Direct care occupations comprise the largest proportion (58) of healthcare employees in Canada and consist of registered nurses (RNs), licensed practical nurses (LPNs) and care aides (CAs).13 Engkvist et al. (1998) describe a similar grouping of nursing occupations in Sweden with general RNs, state registered nurses (LPNs) and auxiliary nurses (CAs).4 Such employees work in various settings (acute care, nursing homes and community care) across the healthcare system. These settings, providing care specific to the needs of patients/residents/clients, have very differing task requirements. Due to shortages in the direct care occupations, workers have more opportunities to choose where they prefer to work. While wage differentials may influence recruitment and retention, as Spetz (2003) has noted, wage increases are not viable solutions for resolving the workforce shortages; work conditions were more important for recruiting and retaining personnel.5 Thus a study of differential risk of injuries for the various direct care occupations in different health settings is warranted.

RNs can work as independent practitioners in all settings or as team members that assign clients and/or client care functions appropriately. LPNs do not work in isolation but as team members and must exercise clinical judgment in accepting assigned client care functions within their own level of competence.6 In many nursing homes, LPNs have been used interchangeably with CAs. CAs must work with the support of RNs and LPNs in providing help to patients/residents/clients with their activities of daily living (such as assistance with personal hygiene, dressing, eating and mobility). This often involves lifting, transferring and repositioning of patients/residents/clients.

In the health sector across Canada in 2004, 62.5 of RNs were working in acute care, whereas 13.4 were working in community health and 10.5 in nursing homes.7 Jansen et al. (2000) reports that LPNs were predominantly (57) in acute care, 33 in nursing homes and 10 in community care.8 CAs were predominantly working in nursing homes with some in community care and a smaller proportion in acute care.9 In the future, it is likely that more nurses will be required to work in nursing homes or community care because of policy changes that focus on reducing the number of chronic care residents in acute care settings, and an ageing population who will need ongoing care whether in their home, assisted living or nursing homes. RNs and LPNs may choose not to work in these settings if they perceive these work environments have higher injury risks than acute care.

Changes in the nature of care provided to patients/residents/clients and shifts in work patterns have a great impact on the nursing profession.10 Because of the different tasks and roles for the three nursing occupations within different care settings, each nursing occupation may have different injury experiences.8 11 12 Identifying these different patterns of injury through subgroup analysis by care types may allow for more effective targeting of prevention efforts, as well as help nursing staff make informed decisions. The aim of the present study was to examine how injury characteristics and incidence among the three nursing occupations differ in relation to acute care, nursing homes and community care settings in British Columbia (BC), Canada. Time-at-risk data can provide more accurate injury rates than general rates published by Workers Compensation Boards in Canada and the USA.

METHODS

The Occupational Health and Safety Agency for Healthcare (OHSAH), established in 1999 and jointly governed by healthcare employers and healthcare unions, has the mandate to reduce workplace injuries, illness and time-loss in the healthcare sector. OHSAH collects injury incident data among healthcare workers through the Workplace Health Indicator Tracking and Evaluation (WHITE) database. This web-based surveillance system was developed by OHSAH in collaboration with University of British Columbia researchers to facilitate analysis of workplace incidents and injuries, and provide healthcare stakeholders with comparative performance indicators on workplace health and safety. WHITE data include: descriptions of incidents; demographics of the workplace and injured worker; contributory factors related to location and circumstance of injury; nature of injury, body part involved, type of device, etc. Detailed analysis (stratified by occupation, age, health sector, location, body part, circumstance, etc.) was possible through an On-line Analytical Processing (OLAP) database that merged WHITE, payroll and WorkSafeBC (formerly Workers Compensation Board) databases. OLAP can disaggregate productive hours (denominator values) to the individual level and thus enable rates to be linked to any of the variables associated with injury. Data were cleaned and checked for completeness. Payroll data enabled linking time-at-risk (productive hours) with each person and each injury. Ethical permission was obtained through the University of British Columbia ethical review committee. The administrative databases used in OLAP have only encrypted individual identifiers within an operational tracking system.

This analysis includes 1-year incident data for three large health regions from October 2004 to September 2005: Fraser Health, Northern Health and Interior Health. Incidents that resulted in time-loss or medical care were extracted from WHITE for direct care occupations, and rates were calculated using productive hours obtained directly from the health regions. Facility productive hours were converted into full-time equivalent (FTE) positions (1879.2 productive hours were deemed equivalent to 1 FTE) and injury rates were expressed as the number of injuries per 100 FTEs. Productive hours are defined as paid and overtime hours minus vacation, sickness absence, time-loss injury and any paid hours not doing regular healthcare task. There is agreement amongst government authorities, health employers and unions that 1879.2 productive hours equate to one FTE position. The generally accepted calculation is 7.2 hours/day for 261 workdays (e.g., excluding weekends and statutory holidays) equal 1879.2 productive hours. In order to adjust for reporting bias, in this study we only examined injury claims that resulted in compensation or medical costs. Poisson regression with Generalised Estimating Equations was used to determine the relative risks for injuries associated with the healthcare subsector (i.e., acute care, nursing homes or community care).

RESULTS

During the study period, there were 2784 injury incidents (time-loss and/or requiring healthcare) among the three nursing occupations: 1697 in acute care, 355 in community care and 732 in nursing homes. These incidents resulted in injury rates (per 100 FTE) of 24.3 in acute care, 15.1 in community care and 31.6 in nursing homes. Table 1 shows that CAs had the higher all-injury rates in every sector with the highest rate in the nursing home sector (37.0). LPNs had the next highest all-injury rate, with greatest injury risk in acute care (30.5), followed by 26.8 in nursing homes. LPNs were under-utilised in community care with no associated time-loss injury incidents. RNs had the lowest all-injury rates with their highest injury risk (21.9) occurring in acute care. There was a trend of lower injury rates with increased age among RNs and CAs in acute care as well as among LPNs and CAs in nursing homes. Overall, female nurses had higher injury rates than their male counterparts for all occupations and health settings with the exception of RNs in acute care.

Table 2 presents the proportion of different injury types for the nursing occupations according to the healthcare setting. Musculoskeletal injuries (MSIs) comprised the highest proportion of injuries for each nursing occupation and in each sector. MSIs can be catagorised as locomoter system accidents or locomotor system diseases without a former accident (e.g., chronic back pain, especially among the CAs). In our data there were no identified locomotor system disease claims, probably because these claims are very rarely allowed, and as such most workers cite specific traumatic events as having precipitated exacerbations and resulting time lost from work. Thus all MSIs were related to a traumatic event. For RNs, MSIs ranged from 75.9 of all their injuries in the nursing homes sector to 52.1 in acute care. For LPNs, MSIs contributed to a very similar proportion of all their injuries in acute care and nursing homes (71.4 and 69.4, respectively). For CAs, MSIs represented 73 of all their injuries in the nursing home and community care sectors but only 60.8 of injuries in acute care.

Aggregating all the sectors (Table 2), RNs had a higher proportion of total injuries comprised of puncture injuries (21.3) compared with LPNs (14.4) and CAs (3.7). Of note, RNs puncture wounds comprised a similar proportion of all injuries in acute care and community care, and a lower proportion in long-term care. Irritation and allergy incidents were highest amongst RNs (11.1) followed by LPNs (7.2) and CAs (5.1). Other injuries (the aggregate of burns, cuts, bruises, infections and psychological trauma) were highest amongst CAs (14.7) followed by RNs (13.7) and LPNs (7.5).

Table 3 shows the distribution of nature of injuries in acute care departments for RNs, LPNs and CAs. Examining total injuries revealed differences across the nursing occupations by department in which injuries occurred and this distribution reflected the utilisation of RNs predominantly in these areas. For RNs the majority of injuries (59.8) occurred in general medical wards and surgery. For LPNs the majority (41.5) of injuries occurred in general medical wards although a substantial amount occurred in rehabilitation/extended care (18.5), surgery/operating room (15.7) and in infection control and related areas (12.9).

For CAs the predominant departments for injury were rehabilitation/extended care (38.6), and infection control and related areas (24.4).

For RNs the highest adjusted relative risk (RR) for all-injuries was in acute care, but the risk for MSIs was highest in the nursing homes (Table 4). For LPNs the highest relative risk of all-injuries and MSIs was in acute care. For CAs the highest risk of MSIs was in nursing homes compared with acute care. The risk of all-injuries and MSIs was low among RNs and CAs in the community care compared with similar injuries in acute care.

Table 5 presents injury risk by occupations within each healthcare sector. In acute care, CAs had the highest RR of all injuries (RR 1.40, p<0.0001) and MSIs (RR 1.82, p<0.0001) followed by LPNs (RR 1.33, p<0.0001 and RR 1.75, p<0.0001 respectively). In the nursing homes, CAs had twice the injury risk of RNs for all-injuries (RR 2.06, p<0.0001) and MSIs (RR 2.16, p<0.0001). Compared with RNs, the injury risk for LPNs was higher for all-injuries (RR 1.43, p0.01) but for MSIs, the difference in injury risk was not statistically significant (RR 1.28, p0.12).

DISCUSSION

This is one of the first studies that examined injuries across all direct care occupations by specific healthcare setting with data analysed from a very large healthcare study population. The rates in our study are high compared with published rates by WorkSafeBC, as our rates are calculated from actual productive hours for each occupation and therefore provide a more accurate measure of time-at-risk per person and per accident. WorkSafeBC uses a different denominator that is not comparable. Published rates by Workers Compensation Boards in Canada and the USA generally report injury rates based on Labor Force Survey denominator values and so the rates are not occupation-specific (including many occupations in a group). These generalised denominator values inevitably dilute the exposure rate by lumping low-risk occupations with high-risk occupations. This leads to lower calculated injury rates. WorkSafeBC also report time-loss only whereas the present study accounted for any injury requiring time-loss or healthcare. Our data included all healthcare workers working in hospitals and nursing homes affiliated to the publicly funded health regions.

Our study findings confirmed that the different risks for occupational injuries may be based on the particular tasks and roles each occupation is required to fulfil within each healthcare subsector.13 14 This is consistent with MSIs being found as the most common (54 to 71) type of injury across all direct care occupations in all healthcare subsectors. RNs were the least vulnerable for all-injuries and MSIs. CAs were the most vulnerable occupation for sustaining most work-related injuries. WorkSafeBC (2006) reported that 4040 (60) of 6731 compensation claims first paid in 2005 within the BC healthcare and social assistance sector, were related to overexertion and bodily motion injuries.15 Though MSIs comprise the major portion of time-loss injuries, other injuries are also commonly experienced among direct care occupations.15 16 Injuries not related to musculoskeletal disability (including burns, bruises, abrasions, cuts, punctures, skin/mucous membrane irritation, respiratory irritation, allergies, infections, psychological trauma, etc.) accounted for 40 of compensation claims. Our study examined incidents by nature of injuries (e.g., MSI, puncture, irritation, etc.), whereas the WorkSafeBC reports were typically based on cause of injury (e.g., exertion, fall, machinery, material handling, etc.). As expected, the department in which injuries occurred (Table 3) reflected the different utilisation of each direct care occupation across the acute care departments. The prevalence of injuries specific to each direct care occupation is dependent on the number of people in that occupation in each department, but we present only the relative proportion of injuries across departments because breaking down the number of injuries by three occupations, three sub-sectors and by five injury categories and nine departments would not leave enough data to calculate meaningful rates.

Studies have indicated that work-related MSIs are predominant amongst nurses and other direct care occupations.1720 Low back injury is the most frequent MSI in nurses, followed by neck and shoulder problems.21 Nursing work is physically demanding, requiring heavy lifting, bending and twisting, and other awkward postures that are associated with MSIs.2224 Physical demands increase the odds of injury due to creation of compression, rotation and shear forces that exceed body tolerances.2529 Psychological job demands can also amplify the effects of physical exertion and thereby increase injury risk.3032 Appropriate workplace interventions must be in place to entice direct care occupations so that the different employment subsectors offer comparable work opportunities for direct care healthcare workforce. Our study enables the comparison of injury rates for various types of injury across the healthcare subsectors by occupation and provides guidance on which of them requires higher and urgent attention.

The are several reports of the high risk of work-related MSI among nursing personnel in a number of healthcare settings, including acute care,5 22 nursing homes22 and community care settings.22 33 The US Bureau of Labor Statistics reported that incidence rates in 2004 were 9.7 injuries per 100 FTE for nursing homes and residential care facilities, whereas hospitals had a rate of 8.3.34 WorkSafeBC (2002)35 reported higher risk for workers in nursing homes (9.0 injuries per 100 FTE in 2001) compared with acute care (7.0). The higher nursing home injury rates are attributed to the provision of care for more vulnerable elderly residents, who require much lifting and transferring. Fuortes et al. (1994)14 reported that occupational duties requiring twisting and lifting increased the risk of low-back injury by 4.84 times. Bongers et al. (1993)13 as well as Fredriksson et al (2002)25 found that increased exposure to twisting, lifting and diminished recovery time between exposures increased the likelihood of worker injury. RNs and LPNs have medical/nursing/administrative tasks that take priority over the lifting and transferring of residents/patients the predominant tasks of CAs. Since CAs perform lifting and transferring more frequently than RNs or LPNs and consequently have shorter periods to recover between events, it is expected that CAs would have higher injury rates. Fuortes et al. (1994)14 found the incidence of low-back injury in CAs was 3.3 times higher than in RNs and LPNs. Ostry et al. (2003)36 found that in acute care, LPNs aggregated with CAs were more likely than RNs to experience: any injury (1.59 times), patient-care injury (1.80 times) and violence-related injury (3.25 times). The different tasks between occupations may explain injury differences between occupations and these differences agree with the findings from previous studies using facility-specific data (e.g., Ostry et al.).36 However, as suggested above, facility-specific data produce higher injury rates than rates reported by Workers Compensation Boards, as the generic denominator data used by Compensation Boards tend to result in lower injury estimates than the actual exposure risk.

Among CAs in the acute care and nursing home sectors and among RNs in acute care, age was found to protect workers from injury. But this relationship might be confounded by experience, healthy worker effect or the fact that older workers were holding safer positions. The relationship of work-related injury and age was explored by the Canadian Institute For Health Information.37 The average age of the BC nurses (45.8 years) is higher than any other Canadian province and Canada in general (44.6 years).37 Across Canada in 2004, 36 of the RN were aged >50 years.37 Rahim-Jamal (2001)9 reported that the LPN age distribution in BC was: 2.0 for those <25 years; 13.3 for those aged 2534 years; 29.9 for those 3544 years; and 54.8 for those 45 years.

Our study population was largely female and comparable to the overall Canadian nursing workforce. Women represented 95 of the Canadian RN population in 2004 and this sex ratio has been consistent since 1999.37 The relationship of work-related injuries and sex was similar to results reported by Gluck and Oleinick (1998)38 as well as Islam et al (2001).39

We should interpret the findings of this study with some limitations in mind. The study population appears comparable with the workforce in other BC health regions but differences in utilisation of RNs, LPNs and CAs across other health regions may cause differences in injury risk across the healthcare subsectors. A 1-year period also restricted the identification of long-term trends especially for LPNs, since the LPN workforce is in transition from being under-utilised in some healthcare subsectors to being used to full potential in all subsectors. The composition of direct care occupations in the acute care workforce is currently changing to incorporate more LPNs and CAs because of the ageing patient population.

Injuries and disabilities among nurses and nursing shortages tremendously affect the quality of healthcare delivery and create strain on the available healthcare workforce. In BC, there were only 28289 RNs serving a population of 41 million.7 The 1:148 ratio of RNs to population in BC is lower that the ratios for Prince Edward Island (1:100) or Newfoundland/Labrador (1:95).7 The BC ratio has been consistent over the last few years.7 The ratio of nurses to population is actually worse if we consider the fact that only half of the nurses are working full-time in Canada and BC. Amongst the 28 289 RN in BC, only 14 122 were working full-time in 2004. We did not have data available in this study to measure familiarity with the workplace. It is conceded that familiarity with the workplace would reduce injury rates. This is partially demonstrated by the lower injury rates of older healthcare workers.

BC has fewer LPNs in proportion to RNs than any other province. In 1998, there were 4424 LPNs in BC representing a ratio of 1 LPN:6.4 RNs compared with the Canadian average of 1 LPN:3 RNS. More than 80 of LPNs were >35 years old and 51 were >45 years old. Jansen et al (2000)7 found that employers under-utilised the following LPN certified competencies: administering oral medications, dressing simple wounds, catheterisations, psychogeriatrics, subcutaneous injections and performing certain assessments. There was a higher utilisation of competencies in: administering topical medications and assisting with deep breathing and coughing.

According to the College of Registered Nurses of BC (CRNBC), RNs are required to complete the baccalaureate training and successful completion of the Canadian Registered Nurse Examination and be a registrant with the CRNBC.6 LPNs enter practice after completing a 1-year certification programme and the successful completion of the Canadian Practical Nurse Registration Examination.39 The certification programme has shifted from a task-oriented model to one that emphasises critical thinking and independent problem-solving. To work as an LPN in BC, the worker must be a registrant with the College of Licensed Practical Nurses of BC.40 The certificate programme for CAs was standardised to 20 weeks and was designed to enable a combined Resident Care Attendant program and Home Support Worker credential.

Prevention of occupational injuries among the healthcare workforce is vital to provide quality patient care service, improve employee morale, and enhance productivity by reducing time-loss and other absenteeism.41 This study identified vulnerable groups within the nursing occupation across healthcare settings. Results indicate that rather than focusing only on acute care settings, more attention is required to target injury prevention efforts in nursing homes and community care. Among the many factors that increase risk of injury among healthcare personnel are organisation causes (staffing shortages and stress due to organisational change) and individual causes (an ageing workforce and patients, sicker and obese patients, etc.). Due to the increase in chronic diseases amongst the ageing workforce and the ageing care-recipients, the direct care workforce is more susceptible to injury while the ageing patients/residents/clients require more help with activities of daily living.

Our findings indicate that reduction of injuries may be more easily achieved by targeting the high injury rate of CAs. Since MSIs are the prevalent type of injury, opportunities for reduction of injuries can be optimised by ensuring that all direct care occupations, especially older workers, have easy access to equipment (such as floor and ceiling lifts) to reduce stress on muscles, joints and back. With better understanding of the injury risks across occupations and healthcare subsectors, policy-makers, union representatives and compensation officials will be better able to implement strategies to enable direct care workers to choose safer workplaces that match their career goals and interests with the needs of the care-recipient population.