Copyright 2018 American Nephrology Nurses Association (ANNA) …€¦ · urse health and safety and the environments in which nurses work impact nurses, patients, and healthcare organizations

Nephrology Nursing Journal March-April 2018 Vol. 45, No. 2 117

The Health and Safety of NephrologyNurses and the Environments inWhich They Work: Important forNurses, Patients, and Organizations

Nurse health and safety and theenvironments in which nurseswork impact nurses, patients,and healthcare organizations.

In 1999, a landmark study by theInstitute of Medicine (IOM) (now theNational Academy of Medicine[NAM]), To Err Is Human, Building aSafer Health System, identified the num-ber of patient deaths and adverseevents due to medical errors, and as aresult, focused a spotlight on patientsafety (IOM, 2000). Since that time,there has been a continually increas-ing emphasis on patient safety andpatient safety culture. However, earlyin that journey, there began to be arealization that the health, safety, andwork environments of registered nurs-es (RNs) and other healthcare pro -viders was a critical factor not only forpatient safety and patient safety cul-ture, but also for patient, nurse, andorganizational outcomes. In 2004, theIOM published a landmark report,Keeping Patients Safe: Transforming theWork Environment of Nurses, which rec-ognized the value of nurses and theenvironments in which they providecare, and discussed ways to designnurses’ work environments to enablethem to provide safer patient care.Based on their review of research,they concluded that nursing actionswere directly related to better patientoutcomes and nursing vigilancedefended patients against errors, and

Beth T. UlrichTamara M. Kear

Continuing NursingEducation

Beth T. Ulrich, EdD, RN, FACHE, FAAN, isEditor, the Nephrology Nursing Journal, and aProfessor, Cizik School of Nursing, University ofTexas Health Science Center at Houston,Pearland, TX.

Tamara M. Kear, PhD, RN, CNS, CNN, is anAssociate Professor, Villanova University, M.Louise Fitzpatrick College of Nursing, Villanova,PA; an Editorial Board Member, the NephrologyNursing Journal; and Director, ANNA Board ofDirectors.

Statements of Disclosure:

Tamara M. Kear disclosed that she is a member of the ANNA Board of Directors, serves on the ScientificAdvisory Board for Kibow Biotech, Inc., and is employed by Fresenius Kidney Care as an acute hemodialysisRN.

Beth T. Ulrich rported no actual or potential conflict of interest in relation to this continuing nursing edu-cation activity.

Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation canbe found on page 140.

that both were dependent on the envi-ronments in which nurses worked.

The quality of nurse work environ-ments also has a significant relation-ship to patient satisfaction. For exam-ple, McHugh, Kutney-Lee, Cimiotti,Sloane, and Aiken (2011) found thatnurse job satisfaction as measured bytwo Hospital Consumer Assessment ofHealthcare Providers and Systems(HCAHPS) measures – hospital ratingand willingness to recommend thehospital. For every 10% of nurses whoreported dissatisfaction with their jobs,the percentage of patients who woulddefinitely recommend the hospitaldecreased by about 2%.

Researchers are increasingly identi-fying the relationship betweenemployee safety and patient safety cul-ture (Mohr, Eaton, McPhaul, &Hodgson, 2015). Hall, Johnson, Watt,Tsipa, and O’Connor (2016), in a sys-tematic review of evidence on theassociation between healthcare profes-sionals’ wellbeing and burnout withpatient safety, found that in the major-ity of studies reviewed, poor wellbeingand moderate to high levels of burnoutwere associated with poor patient safe-ty outcomes (e.g., medical errors). Arecent cross-sectional descriptive studyby Melnyk and colleagues (2018)found that RNs with worse physical

Copyright 2018 American Nephrology Nurses Association.

Ulrich B.T., & Kear T.M. (2018). The health and safety of nephrology nurses and theenvironments in which they work: Important for nurses, patients, and organiza-tions. Nephrology Nursing Journal, 45(2), 117-139, 168.

Nurse health and safety and the environments in which nurses work impact nurses,patient safety and quality of care, and organizational outcomes. In January 2018, weconducted a comprehensive national assessment of the overall health and safety ofnephrology nurses and their work environments as a follow-up study to the 2014 studyon Patient Safety Culture in Nephrology Nurse Settings conducted by AmericanNephrology Nurses Association. This article presents initial broad findings of thisnational study. Results identified a number of opportunities for improvement in nephrol-ogy nurse work environments, especially in the areas of staffing, optimizing the knowl-edge and skills of registered nurses, and mental and physical health.

Key Words: Health, safety, nurses, work environment, culture of safety.

Copyright 2018 American Nephrology Nurses Association (ANNA) All rights reserved. No part of this document may be reproduced or transmitted in any form without the written permission of the American Nephrology Nurses Association.

Nephrology Nursing Journal March-April 2018 Vol. 45, No. 2118

The Health and Safety of Nephrology Nurses and the Environments in Which They Work: Important for Nurses, Patients, and Organizations

and mental health were associatedwith a 26% to 71% higher likelihood ofmedical errors. This supports resultsof previous studies that found associa-tions between the physical and mentalwell-being of RNs and other healthcare team members and patient out-comes (Hall et al., 2016). The LucienLeape Institute at the National PatientSafety Foundation (2013) describesworkplace safety as “a workplace freefrom the risks of both physical andpsychological harm” and furthernoted that “workplace safety is inextri-cably linked to patient safety. Unlesscaregivers are given the protection,respect, and support they need, theyare more likely to make errors, fail tofollow safe practices, and not workwell in teams” (p. 1).

A number of nursing and health-care organizations and associations(American Nurses Association [ANA],American Organization of NurseExecutives [AONE], The Joint Com -mission, IOM, Nursing OrganizationsAlliance [NOA], American Associa -tion of Critical-Care Nurses, Ameri -can Association of Colleges ofNursing, Agency for HealthcareResearch and Quality [AHRQ]) haveworked to define what constitutes ahealthy, positive, and safe work envi-ronment for nurses. The healthy workenvironment standards created by the

American Association of Critical-CareNurses in 2005 and revised in 2016are one example (see Table 1). Thesestandards align with the ANA Code ofEthics (2015a) and are backed byextensive evidence. In 2018, ANAdescribed a healthy work environ-ment as one that is “safe, empowering,and satisfying” (p. 1).

To our knowledge, while studies inthe past have assessed parts of thework environments of nephrologynurses, there has never been a com-prehensive national assessment of theoverall health and safety of nephrolo-gy nurses and their work environ-ments. The American NephrologyNurses Association (ANNA) andNephrology News and Issues (NNI) part-nered to conduct such a study inJanuary 2018. This is a follow-up studyto the ANNA study on Patient SafetyCulture in Nephrology Nurse Settingsconducted in 2014 (Ulrich & Kear,2014). This article presents the broadfindings of this premier national studyon the health and safety of nephrologynurses and their work environments.Subsequent articles will address specif-ic areas of the study in greater detail.

MethodsThis is a mixed methods study in

which both quantitative and qualita-

tive data were collected to assess thecurrent state of the health and safety ofRNs in nephrology nurse practice set-tings. The survey was created basedon an extensive literature review ofnurse health and safety, as well as pre-vious studies of nurse health, safety,and work environments. The team ofresearchers conducting this studyworked together to develop the sur-vey. Input from a face-to-face focusgroup with 15 nephrology nurses andinput from nephrology nurses solicit-ed on the ANNA Open Forum alsoinformed the inclusion of content onthe survey. As an example, informa-tion obtained from the focus groupprovided insight the researchers need-ed to add survey items to assess griefafter the loss of a patient. The surveycontained quantitative items and fouropen-ended qualitative questions con-cerning meaningful recognition; keycurrent issues, opportunities, and chal-lenges for nephrology nurses; nursesafety and work environment issues;and comments and suggestions aboutthe health and safety of nephrologynurse practice settings.

A convenience sample was used.Invitations to participate in the studywere sent via email, Twitter, andFacebook to all RN members ofANNA. In addition, the invitation wasposted on NNI’s website and includedin their email blasts. SurveyMonkey®was used for data collection. The sur-vey was conducted in January 2018over a three-week period.

Results

In all, 1,070 RNs currently work-ing as an RN in nephrology participat-ed in the study. Demographic data ofparticipants are shown in Table 2. Theaverage age of study participants was52.69 years (range from 24 to 74years), with 59% over the age of 54years. Participants had an average of24.07 years of experience as an RN,18.69 years of experience as anephrology nurse, and 11.82 yearsworking for the same employer.Nurses in direct care positions madeup 55% of the sample. Half of the par-ticipants work in chronic outpatient

Table 1AACN Healthy Work Environment Standards

• Skilled Communication: Nurses must be as proficient in communication skillsas they are in clinical skills.

• True Collaboration: Nurses must be relentless in pursuing and fostering truecollaboration.

• Effective Decision Making: Nurses must be valued and committed partners inmaking policy, directing and evaluating clinical care, and leading organizationaloperations.

• Appropriate Staffing: Staffing must ensure the effective match between patientneeds and nurse competencies.

• Meaningful Recognition: Nurses must be recognized and must recognize oth-ers for the value each brings to the work of the organization.

• Authentic Leadership: Nurse leaders must fully embrace the imperative of ahealthy work environment, authentically live it, and engage others in its achieve-ment.

Source: American Association of Critical-Care Nurses, 2016, p. 10.



hemodialysis units, and 23% work inacute hemodialysis units. Over half(55%) reported being certified in anursing specialty.

In reporting results of the survey,the terms “participants” and “nurses”are both used to indicate RN partici-pants who responded to the survey,Results include data from the quanti-tative survey items and the open-ended qualitative questions.

Patient Safety and Qualityof Care

About 73% of participants report-ed the overall patient safety in theirwork unit was excellent (26%) or verygood (47%). Just over half (56%) ofparticipants said systems and process-es that were in place in their work unitto prevent, catch, and correct prob-lems that have the potential to affectpatients were excellent (15%) or verygood (41%) (see Table 3). The qualityof care was reported as excellent inthe work unit by 48% of participantsand excellent in the organization by35% (see Table 4). Regarding how thequality of patient care had changed inthe past year, about one-third saidthere was no change in either theorganization or the work unit, 21%said much better in the organization,and 25% said much better in the workunit.

SatisfactionWhen we asked participants, inde-

pendent of their present jobs, how sat-isfied they were with being an RN,66% reported being very satisfied, and28% said somewhat satisfied (seeTable 5). However, when asked howsatisfied they were with their presentjob, only 43% reported being very sat-isfied, and 44% said somewhat satis-fied. A majority (59%) would definite-ly and 32% would probably advise aqualified individual to pursue a careerin nursing. Regarding advising acareer in nephrology nursing, 51%definitely would and 39% probablywould encourage this career option.

Mental and Physical WellbeingMental and physical wellbeing

includes mental and physical health,

Table 2Demographic Data

Age Average Range (SD)52.69 24 to 74 (10.32)

Generation PercentageSilent Generation (73 and up) 1%Baby Boomer Generation (54-72) 58%Generation X (38-53) 31%Millennials (22-37) 10%

Nursing Experience Average Range (SD)Years as an RN 24.07 1 to 52 (12.95)Years as a Nephrology Nurse 18.69 1 to 50 (12.08)Years Working for Current Employer 11.82 1 to 46 (10.21)

Type of Organization PercentageFor-Profit 56%Not-for-profit 44%

Sex PercentageFemale 94%Male 6%

Member of ANNA? PercentageYes 77%No 23%

Primary Role Number PercentageRN – Direct Care (Staff Nurse) 565 55%Manager/Administrator 230 22%APRN/NP 27 3%Educator 95 9%Other 119 12%

Primary Work Unit Number PercentageHemodialysis Unit – Chronic Outpatient 519 50%Hemodialysis Unit – Acute Inpatient 240 23%Nephrology Inpatient Unit/Transplant Unit 17 2%Peritoneal Dialysis Clinic 90 9%Outpatient Clinic 30 4%Medical Office 20 2%Other 109 11%

Education – Highest Degree PercentageDiploma 8%Associate Degree 24%Bachelor’s – Nursing 44%Bachelor’s – Other 7%Master’s – Nursing 11%Master’s – Other 5%Doctorate – Nursing/Other 1%

Certified? No Yes45% 55%

CertificationsCNN 68%CNNe 1%CNN-NP 2%CNN-NPe 0%CDN 25%CDNe 0%Other (please specify) (CCRN, CCTC, ANP-BC) 15%

Note: Percentage totals may not add up to 100% due to rounding.




Table 3Patient Safety and Patient Safety Systems and Processes in Work Unit

Overall Grade on Work Unit Patient SafetyFailing Poor Acceptable Very Good Excellent

2018 NHS Study 0% 4% 23% 47% 26%2014 PSC Study 0% 3% 20% 51% 26%

Rating for Work Unit Systems and Processes in Place to Prevent, Catch, and Correct Problems That Have the Potential to Affect Patients

Poor Fair Good Very Good Excellent2018 NHS Study 4% 14% 27% 41% 15%2014 PSC Study 3% 11% 28% 42% 16%

Table 4Quality of Care for Patients

Quality of Patient Care Poor Fair Good Excellent

Work Unit 1% 7% 44% 48%Organization 1% 11% 51% 35%Change in Quality of Patient Care in the Past Year

No Change Much Worse Somewhat Worse Somewhat Better Much BetterWork Unit 35% 2% 14% 24% 25%Organization 34% 2% 15% 29% 21%

Table 5Career and Job Satisfaction and Willingness to Recommend

Very Satisfied

SomewhatSatisfied

SomewhatDissatisfied

Very Dissatisfied

Independent of your present job, how satisfied are youwith being a Registered Nurse?

66% 28% 5% 2%

On the whole, how satisfied are you with your current job?

43% 44% 10% 4%

Definitely Would

Probably Would

Probably Would Not

Definitely Would Not

How likely are you to advise a qualified individual topursue a career in nursing?

59% 32% 8% 1%

How likely are you to advise a qualified individual topursue a career in Nephrology Nursing?

51% 39% 9% 2%






exposure to hazards, injuries, workhours and intensity, and mentalhealth.

Mental and physical abuse.Participants were first asked if theirorganizations had zero tolerance poli-cies on verbal and physical abuse ofstaff. Over half (62%) said their organ-ization had a zero tolerance policy onverbal abuse of staff, 21% said theorganization did not have a zero toler-ance policy on verbal abuse of staff,and 17% did not know; 78% said theirorganization had a zero tolerance pol-icy on physical abuse of staff, 10% saidthe organization did not have a zerotolerance policy on physical abuse ofstaff, and 13% did not know (see Table6). However, when asked later in thesurvey to what degree verbal abusewas tolerated, only 50% said not at all,and 10% said frequently. Regardingtolerance of physical abuse, 82% saidit was not tolerated at all.

In addition to providing the infor-mation on policies and tolerance ofabuse, participants were also asked toreport the number of times in the pastyear they had experienced abusivebehavior from various sources (seeTable 7). Options were any numberbetween 1 and 52, and greater than52. Responses of greater than 52 timeswere entered as 53.

Patients were the most frequentsource of all types of abusive behavior.Patients were the source of 501 inci-

dents of sexual harassment reportedby 17% of participants; 734 incidentsof discrimination reported by 20% ofparticipants; 2758 incidents of verbalabuse reported by 57% of participants,237 incidents of physical abuse report-ed by 9% of participants; and 491threats reported by 22% of partici-pants. The most frequently reportedtype of abuse overall was verbalabuse, with 5515 incidents reported.

One nurse reported being sexuallyharassed by an employee and report-ing the harassment. The nurseexplained the clinical director did notaddress the unprofessional behaviorbecause they were friends. After 10years of continued harassment of co-workers, a report was made to highermanagement, and the employee com-mitting the harassment was fired.

Reporting abuse. Only 57% ofparticipants said they reported inci-dents to their supervisor. Of thosewho reported incidents, only 36% saidthe problem was resolved satisfactori-ly, while 40% said there was “somediscussion, but nothing was done” or“there was no follow-up.” Of thosewho did not report incidents, 29% saidthey did report incidents because they“did not think it was a major issue,”and 20% said they did not reportbecause they “didn’t think anythingwould be done about it.”

Exposure to hazards. Partici -pants were also questioned about their

exposure to hazards (see Table 8). Thetop four hazards identified were:• Bending, stooping, pushing, squat-

ting, lifting, moving dialysis andwater treatment equipment or sup-plies, reaching to provide patientcare (41% very frequently, 36% fre-quently).

• Prolonged standing (36% very fre-quently, 34% frequently).

• Bloodborne pathogens (33% veryfrequently, 33% frequently).

• Needlesticks and other sharpsinjuries (24% very frequently, 16%frequently).One nurse stated, “I would not

return to outpatient hemodialysis. It istoo physically demanding, and that iswhere I was threatened and verballyabused many times over 10 years.”The same comments were notedregarding employment in the acutesetting. A nurse reported:

It is really challenging to work inthe acute dialysis setting. Everyday, we experience a lot of stressdue to not being able to leave workon time, shortage of staff, beingverbally abused by patients, threat-ened by confused and noncompli-ant patients.

Another nurse shared that bullyingand lack of support when bullying isreported was a key safety concern.Some participants expressed concern

Table 6Abuse – Policies and Tolerance

Abuse PoliciesYes No Don’t Know

Does your organization have a zero tolerance policy on verbal abuse of staff? 62% 21% 17%Does your organization have a zero tolerance policy on physical abuse of staff? 78% 10% 13%

Tolerance of AbuseNot at All Rarely Occasionally Frequently

To what degree is verbal abuse of staff tolerated in your organization? 50% 20% 20% 10%

To what degree is physical abuse of staff tolerated in yourorganization? 82% 11% 6% 1%





about the security of their work places.One nurse, in response to the questionasking participants to describe a nursesafety or work environment issue, saidsimply there were “shell casings at theback door.”

Most participants reported havingaccess to sharps safety devices at workand consistently using them (see Table9). A slightly lower percentage of par-ticipants reported that infection con-

Source Sexual Harassment Discrimination Verbal Abuse

Percentage of Participants

Reporting Abuse

Number ofIncidentsReported


Reporting Abuse


Percentageof Participants

Reporting Abuse


Patients 17% 501 20% 734 57% 2,758

Patients’ Families/SOs 3% 53 11% 294 30% 891

Other RNs 2% 25 12% 408 21% 480

PCTs/UP 3% 53 8% 417 14% 354

LVNs 0% 1 2% 62 4% 58

Physicians 2% 33 6% 223 21% 447

Nurse Managers 0% 5 9% 217 10% 227

Administrators/Execs 1% 17 7% 176 7% 150

Other Healthcare Personnel 1% 14 5% 153 7% 150

Total Incidents 702 2,684 5,515

Source Physical Abuse Threats


Reporting Abuse



Reporting Abuse


Patients 9% 237 22% 491

Patients’ Families/SOs 1% 17 6% 183

Other RNs 1% 7 2% 31

PCTs/UP 1% 6 2% 23

LVNs 0% 1 0% 4

Physicians 0% 1 1% 20

Nurse Managers 0% 1 1% 8

Administrators/Execs 0% 13 1% 5

Other Healthcare Personnel 1% 5 1% 6

Total Incidents 288 771

trol practices are followed per estab-lished unit protocols and that personalprotective equipment (PPE) is worn bystaff per unit protocol. Forty percent(40%) strongly agreed and 46% agreedthat if they saw a colleague breachinga safety practice (e.g., not washinghands or wearing PPE), they wouldaddress it with the colleague at thetime it was happening.

One participant stated her facilityhas an onsite infection control personwho is available for educating andmonitoring staff to prevent potentialerrors and injuries. Other participantsreported that education and reinforce-ment related to infection control wasneeded in their work environmentsbecause infection control practiceswere not being followed. One partici-pant stated:

Table 7Abusive Behavior – Sources, Percentage of Participants Reporting, and Number of Incidents

Reported Having Occurred in the Past 12 Months



Table 8Hazard Exposure – In your current work environment, which of the following health and safety hazards

are you exposed to and how frequently?

Never Seldom FrequentlyVery

FrequentlyChemical agents 18% 34% 32% 16%High-level disinfectants 18% 32% 33% 17%Sterilants 38% 39% 17% 6%Hazardous drugs 51% 40% 7% 3%Latex 43% 29% 13% 15%Poor indoor air quality 43% 39% 12% 6%Infectious disease agents 17% 36% 29% 18%Blood-born pathogens 7% 28% 33% 33%Needlesticks and other sharps injuries 18% 42% 16% 24%High noise level 19% 42% 27% 13%Prolonged standing 7% 23% 34% 36%Lifting or repositioning heavy objects 8% 36% 35% 20%Lack of sunlight / daylight 17% 30% 30% 23%Bending, stooping, pushing, squatting, lifting, moving dialysis & watertreatment equipment or supplies, reaching to provide patient care

7% 16% 36% 41%

Poor workplace security 27% 45% 16% 12%Unrestricted movement by non-employees around the facility (patients,family transportation providers, general public)

23% 43% 22% 12%

Entering and leaving a workplace that lacks security & safety features(poor outdoor and entrance lighting, dark parking lot, remote location,arriving or leaving work alone, high crime neighborhood)

27% 41% 20% 12%


Table 9Safety Practices

StronglyAgree Agree Disagree

StronglyDisagree

I have access to sharps safety devices. 67% 29% 2% 2%I consistently use sharps safety devices. 68% 26% 4% 3%Infection control practices are followed per established unit protocols. 48% 44% 7% 2%Personal protective equipment (PPE) is worn by staff per unit protocols. 49% 41% 8% 2%If I see a colleague breaching a safety practice (e.g., not washing hands or using PPE), I address it with my colleague at the time it washappening.

40% 46% 12% 2%





Most of us are pretty good at wear-ing clean gloves, but not all. Wedon’t have time to sanitizebetween glove changes due to theassembly line pressure. MDs, NPs,and RDs routinely go frommachine to machine without glov-ing or sanitizing. Direct care staffhave brought this up to our man-ager, but nothing changes.

Injuries. Participants were askedabout actual injuries they experiencedin their work environment (see Figure1). Of those reporting, 37% had expe-rienced musculoskeletal injuries, 37%had been exposed to infectious dis-eases, 19% had been exposed to haz-ardous chemicals, 12% had had a fallor a slip, and 5% had been stuck by aneedle. Some participants had experi-enced more than one type of injury onmore than one occasion.

Unsafe environmental conditionsreported included wet floors, expo-sure to bleach, lifting heavy patients,pushing and moving heavy equip-ment and supplies, and exposure tobloodborne pathogens. One nurseshared: “I have to put away largeboxes of supplies often on a ladder. Itis unsafe for me.” Another nursereported working in a basement withpoor air quality. Another nurse report-ed a proactive approach to avoidingfalls by pulling dialysis machines thatleak water off the floor immediatelyfor maintenance service.

Long, intense hours. Workinglong hours and hours without reliefwere another area of questions (seeTable 10). Thirty-five percent of par-ticipants said they worked more than

40%

35%

30%

25%

20%

15%

10%

5%

0

37% 37%

19%

12%

5%

Musculoskeletalinjuries (i.e., back injury or

muscle strain orsprain

Exposure toinfectiousdiseases

Exposure tohazardouschemicals

Fall or slip Needlestick

Figure 1Physical Harm Experienced in the Past 12 Months Working as a Nurse

Table 10Work Hours and Potential Fatigue

VeryFrequently Frequently Seldom Rarely

How often do you work more than 12 hours in a shift? 14% 21% 30% 35%How often do you work through your break times or meal times? 26% 33% 25% 17%How often is it difficult for you to find time or coverage to go to the bathroom? 9% 16% 31% 44%Note: Percentage totals may not add up to 100% due to rounding.

Table 11Working in a Chronic Hemodialysis Units – Transition Times

Does your state mandate the time between patients? PercentageNo 46%Yes 33%Don’t Know 20%

Has your unit implemented mandatory transition times between patients? Percentage

No 31%Yes – 45 minutes 37%Yes – 30 minutes 14%Yes – Other 17%Note: Percentage totals may not add up to 100% due to rounding.



12 hours in a shift, with 21% reportingit occurred frequently and 14% veryfrequently. Twenty-six percent (26%)of participants said that they very fre-quently worked through their breaktimes and meal times; while 25% (9%very frequently and 16% frequently)said it was difficult for them to find thetime or coverage to go to the bath-room.

Long work hours was the secondmost common key concern expressedin the narrative responses (staffing wasfirst). Nurses, particularly those work-ing in the acute environment, report-ed working 16 to 18 hours a day. Aparticipant replied:

Working 16 hours a day, day afterday, with no end in sight not onlyphysically exhausts you, but it alsomentally exhausts you. This issuehas not been resolved as we havenot been able to find trained dialysisnurses to fill positions, nor have webeen able to hire, train, and retainnurses to help alleviate this issue.

Another nurse offered a potentialsolution to the long hours by stating:“I have worked in acutes. I left due to16- to 18-hour shifts. It was veryunsafe. There should be a mandatedamount of time a nurse can work, justlike truck drivers on the road.”

Time between patients contributespositively or negatively to the availabil-ity of break times, meal times, and get-ting the work done in the allotted hours(see Table 11). We asked RNs in chron-ic hemodialysis units whether or nottheir state mandated the time betweenpatients, and 33% said yes, 46% saidno, and 21% did not know. We thenasked whether the participant’s unithad implemented mandatory transi-tion times between patients, and 68%said yes. Over half (54%) of thosereporting the enactment of mandatorytransition times reported a mandatorytransition time of 45 minutes.

We also asked about being on call.Of the 855 participants who respond-ed to the question about being on call,39% reported being on call in a recentfour-week period. Of those who wereon call:

• 88% of the time, call followed aday of regular work hours.

• 77% of the time, RN was sched-uled to work a full day immediate-ly following call.

• 59% of RNs on call were called into work.Participants provided insight into

on-call responsibilities. One nurse stat-ed she worked long hours while oncall, but being called in does not hap-

pen that often. Another reportedworking 22 hours straight: “I did myregular shift and was on call after-wards, and had to start a patient onCRRT. The patient clotted 3 systemsand needed 4 hours of hemodialysis.”This nurse ended her story by explain-ing she called for back-up assistancefrom a colleague after 20 hours, so shecould go home and sleep.

Between RNs

Between RNs & Physicians

Between RNs & Patient Care Technicians/Unlicensed Personnel

Between RNs & Nurse Managers

Between RNs & Administrators/Executives

Excellent Good Fair Poor

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 2How would you rate the quality of communication in your

organization among the following?

Collaboration between RNs

Collaboration between RNs & Physicians

Collaboration between RNs &Patient Care Technicians/Unlicensed Personnel

Collaboration between RNs & Nurse Managers

Collaboration between RNs &Administrators/Executives

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Figure 3How would you rate the quality of collaboration in your

organization among the following?




Regarding overtime, 20% of par-ticipants said it is required; 38% say itis voluntary, but feels like it isrequired; and only 42% say that it isvoluntary.

Mental health. Mental health isalso a health and safety issue for nurs-es. Participants were asked about theirexperiences with moral distress andgrief. Moral distress refers to a situa-tion in which a nurse knows theappropriate action to take, but isunable to act or acts in a manor con-trary to his or her personal and profes-sional values. When asked about theextent they experienced moral dis-tress in their nursing practice, 4% ofparticipants reported it occurs veryfrequently, 9% said frequently, 34%said occasionally, and 53% said veryrarely. One nurse described her expe-rience of moral distress: “Patients con-tinue to receive treatment far beyondthe point that seems humane – toextend life, for example, as almosthaving to restrain a patient just to havetreatments in order to satisfy memberswho are not ready for death.”

Grief after the loss of a patient wasmuch more frequent, with 54% of par-ticipants saying they had experiencedsuch grief in the past year. Nursesshared narratives related to end-of-lifechallenges and deaths of patients. Onenurse stated the greatest challenge shefaces as a nephrology nurse is “devel-oping a closeness with patients andthen they die.” In addition, when rat-ing the nurse manager skill of address-ing nursing grief after the death of apatient (bereavement support, de -briefing, etc.), only 18% rated thenurse manager skill as excellent, and38% rated it as good. Almost 44%rated the skill as only fair (26%) orpoor (18%).

Communication,Collaboration, and Respect

Participants were asked to rate thequality of communication and collabo-ration between RNs and other RNs,physicians, patient care technicians/unlicensed personnel (PCTs/UP),nurse managers, and administrator/executives. Both communication andcollaboration were rated highest

among RNs, followed by RNs andphysicians, RNs and PCTs/UP, RNsand nurse managers, with the commu-nication and collaboration betweenRNs and administrators/executivesrated the lowest (see Figures 2 and 3).Respect for RNs was rated highest byother RNs, physicians, and nurse man-agers, and lowest by PCTs/UP andadministrators/executive (see Figure 4).

Participants shared stories aboutchallenges working and communicat-ing with PCTs. One nurse stated that“techs and secretaries run the unit”and that a new manager is working toresolve this issue. Another stated: “Iwill reiterate that there is poor techsupport. Poor attitudes, poor atten-dance, and overall disrespect.” A par-ticipant provided a story of advocacyon behalf of nurses, PCTs, andpatients that demonstrates effectivecollaboration, communication, andimproved processes and outcomes forpatients and the healthcare team.

Several years ago, we had a fre-quent change-over of PCTs, fre-quent call-offs, no shows, no-calls,and no consequences. We had fre-quent infiltrations, blood loss, andinfections. I joined ANNA andANA for advice, and both organi-zations were very supportive.

Eventually, on the advice of both[organizations], I called the statehealth department. We wereinspected. The result was dramat-ic. Our nurse-to-patient and PCT-to-patient ratio were fixed to 1:12and 1:14 instead of 1:18 and 1:7.Our change overtime betweenpatients was increased to 60 min-utes instead of 15. We had stateauditors and company auditors inthe clinic almost daily for weeks.Our infection control practiceswere ramped up. We were bleach-ing wall boxes and drains now,and changing gloves and washinghands more often. There is stillsome resistance to some PPE. Wespoke up, documented, saved flowsheets, and made our case to thestate. I kept all my correspondenc-es with ANNA and ANA. It wasawesome. Thank you!

Another nurse shared her experi-ence working in critical care nursingcompared to nephrology nursing, andher perception related to respect.

I worked in ICU for many years asa traveler, and felt respected andappreciated, by far. Most units hadgood teamwork, and nurses sup-ported each other. Now in dialysis,

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Other RNs

Physicians

Patient Care Technicians/Unlicensed Personnel

Other Health Care Colleagues (for example, socialworkers, dieticians, pharmacists)

Nurse Managers

Administrators/Executives


Figure 4In your organization, how would you rate the respect for

RNs by each of the following?



I find most dialysis nurses to bevery stressed, unhelpful, andunsupportive of each other. As atraveler in dialysis now, I see manyvery unhappy nurses and dysfunc-tional teams, along with a sense ofbeing undervalued and unempow-ered to make improvements oreven see the need to change. Thebiggest sense of value for manydialysis nurses seems to be howfast and how much they can work.

Another nurse working in theacute setting shared her positive per-ception that she had earned greatrespect in the hospital environmentworking with staff in the emergencydepartment.

Staffing and Work That GetsDone

We asked participants aboutstaffing: “With regard to staffing foryour unit, how often do you have theright number of RN staff with the rightknowledge and skills?” Only 24% ofparticipants said all the time (seeFigure 5). Another 38% said morethan 75% of the time, and 19% said50% to 75% of the time. Nineteen per-cent (19%) reported adequate staffingoccurred less than 50% of the time(13% said 25% to 49% of the time, and6% said less than 25% of the time).Participants who worked in chronichemodialysis units also reported thatfrequently (19%) and often (23%) theywere the only RN providing care inthe unit (see Table 12).

The largest number of narrativeresponses on the four open-endedquestions posed to participants elicit-ed responses related to staffing issuesand patient ratios. Nurses sharednumerous stories about understaffing,unsafe staffing ratios, and unreason-able nurse-to-patient and PCT-to-patient ratios. Comments regardingkey issues and challenges for nephrol-ogy nurses included stories related to“safe staff-to-patient ratios should beadopted, both in inpatient and outpa-tient environments,” and commentswith just the words “staffing,” “lack ofstaffing,” ”poor staffing,” “not enoughstaff,” and the issue of “being inade-

100%90%80%70%60%50%40%30%20%10%

0

6%13% 19%

38%

24%

Less Than 25%of the Time

Between 25%-49% of the Time

50%-75% ofthe Time

More Than 75%of the Time

All the Tiime


Figure 5With regard to staffing for your unit, how often do you have the right number of RN staff with the right knowledge and skills?

Table 12Working in a Chronic Hemodialysis Unit – How often are you the only

RN providing patient care in your unit?How often are you the only RN providing

patient care in your unit? PercentageNever 33%Seldom 25%Often 23%Frequently 19%Note: Percentage totals may not add up to 100% due to rounding.

Direct care (assessments, medications, procedures, monitoring, etc.)

Documentation of care provided

Collaboration with the interprofessionalism

Comforting/talking with patients

Teaching patints or family

Developing or updating plans of care/care plans

0 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

75-100% of the Work Done 51-74% of the Work Done 0-50% of the Work Done

Figure 6At the end of a typical shift, to what degree do you feel you

got the following work done?




quately staffed to work with ourpatients.” Poor staffing and insufficientstaffing ratios were the greatest con-cerns reported by nurses whoresponded to this survey.

RNs prioritize their work based onpatient needs and available resources.We asked participants, “At the end ofa typical shift, to what degree do youfeel you got the following workdone?” Direct care tasks and docu-mentation were the work that gotcompleted most often, collaborationnext, while work involving collabora-tion with the interprofessional team,comforting/talking with patients, andteaching patients or family were com-pleted far less often. Developing orupdating plans of care was the least-often completed work (see Figure 6).

Regarding unfinished work at theend of a shift, one nurse explained:“There is not enough time to com-plete documentation. Not enoughtime to communicate with patientsand families.” Another nurse reportedshe does not have enough staff or timeto counsel and educate patients, andthere is too much redundant paper-work. Finally, a nurse shared:

There is not enough time toencourage, educate, follow up witheducation, goal-setting, or empow-erment for patients to have betteroutcomes. All patients want toknow is that someone cares, butthat takes time to listen, and ourtime does not allow for that veryoften.

Expressing frustration with thelimited scope of work nephrologynurses do, one nurse said:

Nephrology nurses are puppets tothe protocols of patient care…thebakers of ‘cookie cutter’ dialysisorders, and the assembly line cap-tains of pushing meds and chartingon patient after patient as fast aspossible. Nephrology nurses arenot asked to use their experiencesto make nursing decisions in pro-viding patient care. Does anyoneknow what that is anymore?

Continuing Education and Certification

Participants were asked about thedegree to which their organizations sup-port continuing education (CE) and cer-tification. Regarding support of CE,60% said that their organization pro-vides in-house CE; 36% that theirorganization pays CE registration fees;and 34% said their organization pro-vides paid time off for CE (see Figure7). Regarding certification, 61% said

their organization pays the initial exam-ination fee; 44% recognize nurses whoachieve certification; and 33% pay forthe re-certification fees (see Figure 8).

Nurses provided in narratives theirdesire for compensation and time offto attend professional conferences andcontinue their education. Nurses per-ceived there were limited opportuni-ties to advance their careers innephrology nursing. One nurse stat-ed: “There is a lack of opportunity for

Pays/reimburses initial exam fee

Recognizes nurses who achieve certification

Pays/reimburses for re-certification fee

Provides salary differential for certification

Gives bonus for initial certification

Offers unpaid time off for courses

Pays registration fees for courses

Offers paid time off for courses

Gives bonus for re-certification

0 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

61%

44%

33%

27%

13%

12%

12%

8%

5%

Provides in-house CE

Pays CE registration fees

Provides paid time off for CE

Provides time off without pay for CE

Pays for travel CE programs

No support

Pays for a professional association membership,which entitles me to free CNE

60%

36%

34%

22%

21%

18%

18%

0 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

Figure 7To what degree does your organization support

continuing education (CE) for RNs?

Figure 8To what degree does your organization support

specialty nursing certification?



advancement in career, lack of oppor-tunity for learning on the job, and ahighly repetitive work environment.”

RecognitionThe majority RN participants in

the study expressed agreement thatthey are recognized for the value eachbrings to the work of the organization,though that recognition is reported to

come slightly more from the work unitthan the organization. When askedthe source of the most meaningfulrecognition, 44% said patients andfamilies, and 21% said administra-tors/executives (see Figure 9).

Nurses shared many stories ofrecognition received from ANNA,peers, various national associations,employers, patients, families, and

community-based organizations. Themost meaningful recognition nursesmentioned in narratives came frompatients and families in the form ofverbal and written notations of grati-tude. One nurse wrote: “The mostimportant was when I was recognizedby my patients to be the most caringnurse manager.” Nurses shared storiesof their desire for national, specialty,administrative, and employer recogni-tion. Some nurses shared they havenever received any form of recogni-tion for their work as a nurse.

LeadershipDirect care RNs were asked to rate

the skills of their nurse managers (theRN who organizes, directs, and super-vises the patient care in the work unit).Results are shown in Figure 10. Thehighest-rated nurse manager skillswere (from first to third) advocatingfor patients; providing supplies, equip-ment, and other non-human re -sources; and ensuring the provision ofhigh-quality care. The lowest-ratednurse manager skill was addressingnursing grief after the death of apatient. Participants who reported nointent to leave their positions in thenext three years rated the skills of thenurse manager much higher thanthose who expressed intent to leave.For example, 34% of participants whoreported no intent to leave in the nextthree years rated their manager’soverall effectiveness as excellent, com-pared to 15% of those intending toleave in 12 months and 21% for thoseexpressing intent to leave in the nextthree years.

The degree to which RNs have theopportunity to influence decisions thataffect the quality of patient care wasalso measured. Twenty-six percent(26%) of direct care RNs stronglyagreed that RNs have the opportunityto influence decisions that affect thequality of patient care in the organiza-tion, and 30% strongly agreed that RNshave the opportunity in their work unit.Only 22% to 26% of participantsstrongly agreed there were structuredprocesses in place to resolve disputesbetween/among members of thehealthcare team and between/among

Overall effectiveness

Promoting a professional practice environment

Ensuring the provision of high quality care

Addressing nursing grief after death of a patient

Advocating for nurses

Advocating for patients

Leadership

Recognition of others’ contributions

Effective decision-making

Providing supplies, equipment, and other non-human resources

Providing staff resources

Collaboration

Communication

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Patients & families

Administrators/Executives

Other RNs

Nurse Managers

Physicians

Other health care colleagues(other than RNs & Physicians)

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

44%

21%

14%

12%

6%

5%


Figure 9Recognition is most meaningful when it comes from ...

Figure 10Nurse Manager Skills as Rated by Direct Care Nurses




members of the healthcare team andpatients (see Table 13).

A nurse described a situation thatinvolved competing goals of nursingstaff and desires of the patient:

Nurses are dealing with patientsthat have free will to make poorchoices. For example, not takingbinders/medications, skippingtreatments. Patients have the freewill and right to do poor dialysis,and nurses are penalized or evenostracized when patient outcomes

are not adequate due to howpatients manage their own healthwhen not at the clinic. Nurses havea responsibility to educate andencourage patients to be compliantwith their health care; however,nurses are made to feel responsibleor even downtrodden from man-agement when some patientschoose to make poor choices.Nurses will relocate to areas ofhealth care where they feel appre-ciated and can make an impact onthe field.

Job Satisfaction and Intent to Leave

Satisfaction with compensation,work schedule, work-life balance, andfairness of personnel policies is shownin Figure 11. Participants were alsoasked about the main factors that keptthem working in their current organi-zation (see Figure 12). The top threefactors for all participants as a wholewere “people I work with” (41%);“patients I care for” (39%); and “salaryand benefits” (38%). Salary and bene-fits appeared to be a main factor inretention because participants whoindicated they had no intent to leavetheir position in the next three yearswere more likely to indicate salaryand benefits were a main factor thatkept them working in their currentorganization (40% indicated that) thanthose who plan to leave in 12 months(30%) or in three years (32%).Satisfaction with specific benefits isshown in Table 14.

Slightly fewer than 60% of partici-pants expressed no intent to leavetheir present position in the next threeyears, but 40.4% do intend to leave(see Table 15). Almost 17% intend toleave in the next 12 months, andanother 24% intend to leave at sometime in the next three years. Of thetotal participants who said they planto leave in the next 12 months and inthe next 36 months, 37.5% plan toretire. Of those who intend to leave inthe next 12 months, 25.2% plan toretire, 35.9% plan to take a differentposition in clinical/patient care nurs-ing, and 13.0% plan to take a differentposition in non-clinical/patient carenursing. For those who intend to leavein the next 36 months, a much higherpercentage (46.1%) plan to retire.When those who plan to leave wereasked how likely certain actions wouldbe to influence them to reconsidertheir plans to leave their present posi-tion, the top three items (from first tothird) were higher salary and benefits,better leadership, and better staffing(see Figure 13).

Table 13Processes to Resolve Disputes in Organizations and Work UnitsA structured process is provided to resolve disputes among/between

members of the healthcare team.Strongly Agree Agree Disagree

StronglyDisagree

Organization 23% 53% 21% 4%Work Unit 22% 51% 23% 5%

A structured process is provided to resolve disputes among/betweenmembers of the healthcare team and patients.

Strongly Agree Agree Disagree

StronglyDisagree

Organization 26% 58% 13% 3%Work Unit 26% 57% 15% 3%

Fairness or organization’s personnel policies

Balance between my work & personal life

Work schedule

Compensation

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Very Satisfied Satisfied Dissatisfied Very Dissatisfied

Figure 11How satisfied are you with the following aspects or

features of your current job?




Discussion

This was a very detailed study withboth positive and negative findingsregarding the health and safety ofnephrology nurses and the environ-ments in which they work. Each areaof the study results is explored inmore detail in this section.

Patient Safety and QualityQuestions about patient safety and

the quality of care were asked toobtain an overall perspective on thecultures and environments in whichparticipants work. Results on patientsafety and patient safety processes aresimilar to those obtained in the 2014patient safety culture study by Ulrichand Kear. For patient safety, a total of73% of participants rated their overallwork unit patient safety as excellent(26%) or very good (47%) (see Table3). When compared to the mostrecent results from the AHRQ’s(2016) hospital survey on patient safe-ty culture, the average patient safetyrating in this current study would bebetween the 25th and 50th percentileof all AHRQ hospitals (the 25th per-centile was 70%, and the 50th per-centile was 77%). While many of ourparticipants work outside of a hospital

in chronic hemodialysis units, thepatient safety culture should be com-parable.

The quality of care in this study inparticipants’ work units was ratedexcellent by 48% and good by 44%.When asked about how the quality ofcare had changed in the last year, 25%said it was much better and 24% saidsomewhat better, indicating improve-ment in the quality in 49% of partici-pants’ work units (see Table 4).

A concern for both patient safetyand quality of care identified in thisstudy in chronic hemodialysis units isthe frequency of a nurse being theonly RN providing patient care in theunit (see Table 12). A total of 42% ofparticipants in this study who work inchronic hemodialysis units reportedfrequently (19%) or often (23%) beingthe only RN providing patient care inthe unit.

SatisfactionCareer and job satisfaction results

indicated that nephrology nurses arevery satisfied with being an RN andless satisfied with their current posi-tions (see Table 5). This pattern is thesame as the pattern in a number ofnational surveys of nurses in the lasttwo decades (Buerhaus, DesRoches,

Donelan, & Hess, 2009; Ulrich,Lavandero, Woods, & Early, 2014);however, both RN and current posi-tion satisfactions are higher in this sur-vey than in those. Participants in thisstudy are also highly likely to recom-mend both nursing and nephrologynursing as careers for qualified indi-viduals.

Mental and Physical WellbeingMaslow’s (1954, 1971) Hierarchy of

Needs has long been used by nurses inrelation to patients, but it is equallyapplicable to nurses themselves. Thefoundation of the hierarchy is physio-logical needs and safety needs. If anurse’s body is not working well or anurse does not feel safe from physicalharm in the workplace, it is difficult toconcentrate on and perform basic nurs-ing functions, much less the higherorder functions like critical thinking re -quired to provide quality patient care.

Mental and physical abuse.Participants in this study were asked iftheir organizations had zero tolerancepolicies against verbal abuse of staffand physical abuse of staff (see Table6). Zero tolerance policies againstphysical abuse were more prevalent.However, a number of participantsdid not know if these policies existedin their organization (17% did notknow if there was a policy against ver-bal abuse, and 13% did not know ifthere was a policy against physicalabuse). When employees do not knowif policies exist, then policies may aswell not exist.

Results on the number of nephrol-ogy nurses who experience abuse andthe number of incidences they reportis dismal (see Table 7). Sexual harass-ment and discrimination, two areas inwhich there should be zero tolerance,occur at alarming rates, as do verbalabuse, threats, and physical abuse.These results are considerably higherthan results reported more than 10years ago in an ANNA membershipsurvey conducted in 2007 (ANNA,2007). In the 2007 survey, when mem-bers were asked if they had experi-enced abusive behavior while work-ing as a nurse in the previous 12months, 43% of respondents reported

People I work with

Patients I care for

Salary & benefits

Work schedule

Location

Reputation of the organization

Manager of my work unit

Other (please list)

Work environment

Opportunities for professional development

Opportunities for advancement

Meaningful recognition

Support for RNs

Level of staffing

0

41%

39%

38%

25%

19%

12%

10%

10%

9%

9%

6%

3%

3%

3%

5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Figure 12What are the two (2) main factors that keep you

working in your current organization?




experiencing verbal abuse, 10% expe-rienced violence in the workplace, 9%experienced discrimination, and 12%experienced sexual harassment. Theabuse in the current study comes pre-dominantly from patients and theirfamilies/significant others (SOs), butabuse from other RNs, physicians,PCTs, and nurse managers occurs fartoo often.

These abuses can cause stress andburnout in nurses and affect the care

they provide. In reviewing the evi-dence on the effects of bullying, Sauerand McCoy (2017) found that peoplewho are bullied experience high levelsof stress that can lead to stress-relatedillnesses and injuries, a higher inci-dence of musculoskeletal disorders,sleep disturbances, headaches, andlower general health.

Organizations are responsible forproviding their employees with workenvironments that are free from abuse

by other employees as well as fromthird parties. In the case of health care,abuse from third parties wouldinclude abuse from patients, privatephysicians, students, residents, etc.(Frye, 2012; Poyner Spruill, 2013).Results of this current study indicatean opportunity for improvement inincident reporting. This can beachieved by ensuring a culture inwhich open communication is encour-aged and facilitated, and a culture inwhich the organization uses such com-munication in a positive way.

Exposure to hazards. The high-est-occurring hazard reported in thisstudy was bending, stooping, pushing,squatting, lifting, moving dialysis andwater treatment equipment or sup-plies, and reaching to provide patientcare, which was reported as occurringvery frequently by 41% of participantsand frequently by 36% (see Table 8).The second highest-occurring hazardreported was lifting or repositioningheavy objects, reported as occurringvery frequently by 36% of participantsand frequently by 34%. Given thelarge amount of heavy equipmentrequired for hemodialysis, this is notsurprising. Hazard exposure needs tobe addressed and solutions developedto prevent/minimize risks.

The third highest-reported hazardwas exposure to bloodborne patho -gens. The concern about bloodborne

Higher salary & benefits

Better leadership

Better staffing

More meaningful recognition for my contribution

More opportunities for professional development

More flexible scheduling

More opportunities to influence decisions about...

More respect from Administrators/Executives

More respect from Nurse Manager

More autonomy

More/better equipment & technology resources

0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Very Likely Somewhat Likely Not Very Likely Not Likely At All

Figure 13How likely would each of the following be to influence

you to reconsider your plans to leave your present position?

Have

Satisfaction of Those Who Have These BenefitsVery

Satisfied Satisfied DissatisfiedVery

DissatisfiedHealth Insurance 87% 35% 51% 12% 3%Prescription Plan 86% 37% 53% 9% 2%Dental Insurance 89% 33% 53% 12% 2%Vision Insurance 84% 32% 56% 11% 2%Paid Holidays 89% 42% 43% 12% 4%Paid Sick Leave 87% 39% 46% 11% 4%Paid Vacation / PTO 96% 46% 45% 7% 2%401K, Pension, or Other Retirement Program 93% 44% 46% 8% 2%Childcare 20% 16% 47% 21% 16%Tuition Reimbursement 28% 27% 53% 15% 5%

Table 14Satisfaction with Benefits of Those Who Have These Benefits




pathogen hazards is magnified whenone looks at results of questions aboutthe use of sharps safety devices, infec-tion control, the use of PPE, andaddressing breaches of safety practicesby a colleague. No response other thanstrongly agree is acceptable to thesequestions, and yet the strongly agreeresponse only occurs 48% of the timefor following infection control prac-tices, 49% for wearing PPE, and 40%for addressing a colleague who breach-es safety practices. On a positive note,however, these percentages are animprovement over those reported inthe 2014 patient safety study by Ulrichand Kear. In that study, only 23% ofparticipants strongly agreed that infec-tion control practices are followed, and26% strongly agreed that PPE is used(Ulrich & Kear, 2014). It appears not allorganizations provide sharps safetydevices; only 67% of participants in thecurrent study strongly agreed theyhave access to them.

Injuries. The Occupational Safetyand Health Administration (OSHA)identifies health care as one of themost hazardous industries in which towork. In the United States, the inci-dence rate for nonfatal occupationalinjuries in 2016 in health care overallwas 3.9 per 100 full-time workers, withthe incidence in hospitals of 5.5, both

higher than the incidence rate for allworkers of 2.9 (Bureau of LaborStatistics [BLS], 2017). In the currentstudy, 37% of participants reported1,018 incidences of musculoskeletalinjuries (e.g., back injury, musclestrain or sprain) in the past year whileworking as a nurse (see Figure 1); 12%reported 167 incidences of a fall orslip; and 5% reported 43 incidences ofa needlestick injury. Safe patient han-dling and mobility programs havebeen shown to decrease muscu-loskeletal injuries, and voluntary inter-professional national standards havebeen created, along with evaluationtools and strategies (ANA, 2013;Gallager, 2013).

Long, intense hours and fa -tigue. Nurses in this study reportedlong shifts of more than 12 hours,working through break and mealtimes, and even finding it difficult tofind the time or coverage for bath-room breaks (see Table 10). For partic-ipants in this study working in chronichemodialysis units, 19% reported fre-quently and 23% reported often beingthe only RN providing patient care inthe unit. In addition, 39% of partici-pants reported being on call in a four-week period prior to the survey, withcall following a regular day at work88% of the time and with another day

of work scheduled after the call 77% ofthe time. Almost 60% of participantssaid overtime was either required orvoluntary, but felt like it was required.

Nurse fatigue can put the individ-ual nurse, the patient, and the organi-zation at risk. The Joint Commission(2011) issued a sentinel event alert onhealthcare worker fatigue to addresseffects and risks of extended workdays and of cumulative days ofextended hours. Overtime and callhours can exacerbate the issue.Organizations such as the Associationof periOperative Registered Nurses(AORN) (2014) have developed posi-tion statements and guidelines for on-call practices.

The ANA’s (2014) position onnurse fatigue states:

RNs and employers in all care set-tings must collaborate to reducethe risks of nurse fatigue andsleepiness associated with shiftwork and long work hours.Evidence-based strategies must beimplemented to proactivelyaddress nurse fatigue and sleepi-ness; to promote the health, safety,and wellness of RNs; and toensure optimal patient outcomes(p. 1).

Table 15Intent to Leave

Do you plan to leave your present nursing position…No Plans to Leave inthe Next 3 Years

Yes, within theNext 12 Months

Yes, within theNext 3 Years

59.6% 16.7% 23.8%Total planning to leave in next 3 years 40.4%

What do you plan to do after leaving your present nursing position?

Retire 25.2% 46.1%Take a different position in clinical/patient care nursing 35.9% 22.0%Take a different position in non-clinical/patient care nursing 13.0% 9.8%Return to school to pursue additional nursing education 5.2% 6.7%Pursue a job in another profession 2.6% 2.4%Take time out for family or other personal reasons 1.7% 3.1%Other (e.g., teach, unsure, travel nursing, go part time) 16.5% 11.0%Note: Percentage totals may not add up to 100% due to rounding.




An evidence review conducted bySmith-Miller, Shaw-Kokot, Curro,and Jones (2014) found:• A higher incidence of fatigue

among nurses, when compared toother workers.

• Decreased recuperation leads to apropensity to make errors and adecreased ability to detect errors.

• Fatigue affects nurses directly, withreports of drowsy driving andvehicle collisions and near misses.

• Rotating shifts are associated withthe most fatigue effects.

• Greater workplace demands areassociated with increased fatigue,with a factor being the inability totake duty-free breaks.

• Social support of colleagues con-tributes to decreased fatigue.A systematic review of evidence

on the effect of the work environmenton future sleep disturbances foundthat high work demands, job strain,bullying, and effort-reward imbalancewere related to more future sleep dis-turbances, while social support atwork, control, and organizational jus-tice were related to fewer disturbances(Linton et al., 2015).

Mental health. Abuse issues dis-cussed earlier contribute to stress andburnout. Participants in this study alsoreported a great deal of stress concern-ing inadequate staffing and grief afterthe loss of a patient. Over half (54%) ofparticipants in this study said theyhave experienced such grief in thepast year. Unfortunately, they alsoreported nurse managers are not high-ly skilled in addressing that grief withstrategies such as bereavement sup-port and debriefing. Wenzel, Shaha,Klimmek, and Krum (2011), in a studyof oncology nurses, found that creat-ing supportive environments thataddress concerns about workingthrough grief and loss can improvejob satisfaction and decreased com-passion fatigue.

Stress has been related to in -creased healthcare expenditures,workplace accidents, disengagement(which is associated with absenteeism,accidents, and errors), and turnover(Seppala & Cameron, 2015). Jobburnout among nurses also reduces

hand hygiene compliance (Mano -menidis, Panogopoulou, & Montgom -ery, 2017).

Nurses are not the only cliniciansexperiencing stress and burnout. Arecent article by Williams (2018)describes burnout in nephrologistsand notes that “physicians cannotsolve the problem without organiza-tions addressing culture and valuealignment, inefficiencies, and appro-priate resource allocation” (p. 3). In2017, burnout had become so perva-sive in healthcare clinicians that theNAM launched the Action Colla -borative on Clinician Well-Being andResilience, a network of more than 50organizations committed to reversingtrends in clinician burnout. The Colla -borative has three goals: “im provebaseline understanding of challengesto clinician well-being; raise the visi-bility of clinician stress and burnout;and elevate evidence-based, multidis-ciplinary solutions that will improvepatient care by caring for the caregiv-er” (NAM, 2018, p. 1). As of January2018, over 130 healthcare organiza-tions have joined the NAM in formal-ly committing to promote clinicianwellbeing and combat burnout(NAM, 2018).

Promoting joy and meaning inwork is an important strategy in pre-venting and mitigating stress andburnout. A roundtable on joy, mean-ing, and safety in health care notedthat:

An environment that is deficient injoy and meaning, where the work-force is burdened by extreme pro-duction pressures, toxic sociocultu-ral norms, and the risk that theycould be physically or psychologi-cally harmed, is an environmentwhere both the workforce andpatients suffer (Lucien Leape Insti -tute at the National Patient SafetyFoundation, 2013, p. 2).

Resilience is also a key skill todevelop to ensure mental wellbeing.

Communication,Collaboration, and Respect

In this study, communication

between RNs and communicationbetween RNs and physicians wererated the highest, followed by thecommunication between RNs andPCTs/UP, and RNs and nurse man-agers (see Figure 2). Communicationbetween RNs and administrators/executives was rated much lower. Thesame pattern held with regard to col-laboration (see Figure 3). Respect forRNs was rated highest from otherRNs, followed by respect from physi-cians, other healthcare colleagues, andnurse managers. Respect fromPCTs/UP and from administrators/executives was rated the lowest (seeFigure 4).

Communication, collaboration,and respect are the foundation of rela-tionships in health care and have beenshown to be critical to patient safetyand quality patient care. In 2015,Controlled Risk Insurance Company,Ltd. (CRICO) Strategies estimated thatcommunication failures were responsi-ble for 30% of all hospital and medicalpractice malpractice claims for the pre-vious five years. The issue of communi-cation during handoffs has become socritical that in September 2017, TheJoint Com mission issued a sentinelevent alert on inadequate handoff com-munication.

Wang, Wan, Lin, Zhou, and Shang(2017), in a literature review, foundrelationships between nurse-physiciancommunication and patient satisfac-tion, hospital length of stay, occur-rence of adverse events, and health-care costs. Evidence on positive effectsof collaboration goes all the way backto the seminal work of Knaus (a physi-cian), Draper (a nurse), Wagner, andZimmerman (1986), who found asso-ciations between the quality of nurse-physician relationships and patientmortality and nurse job satisfaction –the better the relationships, the lowerthe mortality, and the higher the nursejob satisfaction. Coordination of caresignificantly influenced its effective-ness.

Staffing and Work That GetsDone

Staffing was a major concern ofparticipants in this study. Just over



60% of participants said their workunit had the right number of RN staffwith the right knowledge and skillsmore than 75% of the time, while 19%said it occurred less than 50% of thetime. The association between inade-quate RN staffing and negative out-comes is well established. The ANA(2015b), in a review of the evidence onadequate staffing, found that ensuringadequate staffing levels has beenshown to:• Reduce medical and medication

errors.• Decrease patient complications.• Decrease mortality.• Improve patient satisfaction.• Reduce nurse fatigue.• Decrease nurse burnout.• Improve nurse retention and job

satisfaction.In a study of RN staffing, processes

of care, and patient outcomes,Thomas-Hawkins, Flynn, and Clarke(2008) found that “high patient-to-RNratios and increased numbers of tasksleft undone by RNs were associatedwith an increased likelihood of fre-quent occurrences of dialysis hypoten-sion, skipped dialysis treatments,shortened dialysis treatments, andpatient complaints in hemodialysisunits” (p. 123). Adequate staffingmeans more than the number of nurs-es and how many patients they eachcare for. A nurse is not a nurse is not anurse. Staffing must take into account:• The number of nurses.• The knowledge of nurses.• The competence of nurses.• The experience of nurses.• The number, knowledge, compe-

tence, and experience of supportstaff available to assist the nurses.

• The ability of nurses to lead andwork with teams.

• The number of patients.• The acuity of patients.• The needs of patients.

Staffing affects how much andwhat kind of work gets done. Nursesin this study reported getting directcare tasks and documentation com-pleted regularly; however, higherorder patient care needs requiring theknowledge and critical thinking skillsof an RN were done far less often.

This indicates that RNs are not consis-tently operating or being allowed tooperate at the top of their license.They are spending time doing thingsthat could be effectively done bysomeone else, and as a result, thingsthat could be done by RNs to benefitpatients and organizations are not get-ting done. At the same time, practic-ing below the top of their license is notsatisfying for RNs and does not maxi-mize the organization’s resources orachieve the best patient, financial, andnurse outcomes.

Strategies need to be developed toaddress the inadequate staffing andunderutilization of RN knowledgeand skills described in this study.However, research supports that try-ing to improve staffing without firstensuring the work environment ishealthy is like setting up a revolvingdoor for new hires (Aiken et al., 2011).Indeed, Linda Aiken, who has ledmuch of the research done on nursestaffing and patient outcomes, hasfound that good nurse staffing levelsare necessary but not sufficient forexcellent patient care outcomes, andthat the cost of improving nursestaffing in hospitals with poor workenvironments is not a good invest-ment relative to improving the workenvironment (Aiken, 2013). Her stud-ies indicate that increasing the num-ber of staff when the work environ-ment is poor is a waste of moneybecause the new staff will leave inhigh numbers.

Professional DevelopmentOnly 60% of participants in this

study reported their organization pro-vides in-house CE, and 18% said theirorganization offers no support for CE(see Figure 7). Continued competencerequires continuing professional de -velopment. Without continued com-petence, patients are put at risk.

Just over half (55%) of participantsin this study hold a specialty certifica-tion. This compares favorably withthe results from a recent national sur-vey by American Nurse Today in which48% of the respondents reportedbeing certified (O’Keefe, 2017).Certification support in the current

study was reported by 62% of partici-pants who said their organization paysfor their initial examination fee, 44%who said their organization providessome sort of recognition for nurseswho achieve certification, and 33%whose organization pays for the recer-tification fee (see Figure 8). Takingcourses to prepare for certification isonly minimally supported.

RecognitionRecognition is reported by partici-

pants to be most meaningful when itcomes from patients and families. Thisfinding is consistent with that of othernational studies (Ulrich et al., 2014).What is not consistent with other stud-ies is that in this study, the second mostmeaningful recognition comes fromadministrators/executives. The chal-lenge is to determine best practices forfacilitating meaningful recognition.

LeadershipThe relationship between the per-

ceived skills of the nurse manager andparticipant intent to leave is evident. Arecent study by Press-Ganey (2017)found nurse managers directly andindirectly influence both nurse andpatient outcomes, and “have substan-tial influence over the quality of thenurse work environment and theinfluence of the work environment onoutcomes” (p. 2). Blake, Leach,Robbins, Pike, and Needleman (2013)found a statistically significant rela-tionship between leadership andintent to leave. Nurse manager leader-ship skills have some room forimprovement based on the informa-tion from direct care nurse partici-pants in this study.

Intent to LeaveThe major finding from this study

regarding intent to leave is that 40.4%of participants in this study plan toleave their current positions in thenext three years – 16.7% in the next 12months and another 23.8% sometimein the next three years. Of those plan-ning to leave, 37.5% plan to retire(about one-third of those in the next12 months and two-thirds sometime inthe next three years), and 27.4% plan




to take another clinical position. Thegood news is that participants areclear in what would cause them toreconsider; higher salary and benefits,better leadership, and better staffingare the top three influencers.

There are also influencers to getnurses who plan to retire to stay in thework force. The Robert WoodJohnson Foundation, in 2006, whenthe average age of nurses was increas-ing and it appeared that Baby Boomernurses would soon start to retire, pub-lished a white paper, Wisdom at Work:The Importance of Older and ExperiencedNurses in the Workplace, that discussesmany options for keeping older nursesin the work force. After the paper waspublished, the downturn in the econo-my influenced many of these nurses tostay in their positions, but the informa-tion provided in the paper is just asapplicable now as it was then.

With so many nephrology nursesplanning to retire, however, there willbe a lot of turnover. To prepare for thatturnover, organizations must developbetter recruitment and retention strate-gies, and also find ways to make surethe knowledge of retiring nurses getstransferred to nurses who remain.

What’s Next? What Do We Do with This Information

This is a big study with volumes ofdata that identifies strengths andopportunities in the health and safetyof nephrology nurses and the environ-ments in which they work. It can bedaunting to tackle for nephrologynursing in general and organizationsin particular.

The first step is to read the reportin detail and determine what res-onates for you as a direct care nurse,advanced practice nurse, manager,educator, or administrator/executive.Assess you and your organization. Wehave provided a list of assessmentquestions in Table 16 to assist in thatassessment. This will require beingopen to honestly seeing what is work-ing and what needs to be improved.Engage others in the assessment. Seetheir views. Ask for help. This meansincluding patients as well.

Next, make a plan and implementit. Pick one or two things to improve.You can’t fix everything at once. A listof resources that can be helpful to youin crafting the plan is available inTable 17. Go for at least one easy win.Success builds on success.

Evaluate results. Some plans willwork and some won’t. If the plan wassuccessful, continue it. If it wasn’t suc-cessful, take what you learned andstart over. It is like following the stepsof the nursing process. Collect yourdata through an assessment of yourorganization using the providedresources and tools, make a diagnosisabout what is wrong, develop a plan,implement the plan, evaluate yourresults, communicate your results tostakeholders, and repeat.

ConclusionsThe evidence is clear that nurse

health and safety and the environ-ments in which nurses work impactnurses, patient safety and quality ofcare, and organizational outcomes.Organizations are responsible for pro-viding healthy and safe work environ-ments for their employees, and it iscertainly to their benefit to have satis-fied, productive employees who havethe competency and resources toensure patient safety and provide ahigh quality of care. Individual nursesare responsible for their own profes-sional practice.

Results of this study offer insightinto the health and safety of nephrolo-gy nurses and the environments inwhich they work, and have implica-tions for nurses, patients, and organi-zations. There are some great environ-ments, some that need tweaking, andsome that need improvement overall.

We are not lacking in research orconversations on work environments,but we are often missing the imple-mentation of successful strategies thatlead to improvements, and some-times, we are just missing the time andunderstanding of how high a prioritythis work should be. With the excep-tion of direct costs of paying workers’compensation for injuries or liabilityclaims for hostile work environments,

most outcomes of unhealthy andunsafe work environments are sec-ondary or tertiary costs/benefits thatare not as evident on the bottom line.It is our hope that results of this studywill raise awareness of the issues, andstimulate and facilitate individualnurses, managers, educators, adminis-trators, and executives in organiza-tions to assess nurse health and safetyand the health of their work environ-ments, and to plan and implementstrategies for improvement that bene-fit nurses, patients, and organizations.

ReferencesAiken, L. (2013, February 6). Hospital nurse

staffing and patient outcomes. Webinarpresented by API.

Aiken, L.H., Cimiotti, J.P., Sloane, D.M.,Smith, H.L., Flynn, L., & Neff, D.(2011). Effects of nurse staffing andnurse education on patient deaths inhospitals with different nurse workenvironments. Medical Care, 49(12),1047-1053.

Agency for Healthcare Research andQuality (AHRQ). (2016). Hospital sur-vey on patient safety culture. 2016 usercomparative database report. Rockville,MD: Author.

American Association of Critical-CareNurses (AACN). (2016). AACN stan-dards for establishing and sustaininghealthy work environments (2nd ed.).Aliso Viejo, CA: Author.

American Nephrology Nurse Association(ANNA). (2007). 2007 membership andmarketing survey results. Pitman, NJ:Author.

American Nurses Association (ANA).(2013). Safe patient handling and mobil-ity: Interprofessional national standards.Silver Spring, MD: Author.

American Nurses Association (ANA).(2014). Addressing nurse fatigue to pro-mote safety and health: Joint responsibili-ties of registered nurses and employers toreduce risks. Silver Spring, MD:Author. Retrieved from https://www.nursingworld.org/practice-policy/work-environment/violence-incivility-bullying/

American Nurses Association. (ANA).(2015a). Code of ethics for nurses withinterpretive statements. Silver Spring,MD: Author

References continued on page 139



Table 14Health and Safety of Nephrology Nurses and the Environment in Which They Work – A Quick Assessment

As an individual nurse, ask yourself …If you are a manager, administrator,

or executive, ask yourself …Job satisfaction Am I glad I became an RN? Am I glad I am a

nephrology nurse? Would I advise others to be anRN and to work in nephrology? Am I satisfied withmy current position? If not, what do I need tobecome satisfied?

Do I know if the RNs in our organization aresatisfied in their current positions?

Mental and physicalwellbeing

Have I experienced physical or verbal abuse in myjob? Have I experienced harassment? Has a violentact been committed against me? Who committedthe abuse or violence? Does my employer have azero tolerance policy for harassment, violence, andabuse?

Does the organization have a zero tolerance policyfor harassment, violence, and/or abuse? How arestaff members educated about harassment,violence, and/or abuse? Do staff know a zerotolerance policy exists? Do you follow up on reportsrelated to harassment, violence, and/ or abuse?What happens when the abuser is a patient?

Exposure tohazards

Am I exposed to hazards in my work environment?Is training provided to decrease risks related to thehazards? Do I have access to personal protectiveequipment (PPE), sharps safety devices, patienthandling, and mobility equipment?

What responsibility does the organization take todecrease a staff member’s risk related to exposureto hazards? Does the organization provide thehighest level of protection against hazards in thework environment?

Injuries Have I been injured at work? Could the injury havebeen prevented? Did I miss work time related to theinjury?

Could a staff member’s injury been prevented? Canwe learn from this injury to prevent future injuries?Did the injury have a financial cost for theorganization, staff member, and patients?

Long, intense hoursand fatigue

How many hours do I work in a day, week, andmonth? Is overtime required? Is being on callrequired? Do I feel tired and exhausted due to mywork schedule? Do my work hours interfere with myfamily work balance? Do I call in sick at workbecause I am exhausted?

How many hours does a staff member work in aday, week, and month? How is overtime assignedand handled? Do nurses take call? How many ofhours of call are worked by a nurse weekly? Donurses call in sick?

Mental health Do you experience moral distress? Do you dreadgoing to work? How does the loss of a patientimpact you? Do you engage in unhealthy behaviors(e.g., overeating or drinking excessively) to dealwith the stress of your job?

Have staff members missed work to due to mentalhealth issues? Do you have staff members onleaves of absence related to mental healthchallenges? How do you handle the staff’s griefassociated with the loss of patients?

Communication andcollaboration

Do I communicate effectively with my colleagues?Do they communicate effectively with me? Do Icontribute positively to the team?

How well do staff communicate and collaborate?What does our organization do to facilitate or hindercommunication and collaboration?

Respect Am I respected by my colleagues? Do I showrespect for them?

Do we show respect for our employees?

Staffing and workthat gets done

Is your unit fully staffed? Do you complete all ofyour work in a given work day? Do you leave workfeeling like work was left undone? Do you havetime to counsel and teach patients? Are you theonly RN in the unit?

Is your unit fully staffed? Are you continuously hiringnew staff due to turnover? Do you work on the unitto cover understaffing? Do RNs have time to finishtheir work in a given work day?

Professionaldevelopment

When did I last attend a conference or professionaldevelopment session? Does my organizationprovide time off and cover the cost of professionaldevelopment (continuing education andcertification)?

Does the organization support professionaldevelopment? If so, how is the support provided?Do I support staff members who want to attend aconference or get another nursing degree? Do weoffer tuition reimbursement for employees who wantto further their education?

continued on next page




Table 14 (continued)Health and Safety of Nephrology Nurses and the Environment in Which They Work – A Quick Assessment

As an individual nurse, ask yourself …If you are a manager, administrator,

or executive, ask yourself …Recognition Does my organization recognize staff members?

Have I been recognized for my contributions as anurse? Who recognized me? Was it meaningful?

Does the organization recognize members for theircontribution? How are staff members recognized?What role do I play in recognition? Do I know whatrecognition is meaningful to employees?

Leadership Does my organization have strong leaders? Do theleaders seek and hear my opinion? Does theorganization build leaders from inside? Is there aconstant turnover of leaders in the organization?

Am I a strong leader? Do I have training andeducation in the principles of leadership? Am Iperceived to be a strong leader by the staff?

Intent to Leave Do I plan to leave my current job in the next one tothree years? Do I plan to leave nephrology nursing?Am I going to retire soon?

What is your turnover in each role? Are nursesleaving for another position in a differentorganization? Is the organization struggling to retainstaff members? Do you know the real reasons whyemployees leave? Do you have a plan for retainingolder nurses by modifying their jobs or workschedules?

American Association of Critical-Care Nurses (AACN). (2016). AACN standards for establishing and sustaining healthy workenvironments (2nd ed.). Aliso Viejo, CA: Author. Retrieved from https://www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments

American Nurses Association (ANA). (2013). Safe patient handling and mobility: Interprofessional national standards. SilverSpring, MD: Author.

American Nurses Association (ANA). (2014). Addressing nurse fatigue to promote safety and health: Joint responsibilities ofregistered nurses and employers to reduce risks. Silver Spring, MD: Author. Retrieved from https://nursingworld.org/practice-policy/nursing-excellence/official-position-statements

American Nurses Association (ANA). (2018). Healthy nurse, healthy nation. Silver Spring, MD: Author. Retrieved fromhttps://www.nursingworld.org/practice-policy/work-environment/health-safety/healthy-nurse-healthy-nation/

American Nurses Association (ANA). (2018). Violence, incivility & bullying. Retrieved fromhttp://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/bullyingworkplaceviolence

Centers for Disease Control and Prevention (CDC). (2008). Workbook for designing, implementing, and evaluating a sharpsinjury prevention program. Atlanta, GA: Author. Retrieved fromhttps://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf

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Centers for Disease Control and Prevention (CDC) & the National Institute for Occupational Safety and Health (NIOSH). (2015).NIOSH training for nurses on shift work and long work hours. Retrieved from https://www.cdc.gov/niosh/docs/2015-115/

The Joint Commission. (2012). Improving patient and worker safety. Chicago, IL: Author. Retrieved fromhttps://www.jointcommission.org/assets/1/18/TJC-ImprovingPatientAndWorkerSafety-Monograph.pdf

National Academy of Medicine. (2018). Action collaborative on clinician well-being and resilience. Retrieved fromhttps://nam.edu/initiatives/clinician-resilience-and-well-being/

National Academy of Medicine. (2018). Clinician well-being knowledge hub. Retrieved fromhttp://nam.edu/clinicianwellbeing/?utm_source=National%20Academy%20of%20Medicine&utm_campaign=18b3d7fa9e-CR%20July%20meeting%20registration&utm_medium=email&utm_term=0_b8ba6f1aa1-18b3d7fa9e-146476985

Occupational Safety and Health Administration (OSHA). (2013). Caring for our caregivers: Facts about hospital worker safety.Retrieved from https://www.osha.gov/dsg/hospitals/documents/1.2_Factbook_508.pdf

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Table 15Resources



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