Journal of Gerontological Nursing

Health and Safety Risk at a Skilled Nursing Facility: Nursing Assistants' Perceptions

Jennifer Sofie, MN, ARNP; Basia Belza, PhD, RN; Heather Young, PhD, ARNP, FAAN



Little is known about the perceptions nursing assistants certified (NAC) have related to their occupational health and safety risks and how these perceptions influence the safety precautions taken. The purpose of this study was to describe the perceptions of the occupational health and safety risks perceived by NAC, along with determining the protective mechanisms they used to prevent injury and illness. Ten NAC employed by a skilled nursing facility were interviewed using a semi-structured interview guide. Numerous hazards and protective mechanisms were identified and these were categorized as environmental, physical, or cognitive in nature. Based on the NAC perceptions of their occupational hazards, there were a number of areas in which they were ignorant to concepts the administration believed to be readily available. While the facility has a number of health promotion and safety programs already in place, these alone seem inadequate to meet the perceived needs of the NAC. Strategies are needed in three specific areas to address the knowledge deficits and enhance the overall effectiveness of improving the health and safety of the NAC-communication, fostering teamwork, and educational and training opportunities.



Little is known about the perceptions nursing assistants certified (NAC) have related to their occupational health and safety risks and how these perceptions influence the safety precautions taken. The purpose of this study was to describe the perceptions of the occupational health and safety risks perceived by NAC, along with determining the protective mechanisms they used to prevent injury and illness. Ten NAC employed by a skilled nursing facility were interviewed using a semi-structured interview guide. Numerous hazards and protective mechanisms were identified and these were categorized as environmental, physical, or cognitive in nature. Based on the NAC perceptions of their occupational hazards, there were a number of areas in which they were ignorant to concepts the administration believed to be readily available. While the facility has a number of health promotion and safety programs already in place, these alone seem inadequate to meet the perceived needs of the NAC. Strategies are needed in three specific areas to address the knowledge deficits and enhance the overall effectiveness of improving the health and safety of the NAC-communication, fostering teamwork, and educational and training opportunities.

Nearly 1.3 million (1.1%) of the nation's workers are employed in nursing homes and 600,000 (46.2%) are nursing assistants (Strahan, 1997). Eighty-five percent of the nursing staff at nursing homes are nursing assistants (Wunderlich, Sloan, & Davis, 1996), which emphasizes the prevalence and importance of this group of workers. Nationally, nursing assistants are a similar group in which 93% are women, 89% are younger than age 55; 58% work full-time; 30% are Black, Hispanic, or Asian; and they have an average annual income of $9,000. This population of workers often has no health insurance, nearly half have young children at home, and 24% have no high school degree. Annually, the turnover rate for these workers is estimated to be as high as 100% (Crown, 1994).

According to the 1997 Bureau of Labor and Statistics, nursing and personal care facilities have injury and illness rates (16.2 per 100 full-time employees) higher than those in private industries (8.4 per 100 full-time workers) (U.S. Department of Labor, 1997). These rates are even higher than those in mining and construction industries, which are typically considered high-risk occupations. The injuries primarily involve back sprains and strains resulting from repetitive or heavy lifting.

While the 1970 Occupational Safety and Health Act assures safe and healthy work conditions for the nation's workers, employees continue to be exposed to numerous occupational hazards (Rogers, 1994). Health care workers, particularly nursing assistants, are confronted daily with exposures such as infectious diseases, chemicals, cleaning agents, violence, shift-work, and ergonomie hazards. These, along with psychological stressors related to work load, exposures, and the workplace environment, cumulatively increase job risks.


The Surgeon General's national health recommendations for the year 2000 included occupational objectives aimed at decreasing work-related mortality, injury, lost time, trauma disorders, skin diseases, and hepatitis B infections. A specific goal is to "increase to 70% the number of worksites with more than 50 workers that have implemented health and safety programs targeting the workers" (U.S. Department of Health and Human Services, 1991).

In addition to the national health objectives voiced by the Surgeon General, the American Association of Occupational Health Nurses addresses many important research priorities. They aspire to define strategies to decrease work-related injury, identify occupational hazards of health care workers, and explore factors that contribute to behavior changes by increasing self-protection from occupational hazards among health care workers (Rogers, Agnew, & Pompeii, 2000).


A worker's perception of occupational safety and health risks may be different from that of the employer (Behrens & Brackbill, 1993). There is little published data related to the perceived health risks of employees, and none directly applying to NAC at a skilled nursing facility. Perceptions are highly complex subjective opinions influenced by individual personality, values, beliefs, needs, culture, and life experiences. All of these variables affect how an individual will perceive and interpret stimuli. The key to making sense of perceptions lies in understanding how they influence behavior.

Stewart-Taylor and Cherri (1998) found a causal relationship between risk awareness, behavior, and exposure. A questionnaire was administered to workers actively exposed to asbestos on the job. It was discovered that those who perceived a greater risk of illness were more likely to use protective equipment, thus reducing dieir exposure to the toxic chemical. The researchers also discovered that changing perceptions of risks could lead to lower levels of exposure through increasing usage of protective devices.

Therefore, the purpose of this study was to determine perceptions that NAC held related to their occupational health and safety risks. By understanding NAC perceptions of their risks, opportunities to foster change and improvement at the worksite may emerge, thus decreasing injury and illness rates. Nursing home administrators and nursing staff may be able to use subjective data on risk from nursing assistants when developing and implementing successful health and safety educational programs at long-term nursing care facilities.


Sample Selection

A convenience sample of 10 NAC were recruited from a skilled nursing facility in the Pacific Northwest for this pilot study. The facility had fewer than 100 beds, and employed 50 NAC, 15 RNs, and 4 LPNs. As a skilled nursing facility, residents were dependent on the care of the nursing staff. The NAC spent much of their time caring for residents by helping with activities of daily living such as bathing, eating, and mobility.

The NAC also performed other basic functions, such as monitoring vital signs and changing bed linens. Because of the variety of tasks involved in the skilled nursing unit and the high potential for occupational injury or illness, employees at this site seemed to represent skilled nursing assistants of typical longterm care nursing home facilities. After they are hired, all NAC have orientation covering Occupational Safety and Health Administration required training related to body substance isolation, bloodborne pathogens, and Material Safety Data Sheets (Agnew, 2001). The NAC also attend classes related to body mechanics, abuse, and neglect.

Data Collection

The Institutional Special Projects Review Board and the facilities Research Board granted approval for the study. The instrument used in data collection consisted of a two-part interview. The first part was a form that participants completed on demographics (Table). The second part of the interview consisted of nine semistructured questions (Sidebar on page 14). Although an interview guide was used, information was added to and expanded on as the participants mentioned individual issues.





Figure. Themes identified by nursing assistants certified.

Figure. Themes identified by nursing assistants certified.

Participants were recruited using informational flyers posted throughout the facility and by the researcher personally introducing herself to each NAC. An effort was made to recruit participants from a variety of shifts, ethnic groups, age, and years of experience.

Interviews were scheduled at the participants' convenience, either before or after their shift in a building separate from the working area. At the start of the interview, informed consent was obtained. Each interview was 40 to 60 minutes, and participants were offered $10 at completion as compensation for their time and to cover childcare or transportation-related costs. The taped interviews were then professionally transcribed exactly as they were recorded.

Statistical Analysis

Demographic information was analyzed for frequency and percent. Transcriptions were analyzed by hand, pulling out themes and pertinent perception data. Direct quotes were used as often as possible, and no grammatical corrections were made.

While the themes presented were not exhaustive, they were divided into categories, which were linked and organized into groupings. The intent of the qualitative content analysis was to categorize and allow for the emergence of distinct concepts. After the data were analyzed, a meeting was scheduled with the facility administration to clarify facility policies related to the topics discussed by the NAC. This meeting facilitated a contextual understanding of the findings and allowed for a more accurate evaluation of the ideas presented.


A variety of results were extrapolated from the encounters with tiie NAC. Three main categories emerged from die interviews (Figure):

* Type of hazard perceived.

* Protective mechanisms, or the devices used.

* Proposed solutions to the identified hazards.

These were further broken down into environmental, physical, and cognitive categories. For purposes of this article, only exemplar themes are highlighted from each category.

Environmental Hazards

The participants identified a number of environment-related hazards related to staffing, inadequate teamwork, power struggles, breakdown in communication, and a rushed atmosphere. Highlighted here are several themes.

Staffing Issues. Six of the 10 participants mentioned they felt the facility was often understaffed, leaving the NAC responsible for an almost unmanageable workload. The NAC were responsible for seven to nine residents each shift but when shortstaffed, they had to take on the extra load. A lack of adequate staffing perceived by many of the NAC was attributed to the perception of facility cutbacks, coworker irresponsibility, or a high-perceived turnover rate. One NAC said, "This facility does not hire enough NAC. We're being overworked by taking care of too many residents."

A number of NAC mentioned their coworkers' irresponsibility was extremely irritating. Some NAC would either not go to work or would call in sick minutes before their scheduled shift. These actions often did not allow enough time to find substitutes. One participant said, "We have to pick up the slack and then...meals get behind and pretty soon all that, showers and all, that has to be caught up." Often, the NAC were asked to work double shifts to cover for the absences.

Teamwork. Half the NAC interviewed mentioned that teamwork was non-existent. Without the assistance of others, the NAC were unable to get their work finished in a timely manner and were more likely to get injured. One participant said, "If you can't find help, you want to do by yourself." Not only was it difficult to find help, it was difficult to find willing help. One participant mentioned that many of the NAC were unwilling to help residents not assigned to them.

The participants had a variety of responses to the lack of teamwork from sadness at the inability to perform their jobs to being fed up and wanting to quit. One said, "If you're not good teamwork, you feel sad, sometimes you're angry, you cannot do good work."

Breakdown in Communication. While most NAC mentioned some form of poor communication, 5 of 10 NAC interviewed mentioned specifically not being informed or understanding resident's illnesses. This was despite having full access to resident's charts. One NAC described it as being "kept in the dark." The NAC reported they would not find out for months what type of illness a resident had. The reasons for this were described as "whoever is in charge not telling the aide" or nurses relying on the chart to inform the NAC. This dependence on the chart was problematic at times because many of the aides could not understand the wording or meaning behind illnesses.

Another communication issue was related to lifting and transfers. Many participants voiced concern in determining if a resident was a one- or two-person transfer. The participants expressed confusion related to the nature of determining a resident's transfer needs. One said, "Nobody told me two-person transfer...It's my judgment." While the care plan in each chart details the general lifting and transfer concerns related to each individual resident, none of the participants referred to this information.

Physical Hazards

A number of hazards affected die participants physically, such as a heavy workload, inexperience, lifting and transfers, resident violence, and communicable diseases. Some of these themes are highlighted here.

Workload. The number of residents each participant cared for was perceived as compounding most of die physical hazards. The workloads increased die number of body fluid exposures and lifting or transfers. One participant said:

It doesn't do any good if actually you get a nursing aide loaded with many residents to take care of. You actually giving him the first step to getting himself injured in this job.

Many of the aides felt they were being overworked by caring for too many residents.

Lifting and Transfers. All 10 of the NAC interviewed repeatedly mentioned the significant physical risks associated with lifting and transferring multiple residents. These duties led to many aches and pains, most commonly in the back, shoulder, and wrist joints. Most of die participants said they have experienced either acute or chronic back pain related to lifting residents at some point in their career. When one participant was asked about her opinion related to back problems she said:

It happens, it's going to happen. I mean you can follow the protocol in lifting and transfers, you're picking up somebody else's weight. It's always going to happen. You can take all the precautions that you can to ensure that it doesn't but...your back's not going to like it.

Resident Physical Abuse of Staff. There were four NAC who felt resident violence was a problem, and three felt it was not. Of those who believed resident violence was a problem, three initiated the response. They all referred to residents on the Alzheimer's unit at the facility. One participant said:

I have a few residents who hit me in the stomach. Sometime they hoof me good-I've been hit lots of time in the stomach.

While none of these participants sustained permanent injuries, they still felt they were at risk for resident violence.

Communicable Diseases. Eight of the 10 NAC interviewed felt their jobs exposed them to communicable diseases, and only 2 of the 10 participants did not perceive this as a risk. The diseases mentioned most often were tuberculosis, hepatitis B, and scabies. Tuberculosis was of most concern because 4 of the 10 participants said an immunization was not available, unlike for hepatitis B. While tuberculosis seemed to be a great concern, none of the participants expressed awareness that the residents are tested for tuberculosis at admission to the faculty.

Many of the participants voiced concern in working with residents they were unfamiliar with because of the uncertainty of their medical status. One NAC said, "Many people, you don't know what disease or sickness they have, like HIV or other viruses like hepatitis A, B, or C."

Two participants associated high risk of infectious disease to issues related to protective gloves. One participant said the staff often improperly used gloves. This NAC said caregivers often would contaminate clean areas by using dirty gloves. For example, a nurse wearing gloves would clean up an incontinent resident, then physically assess the resident, and leave the room touching the door handle with the soiled gloves.

Cognitive Hazards or Stressors

The theme of psychological stress prevailed throughout most of the interviews. It was attributed to the environmental and physical hazards along with a number of other issues such as responsibilities, numerous resident needs, and NAC forgetting to complete certain tasks. One prominent theme is highlighted here.

Responsibility. The NAC felt a great deal of responsibility for the residents. One participant said this applied particularly when transferring residents. She said, "If something happens, you're responsible." Another NAC said the facility relied too heavily on the NAC, and asked, "Where would they be without us?" This same participant said, "You just feel so overwhelmed, because we're it."


Each participant named numerous protective strategies used to prevent injury or illness. For the purposes of this study, these mechanisms were categorized as environmental, physical, or cognitive in nature.


There were essentially three methods the NAC used to ensure environmental protection - communication, time management, and disobeying rules or regulations. These methods reflected the work environment and interactions the NAC had with other staff members. An exemplar follows.

Communication. The main type of communication involved giving and accepting advice from coworkers. Four of the 10 participants said they did this in some way. One participant said she kept herself safe at work by asking a lot of questions. She said she did "not take any risks. If I'm unsure of something, I'll ask the nurse, I'll go right to the nurse with any question."

One participant told residents she would be unable to care for them if they were violent. She said:

Before I deal with my resident, I always explain to them, no matter what. I said if you're going to hurt me, I can't give you care and there's no way we can give you care if you're going to hurt everyone.

This participant believed if she confronted the residents about their unacceptable behavior, they would refrain from continuing it.


There were several types of protective devices or mechanisms used by NAC to decrease the risk of physical hazards. Three of the themes are highlighted below.

Lifting Protection. While all participants who were interviewed mentioned back injuries as an occupational risk, the importance of this theme was further revealed when all of the participants mentioned using some protective mechanism to prevent back injuries. By far the most commonly mentioned technique was the use of proper body mechanics. The techniques were described as "lifting with your thighs," and "bending at the knees." Along with using proper lifting and transferring techniques, 6 of the 10 participants mentioned they used gait belts.

Only 2 of 10 participants mentioned the lifting device located on each floor. When used properly, these participants felt the lift provided some protection from back-related injuries. Although the lift was originally purchased because of NAC recommendations, the device seemed to be used rarely. The participants mentioned using the lift with two specific conditions: "paralysis and obesity." Two participants mentioned how some family members had objected to the use of the lift for various reasons. These two participants also felt the lift required assistance from multiple NAC, with one acting as a spot person.

Communicable Disease Precautions. Personal protective equipment was the most prevalent form of disease protection used by the participants. All of the participants discussed the use of gloves for cleaning bodily fluids such as urine, feces, or blood along with resident skin conditions such as open wounds or dermatitis.

Another mechanism the participants believed to prevent the spread of communicable diseases was handwashing. Two participants specifically and independently said, "I wash my hands first, every time I touch a resident, after, before, I wash hands."

The last prevalent theme independendy expressed by the participants dealt with immunizations. Four participants felt the hepatitis B vaccine offered protection and alleviated fear of contracting the virus. Some of the participants had received the hepatitis B series prior to employment at this facility. One participant incorrectly believed the series was required upon hire. Although the facility strongly recommends that the nursing staff obtain the hepatitis B series, it is not required.

Experiences with Past Injury. A number of participants implemented protective techniques or devices at work in response to previous encounters with occupationally related injuries. Stories of past injuries along with the lasting repercussions were told by nearly half of the NAC interviewed. These participants used certain techniques based on their individual experiences with injuries to prevent the occurrence of similar situations. They learned from experience what not to do. There was an increased awareness of injury potential that led to the use of safety precautions.

Cognitive Protectors

Just as cognitive hazards were attributed to environmental and physical hazards, cognitive protectors also had environmental and physical influences. Cognitive protectors expressed by the NAC are multifaceted, and involve diinking and conceptualizing, tolerating and accepting residents, watching out for one's self, and maintaining a positive attitude. One theme is highlighted here.

Critically Thinking. It was evident that most of the NAC did a great deal of thinking throughout their shifts. They not only had to prioritize demands from nurses, residents, and families, but also had to ensure their own safety and that of the residents. The ability to handle myriad tasks was attributed to experience by many of the participants. One of the participants felt that her job was a bit easier because of her experience and "knowing the routines." Another participant said, "The idea of taking care of residents has to do with trial and error." With experience, the participants were able to anticipate accidents and prevent injuries. To anticipate a potentially dangerous situation, the participants had to critically think ahead and take action through preventive measures.


The solutions the participants either independently offered or revealed with prompting were environmental or physical in nature.

Environmental Solutions

The environmentally related solutions perceived by the participants can be divided into those pertaining to staffing, communication, and teamwork issues. A few of the exemplars are highlighted in this article.

Staffing. This was by far the most common theme that prevailed when participants discussed solutions to problems revealed. The NAC believed increased staffing would greatly reduce job-related stress and injury potential for both the residents and NAC. Not only would the NAC have to "lift less," they believed the overall job would be "less exhausting." The majority of participants perceived part of the staffing issues could be resolved with increased coworker responsibility. It was noted by a few NAC that if the staff were held more accountable, a large portion of the staffing problems could be resolved.

Communication. Poor communication among the staff contributed to stress and discontentment for the NAC. The participants said better communication would improve the work environment and allow for improved resident care. In particular, two participants believed a recent breakdown had been the eUmination of shift reports to the NAC from the previous shift's nursing staff. These participants believed one concrete solution to the overall problem would be to reinstate this procedure and allow all NAC to receive die group shift report.

Another specific solution proposed by the participants to the perceived impaired communication would be to inform the NAC about resident illnesses and infectious diseases. One participant suggested posting a sign related to the resident's condition as a method of notifying the NAC. However, this poses resident rights issues.

To decrease musculoskeletal injuries, one participant requested transfer requirements for each resident to be firmly defined and written down. The transfer abilities of each resident are recorded in the chart. This results in additional issues related to comprehension and retrieval of information by the NAC. With better communication, the participants hoped for a healthier work environment and improved teamwork.

Teamwork. The participants perceived that lack of teamwork contributed to injuries, stress, and job dissatisfaction. One participant stated, "The safety thing is everybody's responsibility." The NAC expressed the need for camaraderie and a communal effort to accomplish daily tasks. Instead of focusing on their own duties, the participants expressed a need to "help each other out." This could be accomplished through reminders when a coworker is forgetful or offering to assist in transfers. One participant was convinced that teamwork would build friendships, which in turn would build commitment, inevitably leading to a better work environment and a decrease in staff turnover.

Physical Solutions

Three areas were addressed pertaining to specific physical solutions - meeting personal needs, protective devices, and chemical use training. Although only 3 of the 10 NAC mentioned these areas, they are vital to die prevention of hazards. One of diese themes is highlighted in the following section.

Meeting Personal Needs. One participant expressed the importance of ensuring the NAC received their breaks. This participant offered the following advice to her coworkers:

Take your breaks. You're allotted two 10 or 15 minute breaks - take mem - you might have to leave a couple people sitting up a couple minutes longer than they diink they should. But if you need to sit down and put your feet up for a few minutes, then do it.


The participants in this study were a diverse group of NAC that differed somewhat from the description given by Crown (1994). The NAC interviewed for this study were ethnically diverse and all had at least a high school diploma, and four individuals had either a baccalaureate or master's degree. Those NAC holding higher educational degrees were immigrants who spoke English as a second language.

The protective devices or methods most commonly used by the participants were consistent with the identified hazards. In other words, the NAC protected themselves against situations or substances deemed hazardous or harmful to their health and safety. The perceptions of the participants influenced the protective actions they used. This is consistent with the studies of Behrens and Brackbill (1993) who showed a clear relationship between perception and behavior.

Based on the NAC perceptions of their occupational hazards, there were a number of areas in which they seemed ignorant to concepts the administration believed to be readily available. While the facility has a number of health promotion and safety programs already in place, these alone seem to inadequately meet the needs of the NAC. Additional reminders or booster sessions based on the health and safety goals of the facility focusing specifically on areas of knowledge deficit could enhance the overall effectiveness of information transmission and retention. Strategies are needed in three specific areas to improve the health and safety of the workers in terms of communication, fostering teamwork, and training and educational opportunities.


Many of the participants were unaware that information related to transfers has been obtained and documented for each resident in the Minimum Data Set for Nursing Home Resident Assessment and Care Screening, as required by the HCFA government regulation (Strahan, 1997). While the documentation of transfer information is enforced by administration, the question remains how to ensure NAC access and review their flow sheets.

Another communication issue involves residents' illnesses. A few participants mentioned this information could be found in the chart, however, they believed it was often too difficult to locate or they had trouble interpreting it. Information related to the residents' specific illnesses and diseases can be found in the front of each chart. Further investigation is needed.

Team Work

Administrative staff tried to alleviate some of the tension and stress involved in patient care by pairing two NAC together. The paired NAC cover breaks and assist with transfers, showering, or other duties when requested. Personality conflicts between the paired coworkers often drove the NAC to seek "friends" to help with duties rather than simply relying on the assigned coworker. Strengthening teamwork so the NAC have an understanding that the team works together to accomplish tasks is a reasonable administrative goal.

Training and Educational Opportunities

According to Novak and Chappell (1994), nursing assistants risk burnout from the stress of working with high proportions of cognitively impaired residents. While this facility does offer training related to dementia and abuse and neglect, the staff may benefit from a program that reinforces the boundaries of acceptable and unacceptable resident behavior, particularly on the dementia unit. Along with empowering the NAC to report problematic resident behavior, the NAC could be taught how to handle these situations appropriately.

Because of the high number of participants concerned with contracting communicable diseases from the residents, it may prove comforting for the charge nurse to hold in-services related to various infectious diseases, such as tuberculosis and hepatitis. These could cover disease etiology, transmission, and preventive measures. Administrative staff could reinforce and evaluate the effectiveness of the teaching.


Because of the small size of the convenience sample, the generalizability of these results is limited. The generalizability is further restricted because of the discrepancy between the high self-reported educational levels of the sample compared to nursing assistants nationally.

Results are limited because of the sole inclusion of willing NAC perspectives at the facility. Additionally, no attempt was made to interview other employees, such as housekeepers, nurses, or administration.

The perspectives of the NAC were not validated by the observation of actual hazards or protective mechanisms used in practice. The existence of specific hazards and use of protective devices discussed in the findings are based solely on the perceptions of the NAC. Finally, the study findings were not validated by the NAC, a necessary step in confirming the results.


The Surgeon General's goals for the year 2000 emphasize a hopeful reduction in work-related injury and illness with the implementation of worksite health and safety programs (U.S. Department of Labor, 1997). Nurses can help foster change at the worksite by revealing employee perceptions of risks and increasing awareness of the actual risks that exist. This will help foster increased communication and teamwork leading to a safer and more enjoyable workplace.

The implications from this study will be of interest to nursing home staff and administrators who can use the subjective data to devise effective health and safety education programs at long-term care nursing centers. This study may propagate future studies of worker perceptions and how these influence health and safety at the worksite.


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