Abstract
Objectives: To gain a comprehensive understanding of the occupational hazards encountered by home health care nurses in Japan and to elucidate the reality of harm they incur, the hazardous situations, and the protective measures taken
Methods:A questionnaire survey of managers of home health care nursing agencies in Japan was conducted, and 355 valid responses were obtained. The survey questions concerned the occupational hazards experienced by home health care nursing staff. The occupational hazards were classified into 6 categories, and responses were obtained regarding harm, hazardous situations, and protective measures in each category
Results: The types of harm that occurred at highest rates during the previous 3 years were emotional abuse by the patient or their family members, lower back pain resulting from improper posture while providing care, sexual harassment by the patients and their family members, automobile accidents while traveling to home care sites, and allergic reactions to the environment at home care sites. Some hazardous situations were caused by the unique environments of home care sites
Conclusions: In order to prevent the occurrence of harm, the development of risk assessment tools, educational initiatives to increase awareness of occupational hazards, and consideration of the financial and technical support that will enable the use of assistive devices in the practice of nursing techniques were considered necessary. The development of effective guidelines and manuals specific to the occupational hazards encountered by home health care nurses is an important challenge
Keywords: Japan, home health care nurse, occupational harm, hazardous situation, protective measure
Key points: What is already known on this topic: The occupational hazards of home health care nurses in Japan that have been described in the literature include the insufficient use of protective equipment, differing responses after exposure to blood and other body fluids, and an association between nighttime on-call work and decreased subjective sleep quality; however, there have been few reported studies of this topic.
What this study adds: The present study was the first to provide a comprehensive understanding of the occupational hazards encountered by home health care nurses in Japan and explore the reality of harm incurred, that is, injury or damage to the health of people; hazardous situations, namely, circumstances that result in exposure to a potential source of harm; and protective measures as means of reducing risks. Among the types of harm that occurred at least once during the previous 3 years at home health care nursing agencies in Japan, the highest rates of occurrence of harm were as follows: emotional abuse by patients and their family members (60.0%), lower back pain resulting from improper posture while providing care (58.6%), sexual harassment by patients or their family members (57.7%), automobile accidents while traveling to home care sites (49.3%), and allergic reactions to the environment at home care sites (34.4%); some hazardous situations were caused by the unique environments of home care sites.
How this study might affect research, practice, or policy: In order to prevent the occurrence of harm, the development of risk assessment tools, educational initiatives to increase awareness of occupational hazards, and consideration of the financial and technical support that will enable the use of assistive devices in the practice of nursing techniques at home care sites were considered necessary. The development and widespread use of effective guidelines and manuals specific to the occupational hazards encountered by home health care nurses is an important challenge.
1. Introduction
In order to provide nursing care of higher quality, nurses must maintain their own health. However, hazards that can jeopardize the health of nurses are present in nursing care settings. These include such wide-ranging hazards as exposure to infectious pathogens, hazardous chemicals and radiation, work that causes back pain, working arrangements that affect biological rhythms, and high levels of mental strain and stress.
Previous international studies conducted in recent years have reported that nurses and other health care professionals are exposed to bloodborne infections,1 sharp objects, cytotoxic agents, medical waste products, radiation,2 and chemical disinfectants.3 Moreover, the studies found health effects such as musculoskeletal disorders and respiratory and skin problems4 in health care professionals. The position statement of the International Council of Nurses on occupational health and safety for nurses is as follows: “Every nurse has the right to work in a healthy and safe environment without risk of injury or illness resulting from that work.”5
The National Institute for Occupational Safety and Health of the United States classifies occupational hazards in home health care, which includes home health care nursing, into categories such as musculoskeletal disorders, latex allergy, bloodborne infections, occupational stress, and violence.6 In addition, home health care workers are known to be exposed to occupational hazards that do not arise in medical institutions, such as hazardous situations associated with traveling to the homes of patients, and secondhand smoke and aggressive pets in patients’ homes.7 Home health care nursing often involves a nurse visiting a patient’s residence alone. It takes place in a variety of health care environments that differ from those of medical institutions, and the materials and human resources are constrained. This suggests that there are occupational hazards specific to home health care nursing. The occupational hazards of home health care nurses in Japan that have been described in the literature include the insufficient use of protective equipment,8 differing responses after exposure to blood and other body fluids,9 and an association between nighttime on-call work and decreased subjective sleep quality.10 However, there have been few reported studies of this topic. Home health care nursing agencies in Japan are small, and the organizations that establish them vary. Under circumstances in which guidelines specific to the occupational hazards of home health care nurses have yet to be established, measures to address such hazards may be inadequate. Consequently, in order to identify policies for addressing the occupational hazards encountered by home health care nurses in Japan, the objectives of the present study were to gain a comprehensive understanding of such hazards and elucidate the reality of harm, hazardous situations, and protective measures.
1.1. Operational definitions of terminology used
For the present study, occupational hazards of home health care nurses were defined as follows: Hazardous events that may jeopardize health and safety and are caused by the nature of the work of home health care nurses or their working environment. Based on ISO/IEC Guide 51,11 harm, hazardous situations, and protective measures were specified as elements of the occupational hazards of home health care nurses.
Harm: Injury or damage to the health of people.
Hazardous situation: Circumstance that results in exposure to a potential source of harm.
Protective measure: Means of reducing risks.
2. Methods
2.1. Study design
An anonymous, self-administered questionnaire survey was administered by postal mail. The survey period was from December 2021 to January 2022.
2.2. Participants
The subjects of the survey were managers of home health care nursing agencies in Japan. The target sample size was at least 384 subjects, which was calculated based on a response rate of 50% and allowable sampling error of ±5%. Based on the assumption that 20% of the managers would consent to study participation and provide responses, 1919 agencies were selected. As of September 2021, 6836 agencies were listed as regular members of the National Association for Visiting Nurse Service. Proportional distribution was used to determine the number of agencies in each prefecture to invite participation in the study, and 1919 agencies were randomly selected. One manager at each selected agency was asked to participate.
Responses were obtained from the managers of 356 agencies (response rate 18.6%). One location with numerous non-responses was excluded. Consequently, valid responses were obtained from 355 agencies (valid response rate 18.5%). An overview of the agencies is shown in Table 1. For-profit corporations operated 46.2% of the agencies, and 43.4% were established in combination with a home care support office. The mean (SD) numbers of nursing staff were 5.3 (3.9) full-time staff and 2.9 (3.4) part-time staff. Nighttime home health care was provided by 84.8%, and 65.4% provided support for psychiatric patients.
Table 1.
Overview of home health care nursing agencies.
| Number | (%) | Mean | (SD) | ||
|---|---|---|---|---|---|
| Operating organization | |||||
| Medical corporation | 91 | (25.6) | |||
| For-profit corporation (company) | 164 | (46.2) | |||
| Incorporated association/foundation | 32 | (9.0) | |||
| Social welfare corporation | 25 | (7.0) | |||
| Local government | 2 | (0.6) | |||
| Cooperative | 18 | (5.1) | |||
| Incorporated nonprofit organization | 1 | (0.3) | |||
| Other | 19 | (5.4) | |||
| Affiliated institution(s) (multiple responses allowed) | |||||
| Hospital | 88 | (24.8) | |||
| Clinic | 36 | (10.1) | |||
| Home care support office | 154 | (43.4) | |||
| Day care facility | 95 | (26.8) | |||
| Home care facility | 137 | (38.7) | |||
| Residential facility | 64 | (18.0) | |||
| Other | 22 | (6.2) | |||
| Time since agency established, years | 13 | (10.2) | |||
| Number of nursing staff | |||||
| Full-time | 5.3 | (3.9) | |||
| Part-time | 2.9 | (3.4) | |||
| Number of visits in 1 month (total number) | 627.6 | (533.1) | |||
| System for 24-hour response | |||||
| Nighttime home care provided | 301 | (84.8) | |||
| Nighttime telephone calls taken | 13 | (3.7) | |||
| No | 36 | (10.1) | |||
| No response | 5 | (1.4) | |||
| Psychiatric patient users | |||||
| Yes | 232 | (65.4) | |||
| No | 121 | (34.1) | |||
| No response | 2 | (0.6) | |||
2.3. Data variables
Responses were obtained regarding the occupational hazards that the nurses at each agency had experienced at least once during the previous 3 years. In the survey, the occupational hazards of home health care nurses were classified according to the 6 categories shown below. The types of harm, hazardous situations, and protective measures for each category were extracted after repeated examination by 6 co-investigators, using the literature related to the occupational hazards of home health care nurses for reference. The possible responses were “Present,” “Absent,” or “Unknown” for harm; “Occasionally present,” “Rarely present,” “Nearly absent,” or “Unknown” for hazardous situations; and “Yes” or “No” for protective measures. The appropriateness of the survey items and their wording were ensured under the supervision of a manager of a home health care nursing agency with extensive home health care nursing experience.
2.3.1. Infection
Harm: 4 items, such as infections transmitted in blood, other body fluids, or excretions.
Hazardous situation: 7 items, such as being unable to use personal protective equipment when it is needed.
Protective measure: 5 items, such as preparing guidelines and manuals on preventing infection.
2.3.2. Allergy
Harm: 3 items, such as anaphylactic shock caused by contact with latex products.
Hazardous situation: 3 items, such as nurses being unaware of their own allergies.
Protective measure: 4 items, such as preparing guidelines and manuals on latex allergy.
2.3.3. Exposure to harmful chemicals
Harm: 5 items, such as anticancer agents adhering to the skin and mucous membranes.
Hazardous situation: 3 items, such as being unable to use suitable personal protective equipment when it is needed.
Protective measure: 3 items, such as preparing guidelines and manuals for preventing exposure to hazardous preparations.
2.3.4. Lower back pain and injury
Hazard: 2 items, such as lower back pain resulting from improper posture while providing care.
Hazardous situation: 5 items, such as being unable to maintain proper posture while providing assistance due to the characteristics of the bedding used in the home.
Protective measure: 4 items, such as preparing guidelines and manuals for preventing lower back pain.
2.3.5. Violence and harassment
Harm: 4 items, such as physical violence on the part of patients or their family members.
Hazardous situation: 2 items, such as being unable to share information regarding the patients and their family members.
Protective measure: 3 items, such as preparing guidelines and manuals on preventing violence and harassment.
2.3.6. Traffic accidents during work-related travel
Harm: 3 items, such as automobile accidents during travel to home care sites (or when returning).
Hazardous situation: 5 items, such as traveling under a tight time schedule.
Protective measure: 2 items, such as having opportunities to refocus attention on traffic accidents.
2.4. Statistical analysis
Basic statistics were calculated to summarize the status of occupational hazards encountered by home health care nurses and the measures taken to address them. IBM SPSS Statistics (version 28.0, IBM Corp., Armonk, NY, USA) was used in the analysis.
3. Results
The status of occupational harm, hazardous situations, and protective measures incurred by home health care nurses is shown in Table 2. In the infection category, the most common harm (13.0%) was a needle stick during a patient injection or blood collection. There were 3 hazardous situations, including “unable to use the bathroom at the care patient’s home for handwashing when appropriate,” present in more than 50% of the agencies. There were 4 protective measures, including “hand sanitizer is provided by the agency,” present in more than 50% of the agencies. The most common harm in the allergy category (34.4%) was an allergic reaction to something in the environment at the home care site. The protective measure “work is coordinated to prevent home care nurses at risk of allergies from being exposed to allergens” was present in 50% of the agencies. There was almost no harm in the exposure to harmful chemicals category. In the lower back pain and injury category, the most common harm (58.6%) was lower back pain resulting from improper posture while providing care. There were 4 hazardous situations, including “assistance cannot be provided while maintaining proper posture due to the characteristics of the bedding in the home,” present in more than 50% of the agencies. The protective measure “care is taken so that home care nurses at risk of lower back pain do not engage in work that would place a burden on the lower back” was present in more than 50% of the agencies. Emotional abuse by patients and their family members was the most common harm (60.0%) in the violence and harassment category, followed by sexual harassment by patients and their family members (57.7%). The protective measure “caution is exercised regarding the duties of home care nurses who have previously experienced violence or harassment” was present in more than 50% of the agencies. In the category of traffic accidents during work-related travel, automobile accidents while traveling to home care sites was the most common harm (49.3%). There were 3 hazardous situations, including “travel under a tight time schedule,” present in more than 50% of the agencies. The protective measure “having opportunities to refocus attention on traffic accidents” was present in more than 50% of the agencies.
Table 2.
The status of occupational harms, hazardous situations, and protective measures incurred by home health care nurses.
| Present or yes (%) | Absent or no (%) | Unknown (%) | ||||||
|---|---|---|---|---|---|---|---|---|
| Infection transmitted in patient blood, body fluids, or excretions | 7 | (2.0) | 343 | (96.6) | 5 | (1.4) | ||
| Infection resulting from care of patient with COVID-19 or influenza | 33 | (9.3) | 318 | (89.6) | 4 | (1.1) | ||
| Needle stick during patient injection or blood collection | 46 | (13.0) | 304 | (85.6) | 5 | (1.4) | ||
| Harm | Exposure to patient blood or other body fluids | 35 | (9.9) | 306 | (86.2) | 14 | (3.9) | |
| Unable to use personal protective equipment when it is needed | 45 | (12.7) | 308 | (86.8) | 2 | (0.6) | ||
| Unable to use hand sanitizer when appropriate | 21 | (5.9) | 333 | (93.8) | 1 | (0.3) | ||
| Unable to use the bathroom at the care patient’s home for handwashing when appropriate | 231 | (65.1) | 121 | (34.1) | 3 | (0.8) | ||
| The patient or their family members cannot adequately identify and manage infectious waste | 220 | (62.0) | 122 | (34.4) | 13 | (3.7) | ||
| Materials used for injections or blood collection cannot be placed at appropriate locations due to the home care environment (eg, insufficient room) | 191 | (53.8) | 155 | (43.7) | 9 | (2.5) | ||
| Injection needles cannot be safely discarded after use due to a lack of puncture-resistant containers | 107 | (30.1) | 241 | (67.9) | 7 | (2.0) | ||
| Infection | Hazardous situation | The home care nurse has not received a vaccine needed to protect against infection | 50 | (14.1) | 293 | (82.5) | 12 | (3.4) |
| Guidelines and manuals on preventing infection are prepared | 299 | (84.2) | 56 | (15.8) | — | — | ||
| The information in the guidelines and manuals on preventing infection is promulgated and utilized | 232 | (65.4) | 123 | (34.6) | — | — | ||
| Antibody titers against infections are checked at the time of hiring | 101 | (28.5) | 254 | (71.5) | — | — | ||
| Personal protection equipment is provided by the agency | 342 | (96.6) | 13 | (3.7) | — | — | ||
| Protective measure | Hand sanitizer is provided by the agency | 350 | (98.6) | 5 | (1.4) | — | — | |
| Anaphylactic shock resulting from contact with a latex product | 1 | (0.3) | 349 | (98.3) | 4 | (1.1) | ||
| Dermatologic symptoms resulting from contact with a latex product | 23 | (6.5) | 323 | (91.0) | 8 | (2.3) | ||
| Harm | Allergic reaction to the environment at a home care site (eg, pets, house dust, plants) | 122 | (34.4) | 207 | (58.3) | 25 | (7.0) | |
| Nurses unaware of their own allergies | 76 | (21.5) | 259 | (73.2) | 19 | (5.4) | ||
| Substitutes for latex products not available for use | 23 | (6.5) | 314 | (88.7) | 17 | (4.8) | ||
| Hazardous situation | Information is not shared about environments at home care sites that may be allergenic (eg, pets, house dust, plants) | 110 | (31.1) | 233 | (65.8) | 11 | (3.1) | |
| Guidelines and manuals on latex allergies are prepared | 14 | (4.0) | 340 | (96.0) | — | — | ||
| The information in the guidelines and manuals on latex allergies is promulgated and utilized | 10 | (2.8) | 344 | (97.2) | — | — | ||
| Allergies are checked at the time of hiring | 166 | (46.9) | 188 | (53.1) | — | — | ||
| Allergy | Protective measure | Work is coordinated to prevent home care nurses at risk of allergies from being exposed to allergens | 177 | (50.0) | 177 | (50.0) | — | — |
| Inhalation of an anticancer agent (powder) | 0 | (0.0) | 349 | (98.3) | 4 | (1.1) | ||
| Adherence of an anticancer agent to the skin or mucosa | 2 | (0.6) | 346 | (97.5) | 5 | (1.4) | ||
| Needle stick following anticancer agent intravenous removal | 0 | (0.0) | 349 | (98.3) | 4 | (1.1) | ||
| Adherence to the skin or mucosa of an excretion (eg, vomitus, urine, feces) from a patient receiving an anticancer agent | 6 | (1.7) | 331 | (93.2) | 16 | (4.5) | ||
| Harm | Inhalation or adherence to the skin or mucosa of a chemical such as a hazardous disinfectant | 2 | (0.6) | 341 | (96.1) | 10 | (2.8) | |
| Unable to use suitable personal protective equipment when it is needed | 18 | (5.1) | 316 | (89.5) | 19 | (5.4) | ||
| Home care nurses lack awareness of hazardous preparations, such as anticancer agents | 105 | (29.7) | 224 | (63.5) | 24 | (6.8) | ||
| Hazardous situation | Patients or their family members handle hazardous preparations such as anticancer agents inappropriately | 75 | (21.2) | 238 | (67.4) | 40 | (11.3) | |
| Guidelines and manuals for preventing exposure to hazardous preparations such as anticancer agents are prepared | 61 | (17.3) | 292 | (82.7) | — | — | ||
| Information in the guidelines and manuals on anticancer agents and other hazardous preparations is promulgated and utilized | 48 | (13.6) | 305 | (86.4) | — | — | ||
| Exposure to harmful chemicals | Protective measure | Measures for preventing exposure are also shared with the patients and their family members | 100 | (28.3) | 253 | (71.7) | — | — |
| Lower back pain resulting from improper posture while providing care | 208 | (58.6) | 134 | (37.7) | 12 | (3.4) | ||
| Harm | Injury caused by home care nurse falling while providing care | 45 | (12.7) | 300 | (84.5) | 9 | (2.5) | |
| Assistance cannot be provided while maintaining proper posture due to the living environments at home care sites (eg, small bedrooms, bathrooms, and toilets) | 308 | (87.0) | 40 | (11.3) | 6 | (1.7) | ||
| Assistance cannot be provided while maintaining proper posture due to the characteristics of the bedding in the home | 309 | (87.3) | 40 | (11.3) | 5 | (1.4) | ||
| Home care nurses visit even physically larger patients alone and must strain to assist them | 282 | (79.7) | 69 | (19.5) | 3 | (0.8) | ||
| Assistive devices are not available for use | 236 | (66.7) | 98 | (27.7) | 20 | (5.6) | ||
| Hazardous situation | Lacking knowledge of body mechanics | 157 | (44.4) | 190 | (53.7) | 7 | (2.0) | |
| Guidelines and manuals on preventing lower back pain are prepared | 39 | (11.0) | 315 | (89.0) | — | — | ||
| The information in the guidelines and manuals is promulgated and utilized | 25 | (7.1) | 329 | (92.9) | — | — | ||
| A home care nurse’s risk of lower back pain is determined at the time of hiring | 125 | (35.3) | 229 | (64.7) | — | — | ||
| Lower back pain and injury | Protective measure | Care is taken so that home care nurses at risk of lower back pain do not engage in work that would place a burden on the lower back | 238 | (67.2) | 116 | (32.8) | — | — |
| Physical violence on the part of a patient or their family members | 76 | (21.4) | 270 | (76.1) | 9 | (2.5) | ||
| Emotional abuse (eg, verbal abuse, threats, insults, disregard) by a patient or their family members | 213 | (60.0) | 132 | (37.2) | 10 | (2.8) | ||
| Sexual harassment (eg, sexual behavior) by the patients or their family members | 205 | (57.7) | 137 | (38.6) | 13 | (3.7) | ||
| Harm | Being unable to continue performing one’s duties due to violence and harassment by a patient or their family members | 60 | (16.9) | 282 | (79.4) | 13 | (3.7) | |
| Unable to share information regarding the patients and their family members | 109 | (30.7) | 240 | (67.6) | 6 | (1.7) | ||
| Hazardous situation | The crisis awareness of home care nurses regarding violence and harassment is low | 107 | (30.1) | 240 | (67.6) | 8 | (2.3) | |
| Guidelines and manuals on preventing violence and harassment are prepared | 167 | (47.0) | 188 | (53.0) | — | — | ||
| The information in the guidelines and manuals is promulgated and utilized | 107 | (30.1) | 248 | (69.9) | — | — | ||
| Violence and harassment | Protective measure | Caution is exercised regarding the duties of home care nurses who have previously experienced violence or harassment | 211 | (59.4) | 144 | (40.6) | — | — |
| Automobile accident during travel to a home care site (or while returning from one) | 175 | (49.3) | 175 | (49.3) | 11 | (3.1) | ||
| Bicycle or motorcycle accident while traveling to a home care site (or returning from one) | 59 | (16.6) | 285 | (80.3) | 11 | (3.1) | ||
| Harm | Accident while walking during travel to a home care site (or while returning from one) | 9 | (2.5) | 333 | (93.8) | 13 | (3.7) | |
| Travel under a tight time schedule. | 277 | (78.0) | 71 | (20.0) | 7 | (2.0) | ||
| Not knowing the directions to the home care site and looking for them while traveling | 213 | (60.0) | 131 | (36.9) | 11 | (3.1) | ||
| Traveling in poor weather, such as during heavy rain, snow, or a storm | 249 | (70.1) | 97 | (27.3) | 9 | (2.5) | ||
| Traveling during a weather-related natural disaster | 177 | (49.9) | 161 | (45.4) | 17 | (4.8) | ||
| Hazardous situation | Traveling while drowsy due to being on call at night | 144 | (40.6) | 184 | (51.8) | 27 | (7.6) | |
| Having opportunities to refocus attention on traffic accidents | 260 | (73.2) | 95 | (26.8) | — | — | ||
| Traffic accidents during work-related travel | Protective measure | Preparing and promulgating a manual on how to respond during weather-related natural disasters | 129 | (36.3) | 226 | (63.7) | — | — |
Responses were obtained regarding the occupational hazards that the nurses at each agency had experienced at least once during the previous 3 years.
4. Discussion
The present study is, to our knowledge, the first attempt to gain a comprehensive understanding of the occupational hazards associated with home health care nursing in Japan and explore the reality of harm incurred, hazardous situations, and protective measures.
The following were the types of harm that occurred at least once during the previous 3 years with high rates in Japanese home health care nursing agencies. These were emotional abuse by the patient or their family members (60.0%), lower back pain resulting from improper posture while providing care (58.6%), sexual harassment by the patients or their family members (57.7%), automobile accidents while traveling to home care sites (49.3%), and allergic reactions to the environment at home care sites (34.4%).
A previous study in which focus group interviews were conducted with 4 managers of home health care nursing agencies in Japan extracted the following adverse events among home health care workers: needle stick accidents, traffic accidents during work-related travel, accidents involving pets, and harassment.12 Although the results of the present study agreed in part with those of the previous study, the present study, which involved a comprehensive, nationwide survey, elucidated in greater detail the circumstances in which harm occurred.
4.1. Infection
Infection is a known hazard within the health care environment. Lack of a working area, lack of proper disposal for sharp objects, and unexpected interruptions from family or pets were identified as unique to the home care environment and led to bloodborne pathogen exposure.13,14 In the present study, “unable to use the bathroom at the care patient’s home for handwashing when appropriate,” “the patient or their family members cannot adequately identify and manage infectious waste,” and “materials used for injections or blood collection cannot be placed at appropriate locations due to the home care environment” were also present at many agencies. However, the rates of infection harm were not high, and protective measures such as personal protection equipment or hand sanitizer provided by the agency were considered to have helped avoid the occurrence of harm. The preparation of guidelines and manuals was characteristic of infection protection measures. In Japan, the Ministry of Health, Labour and Welfare has prepared and published an infection control manual for home health care workers. Therefore, each facility is likely to use it or adapt it for their own use. In any case, the results suggest that guidelines and manuals developed based on the actual conditions of home health care are effective protective measures.
4.2. Allergy
In investigating allergies among nurses, many studies have focused on latex allergy. However, the environment at the home care site was the cause of the overwhelming number of allergies seen in home health care nursing. A previous study of 1115 health care workers found that the prevalence of latex sensitization was 4.2%.15 Latex allergy has a high risk of triggering anaphylactic shock, and in 2017 Japan issued an alert to the public regarding skin disorders when using natural rubber products. Although measures are taken for medical equipment, such as the use of substitutes for latex products, nurses find it difficult to eliminate allergens in the home care environment. As it has been reported that home health care nurses essentially have to adapt to the client’s environment,16 home health care nurses are characterized by focusing on the culture of the home and creating care that is necessary and sustainable for the well-being of that home. Nurses need to understand their own allergy risk and self-manage by sharing information about allergens present in the care environment and wearing appropriate personal protective equipment.
4.3. Exposure to harmful chemicals
Exposure to harmful chemicals, mainly anticancer agents, rarely occurred. The “lack of awareness among nurses” (29.7%) as a hazardous situation may indicate that exposure to hazardous chemicals is underreported. Home health care nurses are exposed to anticancer drugs during handling, for example, when they bring anticancer drugs to home treatment to administer intravenous infusions. In addition, anticancer drugs are excreted in the urine after administration, even in patients who have completed intravenous anticancer drug infusion as an outpatient, so anticancer drug exposure can occur during the handling of patient waste and during daily life assistance for home patients for between 2 and 7 days after treatment.17 With the shift of anticancer drug treatment from the inpatient to the outpatient setting and the increase in the number of aged households, it is estimated that opportunities for home health care nurses to be exposed to anticancer drugs will increase; however, awareness of the health risks associated with exposure may not yet be sufficient.
4.4. Lower back pain and injury
Lower back pain is one of the main health problems globally,18 and nurses are considered to be a group at high risk of lower back pain and other musculoskeletal disorders. Moreover, home health care nurses have been reported to have a higher long-term incidence of lower back pain than nurses who work at medical institutions.19 In the present survey, lower back pain occurred in approximately 60% of the agencies over the past 3 years, and the hazardous situations suggest that the unique environment of home health care is conducive to lower back pain. However, the main protective measure is “care is taken so that home care nurses at risk of lower back pain do not engage in work that would place a burden on the lower back,” suggesting that fundamental preventive measures are not widely used.
The guidelines of the Occupational Safety and Health Administration (OSHA) in the United States address the issue of musculoskeletal disorders caused by lifting patients and advocate for the use of suspension lifts and slide boards to assist in transferring and transporting patients in long-term care facilities.20 In Japan, assistive devices such as suspension lifts and slide boards recommended by the OSHA are covered by long-term care insurance and can be loaned for a 10% copayment. However, many agencies in the present study (66.7%) responded that they could not use assistive devices because they had none. The reasons for the lack of progress in making assistive devices available in homes are thought to include environmental, economic, and technical factors. It is our hope that future studies will clarify the problems and revise the system in accordance with the actual situation.
4.5. Violence and harassment
In the present survey, emotional abuse and sexual harassment by a patient or their family members occurred in approximately 60% of the agencies over the past 3 years. Nursing is considered an occupation with one of the highest risks of harm resulting from violence.21 A meta-analysis of 136 reports in the literature from various countries regarding violence against nurses showed this to be an international problem.22 In a previous study of home dementia care, health care workers indicated that physical violence, verbal attacks, and sexual harassment occurred frequently in their work and that they were resigned to such treatment.23 However, violence and harassment have significant negative physical, mental, and social effects on those who experience them. Such harm must therefore not be considered part of the job.
Verbal abuse has been found to be positively correlated with the length of the worker’s home health care nursing experience,24 suggesting that it also occurs after continuous involvement with patients. To prevent violence on the part of a patient or their family members, the risk of such violence must be accurately assessed based on timely information. Just as there are individual differences in how the same behavior is perceived with regard to verbal abuse and sexual harassment, there are also individual differences in how information on the risk of such behavior is perceived, which may make it difficult for essential information to be shared. What is needed are educational initiatives to increase awareness of violence and harassment directed at home health care nurses, orientations aimed at establishing a common perspective with patients and their family members, and the development of tools for continuously performing consistent risk assessments.
4.6. Traffic accidents during work-related travel
Automobile accidents during travel to home care sites had occurred at approximately half of the agencies. Although there have been studies of automobile accidents involving nurses that have focused on drowsiness and fatigue after night shifts at medical facilities,25 there have been few studies of automobile accidents related to travel by home health care nurses. The survey found that the most hazardous situations for traffic accidents in home health care nursing are “travel under a tight time schedule,” “not knowing the directions to the home care site and looking for them while traveling,” and “traveling in poor weather, such as during heavy rain, snow, or a storm.” Consequently, one method of addressing this problem is to allow greater leeway in visit schedules. However, because travel time to home care sites is legally regarded as working time in Japan, schedules may be planned so that excess travel time is avoided. Providing information management systems that enable patient information to be reviewed and records to be entered outside the agency may facilitate safe travel and the effective use of time.
4.7. Challenges in addressing the occupational hazards encountered by home health care nurses
The detailed situation of the 6 occupational hazards associated with home health care nurses revealed the challenges needed for each. The preparation of guidelines and manuals was investigated as a common protective measure, but considerable variability was seen. Regarding infection, more than 80% of the agencies had prepared guidelines and manuals, and there were fewer occurrences of harm, suggesting that the guidelines and manuals were effective in preventing harm. Few guidelines specific to the occupational hazards of home health care nurses have been developed in Japan. Under these circumstances, it is likely that the guidelines and manuals used at the agencies have been prepared by means such as adapting the relevant guidelines that are available. First, the occupational hazards encountered by home health care nurses in Japan should be delineated and guidelines indicating the direction of measures to prevent such hazards developed. Because the situations in which home health care nursing takes place are extremely varied, it is necessary to accumulate data that will lead to the development of greater specific policy manuals.
4.8. Limitations
First, the present survey asked agency managers about the occupational hazards that their agency had encountered in the previous 3 years. Consequently, memory errors and management changes may have resulted in recall bias. In addition, because this was a cross-sectional survey, causal relationships cannot be determined. Consequently, the direction of the relationships between harm, hazardous situations, and protective measures may actually have been the opposite of the direction that we assumed (ie, that hazardous situations led to harm and that protective measures reduced harm). A longitudinal study design that includes an accurate temporal sequence of events is needed in the future to elucidate the causal relationships. Second, the valid response rate in the present survey was low. Caution is required regarding the generalizability of the results. Third, the occupational hazards that were identified in the present survey were the results for the range of harm, hazardous situations, and protective measures that we specified. Although these were specified after a thorough examination by the investigators based on the literature, the patients, their family members, and the home environments involved are more complex, and many factors may be relevant. Moreover, occupational hazards should be identified by considering not only whether harm occurred but also the frequency with which it occurred and its impact. Collecting more detailed information in order to make sense of complex situations remains a topic for the future.
4.9. Conclusion
The present study is the first to provide a comprehensive understanding of the occupational hazards encountered by home health care nurses in Japan and explore the reality of harm incurred, hazardous situations, and protective measures. Among the types of harm that occurred at least once during the previous 3 years at home health care nursing agencies in Japan, the highest rates of occurrence of harm were as follows: emotional abuse by patients and their family members (60.0%), lower back pain resulting from improper posture while providing care (58.6%), sexual harassment by patients or their family members (57.7%), automobile accidents while traveling to home care sites (49.3%), and allergic reactions to the environment at home care sites (34.4%). In order to prevent the occurrence of harm, the development of risk assessment tools, educational initiatives to increase awareness of occupational hazards, and consideration of the financial and technical support that will enable the use of assistive devices in the practice of nursing techniques at home care sites were considered necessary. The development and widespread use of effective guidelines and manuals specific to the occupational hazards encountered by home health care nurses is an important challenge.
Author contributions
Y. Kikuchi was the chairperson of the study group, analyzed the data, and wrote the first draft. M.S designed the research protocol. All authors developed the questionnaire, revised the draft, and reviewed and approved the final manuscript.
Funding
This study was supported by a Grant-in-Aid for Scientific Research (Grant Number 20 K10600) from the Japan Society for the Promotion of Science.
Conflicts of interest
The authors declare no conflicts of interest associated with this manuscript.
Data availability
The data are available in a repository and can be accessed via a DOI link.
Acknowledgments
We express our sincere gratitude to the managers of all participating home health care nursing agencies for their cooperation.
This study was approved by the Ethics Committee at Akita University Graduate School of Medicine (Approval Number 2771). Prior to participation, all subjects were provided with a written explanation of the research’s objectives and procedures. Participants were informed that by completing and returning the questionnaire, they were giving their consent to participate in the study.
Contributor Information
Yukiko Kikuchi, Department of Nursing, Akita University Graduate School of Health Sciences, 010-8543, 1-1-1 Hondo, Akita City, Akita, Japan.
Yukiko Kudo, Department of Nursing, Akita University Graduate School of Health Sciences, 010-8543, 1-1-1 Hondo, Akita City, Akita, Japan.
Reiko Sugiyama, Department of Nursing, Akita University Graduate School of Health Sciences, 010-8543, 1-1-1 Hondo, Akita City, Akita, Japan.
Ryosuke Muto, Department of Nursing, Akita University Graduate School of Health Sciences, 010-8543, 1-1-1 Hondo, Akita City, Akita, Japan.
Makiko Sasaki, Professor Emeritus of Akita University.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data are available in a repository and can be accessed via a DOI link.