be informed and trained to avoid health problems and control methods should be imposed to prevent accidents. These methods can be used for environmental risks, including the replacement of the risk agent, engineering controls, organization of work practices, personal protective equipment, administrative controls and medical examinations programs¹³.

Occupational risks that nursing workers are exposed, are related to direct care to patients, especially possible contact with blood, body fluids, probes, catheters; large number of procedures and therapeutic interventions that need to use sharps; dependency of patients requiring physical effort of workers; invasive diagnostic investigation, exposing workers to infections and unknown diseases¹³.

Subcategory - Exposure to sharps and biological contamination

It was originated from the understanding of the contamination of materials that participants use to care as seen in the speeches:

I think that risk is work with contaminated things and biological materials. (I4)

I think the biggest risk is with sharps, but it is part of the activities of the profession, I'm always watching. (I5)

The reports reveal that workers know that developing their activities, they are exposed to contaminated sharps and they worry about it paying attention to what they are doing.

Nurse professionals play a work of direct and constant care to the patient, being susceptible to contamination by biological material, especially in accidents by percutaneous inoculation, by needles or sharp instruments, being the main responsible for occupational transmission of blood infections¹⁴.

Although, when caring for the risk of infections, they are always present in the hospital environment, due to various microorganisms, only after the discovery of the human immunodeficiency virus, protective measures of occupational workers to potentially contaminated body fluids were instituted in these environments¹⁵.

Thus, exposure to biological risks is worrying, since they cause many health problems. Therefore, the activities involving the direct or indirect care, exposed workers to infections from microorganisms present in blood and/or other body fluids¹⁶.

Subcategory - Human resources and insufficient equipment

Participants also realize they are at risk due to inadequate and insufficient human and material resources to perform their activities more secured, since the demand for care is big.

Here there are statements about this:

The demand is great for patients and there are few employees, you end up having to perform your tasks very fast and this leads to risk. (I3)

Given care for several patients at the same time that is a risk; lack of staff, of equipment and those equipment wer have, are of very poor quality. (I7)

The overcrowding is common in health services. The reduced number of nurses causes overwork, stress and burnout that consequently can cause accidents and harm to patients¹⁷.

In research conducted with nursing professionals of the Clinic Hospital in the Federal University of Uberlândia, MG, the relationships between work, health and living conditions of these professionals were investigated. Problems of physical and mental health were found, mainly resulting from stress and burnout caused by work conditions, such as accelerated pace of work, shortage of human resources, shortage of materials, unhealthy environment, high patient demand, among others, with reflections in their conditions of life¹⁸.

In another study conducted with 73 nurses working a year ago in an emergency room, accelerate pace of work and shortage of human resources were identified. Furthermore, nurses had high levels of stress. These situations leading to the development of physical and/or mental diseases¹⁹.

Subcategory - Exposure to physical and verbal aggression

Another aspect mentioned by participants as risk exposure relates to acts considered violent.
Here are the speeches:

The risk of aggression by patients, it already happened to the employee being physically and verbally assaulted here. (I3)

The aggression by patients has been a risk for all ER health team. (I11)

The statements cited above show the hard reality that workers are living in the health area especially nursing who stay longer with patients with respect to acts taken as violence whether verbal or not. Aggression can be physical or verbal, being the verbal aggression, the most common in hospital environments, but physical aggression are happening too²⁰.

Insults and verbal and physical aggressions or other forms of humiliation reproduce street violence in the context of the work environment resulting in unpredictable outcomes^21,22.

Category 2 - Experiencing the risks in the work of internal materiality

This category was identified because respondents reported experiencing risk situations at work that causes stress. There is the subdivision below.

Subcategory - Living with stress

It was revealed in the interviews:

There is the emotional risk because almost every day we get stressed. (I1)

It's a lot of stress and this leads us to risks. (I9)

Occupational risks related to stress have been cited and discussed since the 1950s as a major health problem. In the 60s, it was demonstrated that the nurse was tending to anxiety, indicating the operative factors: individual care, decision-making and the need to take responsibility and change²³.

The critical patient care in disadvantaged conditions of work, as the lack of materials and equipment, failures and/or improper maintenance, among others, generate constant improvisations of the nursing staff, which can lead to unintentional errors. These situations create psychophysical overloads and can lead to stress of the professionals because they cannot work and keep the nursing care as advocated²⁴.

This hospital environment is a major cause of professional burnout, providing job stress and psychological injuries, resulting an excessive workload, high level of stress for countless reasons and many occupational risks²⁵.

Category 3 - Measures of self-protection for risks at work

It emerged from the understanding of workers on strategies they can use to protect themselves. This category has four subcategories.

The respondents use measures of self-protection, but many times they stopped using them, being exposed to risks.

Subcategory - Using personal protective equipment (PPE)

Here are the statements:

It is very safe to use gloves to not contaminate, but in ER everything is so rushed that I sometimes forget and I've worked without gloves. (I4)

We must always use the PPE, but I not always do it and I regret. (I10)

In the workplace, health professionals are exposed daily to chemicals and biological risks that associated with negligence in the use of PPE potentiate the occupational risks. Thus, the professionals must seek the quality and the improvement of their work, avoiding inappropriate and routine attitudes that endanger their health²⁶.

The use of PPE benefits the worker, employers, and patients. It can lead to higher productivity besides the decrease in the number of licenses - health and reduction of hospital spending on equipment and materials.
The use of PPE must meet the needs of the procedure evaluating the comfort, the size of the equipment and the type of risk involved to avoid costs to the institution and not interfering with the correct execution of the procedure. Not using PPE when indicated, can result in losses for everyone involved, reaching psychosocial, family and relationships problems, in addition to cause workplace accidents²⁶.

Subcategory – diagnosis of patients care

The respondents also commented that the lack of medical diagnosis of the patient is considered a risk to the health team.

It is worth noting this speech:

We need to know the diagnosis, to protect ourselves. There are patients with different diagnoses and sometimes the care is provided without protection. (I12)

When the medical diagnosis is not clear, nurses neglect to protective measures. It is a fact that a delay in confirmation of the disease, on hospitalized patients, and not clarification of medical diagnosis favor the exposure to nursing staff²⁷.

Most of nurses performing patient care, neglect biosafety standards using PPE only when providing patient care and the diagnosis is known, i.e., they forget the vulnerability of the human body to infections and contaminations²⁸.

The worker must protect himself whenever he has contact with biological material and when providing patient care, regardless of medical diagnosis and adopting standard precautions in any situation.

Subcategory – A lot of attention at work

The respondents also stated that while performing their activities they should pay close attention to protect themselves from risks. This speeches are obtained:

We need to pay close attention to what we are doing to protect us, and any carelessness can cause an accident, contamination. (I2)

We must be attentive to everything. (I7)

It is known that attention is a fundamental role in mental orientation of the individual, and consequently preventing AT, as well as for other types of accidents. In this context, it is essential that managers remain vigilant that measures are taken to secure all actions involved²⁹.

The lack of attention during patient care comes from the work overload and the mechanical repetition of technical nursing procedures, leading professionals not to consider the subjectivity in procedures, i.e. the emotions of both professionals and customers¹⁴.

Subcategory – Good relationship with the team

In interviews, participants understand that develop teamwork, cooperation and mutual help are essential to protect themselves from mental problems.

Here there is a declaration of a subject:
 
We always have to work with the team, you have to have colleagues and partners at work because one helps the other. (I7)

The good relationship directly affects the care provided and the job satisfaction being a key factor to increase or decrease stress. The lack of teamwork and cooperation among team members are essential to minimize and/or prevent stress³⁰.

In a research with professional nursing in the state of São Paulo of a family health team, the psychosocial aspects of work were studied. It was concluded that the activity overload and long working hours interfere with welfare of professionals, suggesting that strategies for risk management and the adequacy of human resources are considered for work environments become healthier³¹.

The conditions offered to develop work in health care, contribute to the “quality of service and performance of professionals”^32:493. Furthermore, the physical and mental overloads of these workers are related to the severity and hemodynamic instability of patients hospitalized in units of emergency. Attention, security in the implementation of techniques and constant care can generate psycho-emotional burnout of professionals³² and consequently leading to injuries and diseases.

CONCLUSION

It can be stated that respondents perceive the risks they are exposed at work providing patient care when handling sharps and contaminated equipment by inadequate and insufficient human resources and due to exposure to verbal and physical aggressions, being risks considered visible. On the other hand, they also experience stress situations that may leave them susceptible to risks although in subjective order.

With respect to self-protection, the participants know the importance of using PPE, but not always use them in situations of emergency for lack of time. Protective measures are shared through good relationships with staff and pay attention to develop their activities.

Although the study objectives have been achieved, it had some limitations because of the small number of participants and professionals involved of only one area of the institution studied. Thus, although significant, the results should not be generalized but considered in its singularity.

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