The Safe Home Care Intervention Study: Implementation Methods and Effectiveness Evaluation.

Home care (HC) aides experience numerous safety hazards in clients' homes; many hazards also put clients at risk. We hypothesized that safety coaching led by nurse managers (NMs) during their initial HC needs assessment could prompt clients to improve safety conditions in their homes. Following a 2-arm proof-of-concept intervention study design, intervention NMs used motivational interviewing (MI), facilitated by a safety handbook and video, to coach clients on home safety improvements. Control arm NMs performed intake assessments with no changes to usual practices. Intervention effectiveness was assessed by NMs and aides. Three HC agencies and two elder services contributed 35 intervention and 23 control homes. NMs coached 97% of clients and reported that 94% were engaged; 63% implemented improvements. NMs' and aides' assessments were consistent; homes with clients reported by NMs as resistant to safety changes had higher aides' hazard scores. Client coaching can be effective for improving HC safety.

Coaching Home Care Clients to Prepare Their Homes for Safe Care Visits: A Mixed-Methods Study to Evaluate a Nurse-Led Educational Intervention Process.

Assuring home care (HC) workers' safety is challenging because the work environment is a private home. This paper presents the process evaluation for a proof-of-concept safety intervention study to assess whether nurse-led safety coaching, using motivational interviewing and a safety handbook, could enable HC clients to improve safety in their homes. The process evaluation objectives were to (i) document the intervention's implementation progress and (ii) assess the intervention's dose delivery, dose reception, and fidelity. Five agencies employing liaisons (n = 5) and nurse managers (NMs, n = 8) implemented this study's intervention and control arms. NMs assigned to the intervention arm (n = 6) coached 34 clients. Process evaluation metrics were assessed with mixed-methods data from (i) surveys completed by NMs during the intervention, (ii) postintervention audio-recorded and transcribed interviews (n = 6) with NMs and liaisons, and (iii) study progress tracking tools. The delivered dose efficiency was 85%, measured by the distribution of safety handbook copies to clients. About 94% of clients (n = 32) were considered "engaged" or "maybe engaged" during the safety coaching. Most coached clients (n = 30) were reachable for follow-up by NMs to assess intervention progress. Despite challenges, the intervention was implemented with good fidelity. Safety coaching can be applied in many HC contexts in larger populations.

Aide and Client Safety "Should Go Hand-In-Hand": Qualitative Findings From Home Care Aides, Clients, and Agency Leaders.

Retention of the home care (HC) aide workforce is essential to meet the needs of our aging population. Some studies suggest that improving HC safety could increase job retention. This study objective was to explore qualitatively the connection between aide and client safety and factors impacting this care relationship. Data consisted of audio-recorded, verbatim responses to open-ended questions of two focus groups with aides (n = 10), two in-person interviews with HC agency managers, and 37 phone interviews with those working in (aides, n = 16; managers, n = 12) and receiving (clients, n = 9) HC. Clients reported home layout and accessibility as safety concerns. Aides and managers reported that client family members can make the care job more challenging. The aide-client connection was affected by communication style, family and HC agency support, allotted care time, and job task boundaries. Interventions that address the safety of both clients and aides can influence HC job satisfaction and retention.

"It changed everything": The safe Home care qualitative study of the COVID-19 pandemic's impact on home care aides, clients, and managers.

BACKGROUND: Home care (HC) services are crucial to the health and social wellbeing of older adults, people with disabilities, and the chronically ill. Although the HC sector is growing rapidly in the USA, there is high job turnover among the HC aide workforce. HC provides an important alternative to facility-based care, yet it has often been overlooked within the larger health care system: most recently, in COVID-19 pandemic planning. The objective of the study was to characterize qualitatively the impact of the COVID-19 pandemic on three key HC stakeholders: clients, aides, and agency managers. METHODS: The study included 37 phone interviews conducted during April - November 2020: HC clients (n = 9), aides (n = 16), and agency managers (n = 12). All interviews were audio recorded and transcribed verbatim. Qualitative analysis of the transcripts followed the grounded theory approach. The interview transcriptions were coded line-by-line into hierarchical themes with NVivo 12 software which allowed weighting of themes based on the number of interviews where they were coded. RESULTS: Fear of infection and transmission among HC clients and aides were strong themes. Infection prevention and control became the top priority guiding day-to-day business operations at agencies; sourcing adequate personal protective equipment for staff was the most urgent task. HC aides expressed concerns for their clients who showed signs of depression, due to increased isolation during the pandemic. The disappearance of comforting touch - resulting from physical distancing practices - altered the expression of compassion in the HC aide-client care relationship. CONCLUSIONS: The findings suggest that the pandemic has further increased psychosocial job demands of HC aides. Increased isolation of clients may be contributing to a wider public health problem of elder loneliness and depression. To support the HC stakeholders during the on-going COVID-19 pandemic, for future pandemic planning or other health emergencies, it is important to improve HC aide job retention. This action could also ease the serious care services shortage among the growing population of older adults.

Development and application of an innovative instrument to assess work environment factors for injury prevention in the food service industry.

BACKGROUND: With the growth the food service industry and associated high injury and illness rates, there is a need to assess workplace factors that contribute to injury prevention. OBJECTIVE: The objective of this report is to describe the development, application, and utility of a new instrument to evaluate ergonomics and safety for food service workers. METHODS: Starting with a similar tool developed for use in healthcare, a new tool was designed through a collaborative, participatory process with the stakeholders from a collaborating food service company. The new instrument enables the identification and assessment of key safety and health factors through a focused walkthrough of the physical work environment, and structured interviews exploring the organizational work environment. The researchers applied the instrument at 10 of the partnering company's worksites. RESULTS: The instrument identified factors related to both the physical work environment and organizational and contextual environment (e.g., vendor-client relationships) impacting worker safety and health. CONCLUSIONS: Modern assessment approaches should address both the physical and organizational aspects of the work environment, and consider the context complexities in which the worksites and the industry operate.

"That's not my job": A mixed methods study of challenging client behaviors, boundaries, and home care aide occupational safety and health.

INTRODUCTION: Home care (HC) aide is among the fastest-growing jobs. Aides often work in long-term care relationships with elders or people with disabilities in clients' homes, assisting with daily activities. The purpose of this mixed-methods paper is to elucidate aides' experiences around the boundary-challenging behaviors of clients asking for services beyond aides' job duties and to identify possible interventions. METHODS: A cross-sectional survey of HC aides in Massachusetts (n = 1249) provided quantitative data. Post-survey qualitative data were collected from nine HC aide focus groups (n = 70) and seven in-depth interviews with HC industry and labor representatives. RESULTS: Quantitatively, aides who reported often being asked to do tasks outside their job duties were more likely to report abuse (prevalence ratio [PR] = 1.93; 95%CI: 1.47-2.52 for verbal, PR = 1.81; 95%CI: 1.13-2.91 for physical/sexual) and pain/injury with lost work time or medical care (PR = 1.58; 95%CI: 1.11-2.25). They were also less likely to want to remain in their job (PR = 0.94; 95%CI: 0.89-1.00) or recommend it to others (PR = 0.94; 95%CI: 0.90-0.98). Qualitative data showed that clients' requests for tasks beyond job duties were frequent and can lead to injuries, abuse, and psychosocial stress. Yet, requests often reflected genuine need. Helping clients stay at home, compassion, and feeling appreciated contributed to job satisfaction; therefore, aides can feel conflicted about refusing requests. CONCLUSION: Client task requests outside HC services are a complex problem. Employer support, training, care plans, and feeling part of a care team can help aides navigate professional boundaries while delivering high quality care.

Home care aides' experiences of verbal abuse: a survey of characteristics and risk factors.

OBJECTIVE: Violence from care recipients and family members, including both verbal and physical abuse, is a serious occupational hazard for healthcare and social assistance workers. Most workplace violence studies in this sector focus on hospitals and other institutional settings. This study examined verbal abuse in a large home care (HC) aide population and evaluated risk factors. METHODS: We used questionnaire survey data collected as part of a larger mixed methods study of a range of working conditions among HC aides. This paper focuses on survey responses of HC aides (n=954) who reported on verbal abuse from non-family clients and their family members. Risk factors were identified in univariate and multivariable analyses. RESULTS: Twenty-two per cent (n=206) of aides reported at least one incident of verbal abuse in the 12 months before the survey. Three factors were found to be important in multivariable models: clients with dementia (relative risk (RR) 1.38, 95% CI 1.07 to 1.78), homes with too little space for the aide to work (RR 1.52, 95% CI 1.17 to 1.97) and predictable work hours (RR 0.74, 95% CI 0.58 to 0.94); two additional factors were associated with verbal abuse, although not as strongly: having clients with limited mobility (RR 1.35, 95% CI 0.94 to 1.93) and an unclear plan for care delivery (RR 1.27, 95% CI 0.95 to 1.69). Aides reporting verbal abuse were 11 times as likely to also report physical abuse (RR 11.53; 95% CI 6.84 to 19.45). CONCLUSIONS: Verbal abuse is common among HC aides. These findings suggest specific changes in work organisation and training that may help reduce verbal abuse.

Cleaning and disinfection in home care: A comparison of 2 commercial products with potentially different consequences for respiratory health.

BACKGROUND: Home care aides perform personal care and homemaking services in client homes, including cleaning and disinfection (C&D). Although C&D are performed to remove soil and dust, they are increasingly performed for infection prevention. Many C&D products contain respiratory irritants. The objective of this study was to evaluate 2 commercial products for C&D effectiveness on common household surfaces in seniors' homes. METHODS: Two C&D visits were conducted in 46 seniors' homes. One visit applied a bleach-containing cleaning product and the other applied an environmentally preferable product. Before and after C&D, the study team performed organic soil bioluminometer measurements on surfaces and collected cotton swab and wipe samples for total bacteria count, Staphylococcus aureus, and Clostridium difficile identification. RESULTS: Both products removed microorganisms from tested surfaces. S aureus was found in 7 households, 1 strain of which was methicillin-resistant. Both products removed S aureus from all surfaces. Bleach-containing products removed somewhat more soil than environmentally preferable products, although results were statistically significant for only 1 surface. CONCLUSIONS: The study showed similar, not identical, C&D performance for 2 cleaning products with potentially different consequences for respiratory health. Additional research is needed to develop robust recommendations for safe, effective C&D in home care.

Safety Risks Among Home Infusion Nurses and Other Home Health Care Providers.

In the United States, home health care (HHC) is a rapidly growing industry and home infusion therapy is a rapidly growing market. HHC can present substantial occupational safety and health (OSH) risks. This article summarizes major OSH risks relevant to home infusion therapy by illustrating them through real-life scenarios collected systematically using qualitative research methods by the National Institute for Occupational Safety and Health-funded research projects at the University of Massachusetts Lowell. The need for home infusion therapy will continue to grow in the future, and safety interventions to prevent or minimize OSH risks are essential.

Risk of sharps injuries among home care aides: Results of the Safe Home Care survey.

OBJECTIVES: Home care (HC) aides constitute an essential, rapidly growing workforce. Technology advances are enabling complex medical care at home, including procedures requiring the percutaneous use of sharp medical devices, also known as sharps. Objectives were to quantify risks of sharps injuries (SI) in a large HC aide population, compare risks between major occupational groups, and evaluate SI risk factors. METHODS: A questionnaire survey was administered to aides hired by HC agencies and directly by clients. One thousand one hundred seventy-eight aides completed questions about SI and potential risk factors occurring in the 12 months before the survey. SI rates were calculated and Poisson regression models identified risk factors. RESULTS: Aides had a 2% annual risk of experiencing at least 1 SI (95% confidence interval [CI], 1.1-2.6). Client-hired aides, men, and immigrants had a higher risk than their counterparts. Risk factors among all HC aides included helping a client use a sharp device (rate ratio [RR], 5.62; 95% CI, 2.75-11.50), observing used sharps lying around the home (RR, 2.68; 95% CI, 1.27-5.67), and caring for physically aggressive clients (RR, 2.82; 95% CI, 1.36-5.85). CONCLUSIONS: HC aides experience serious risks of SI. Preventive interventions are needed, including safety training for clients and their families, as well as aides.

We Have to Be Willing to Say the World Has Changed and Now We Have to Figure Out How to Deal With That: An Interview With Charles Levenstein, About New Solutions.

New Solutions: A Journal of Environmental and Occupational Health Policyhas been published for 25 years. To acknowledge this milestone, Dr. Pia Markkanen interviewed Charles Levenstein, Editor Emeritus of the journal, in August 2015. The purpose of this interview was to review the journal's history: from its earliest roots to the present.New Solutionsbegan in 1990 as a project with the Oil, Chemical and Atomic Workers Union (OCAW). Dr. Charles Levenstein was the founding editor and Tony Mazzocchi was the original publisher. We've tapped Dr. Levenstein's memory to learn the intent of starting the journal and how it developed. The interview presents some of the challenges of sustaining a movement journal with the mission of being a bridge between academics and researchers and workers, environmentalists, as well as advocates and activists.

Occupational health of home care aides: results of the safe home care survey.

OBJECTIVES: In countries with ageing populations, home care (HC) aides are among the fastest growing jobs. There are few quantitative studies of HC occupational safety and health (OSH) conditions. The objectives of this study were to: (1) assess quantitatively the OSH hazards and benefits for a wide range of HC working conditions, and (2) compare OSH experiences of HC aides who are employed via different medical and social services systems in Massachusetts, USA. METHODS: HC aides were recruited for a survey via agencies that employ aides and schedule their visits with clients, and through a labour union of aides employed directly by clients or their families. The questionnaire included detailed questions about the most recent HC visits, as well as about individual aides' OSH experiences. RESULTS: The study population included 1249 HC aides (634 agency-employed, 615 client-employed) contributing information on 3484 HC visits. Hazards occurring most frequently related to musculoskeletal strain, exposure to potentially infectious agents and cleaning chemicals for infection prevention and experience of violence. Client-hired and agency-hired aides had similar OSH experiences with a few exceptions, including use of sharps and experience of verbal violence. CONCLUSIONS: The OSH experience of HC aides is similar to that of aides in institutional healthcare settings. Despite OSH challenges, HC aides enjoy caring for others and the benefits of HC work should be enhanced. Quantification of HC hazards and benefits is useful to prioritise resources for the development of preventive interventions and to provide an evidence base for policy-setting.

Occupational Safety, Health, and Well-being Among Home-based Workers in the Informal Economy of Thailand.

The objective of this article is to provide a summary of the issues related to occupational safety and health and well-being among workers in the informal economy of Thailand, with a special emphasis on home-based workers. The reviewed literature includes documents and information sources developed by the International Labour Organization, the National Statistical Office of Thailand, peer-reviewed scientific publications, and master's theses conducted in Thailand. This work is part of a needs and opportunities analysis carried out by the Center for Work, Environment, Nutrition and Development--a partnership between Mahidol University and University of Massachusetts Lowell to identify the gaps in knowledge and research to support government policy development in the area of occupational and environmental health for workers in the informal economy.

Understanding sharps injuries in home healthcare: The Safe Home Care qualitative methods study to identify pathways for injury prevention.

BACKGROUND: Home healthcare is one of the fastest growing sectors in the United States. Percutaneous injuries from sharp medical devices (sharps) are a source of bloodborne pathogen infections among home healthcare workers and community members. Sharps use and disposal practices in the home are highly variable and there is no comprehensive analysis of the system of sharps procurement, use and disposal in home healthcare. This gap is a barrier to effective public health interventions. The objectives of this study were to i) identify the full range of pathways by which sharps enter and exit the home, stakeholders involved, and barriers for using sharps with injury prevention features; and ii) assess the leverage points for preventive interventions. METHODS: This study employed qualitative research methods to develop two systems maps of the use of sharps and prevention of sharps injuries in home healthcare. Twenty-six in-depth interview sessions were conducted including home healthcare agency clinicians, public health practitioners, sharps device manufacturers, injury prevention advocates, pharmacists and others. Interview transcripts were audio-recorded and analyzed thematically using NVIVO qualitative research analysis software. Analysis of supporting archival material also was conducted. All findings guided development of the two maps. RESULTS: Sharps enter the home via multiple complex pathways involving home healthcare providers and home users. The providers reported using sharps with injury prevention features. However, home users' sharps seldom had injury prevention features and sharps were commonly re-used for convenience and cost-savings. Improperly discarded sharps present hazards to caregivers, waste handlers, and community members. The most effective intervention potential exists at the beginning of the sharps systems maps where interventions can eliminate or minimize sharps injuries, in particular with needleless treatment methods and sharps with injury prevention features. Manufacturers and insurance providers can improve safety with more affordable and accessible sharps with injury prevention features for home users. Sharps disposal campaigns, free-of-charge disposal containers, and convenient disposal options remain essential. CONCLUSIONS: Sharps injuries are preventable through public health actions that promote needleless treatment methods, sharps with injury prevention features, and safe disposal practices. Communication about hazards regarding sharps is needed for all home healthcare stakeholders.

A growing fire hazard concern in communities: home oxygen therapy and continued smoking habits.

The Safe Home Care Project investigated both qualitatively and quantitatively a range of occupational safety and health hazards, as well as injury and illness prevention practices, among home care aides in Massachusetts. This article reports on a hazard identified by aides during the study's initial focus groups: smoking by home care clients on long-term oxygen therapy. Following the qualitative phase we conducted a cross-sectional survey among 1,249 aides and found that medical oxygen was present in 9 percent of aide visits (314 of aides' 3,484 recent client visits) and that 25 percent of clients on oxygen therapy were described as smokers. Based on our findings, the Board of Health in a local town conducted a pilot study to address fire hazards related to medical oxygen. Medical oxygen combined with smoking or other sources of ignition is a serious fire and explosion hazard that threatens not only workers who visit homes but also communities.

Characterizing the nature of home care work and occupational hazards: a developmental intervention study.

BACKGROUND: Home care (HC) aide is the fastest growing occupation, yet job hazards are under-studied. This study documents the context of HC aide work, characterizes occupational safety and health (OSH) hazards, and identifies preventive interventions using qualitative methods. METHODS: We conducted 12 focus groups among aides and 26 in-depth interviews comprising 15 HC agency, union, and insurance company representatives as well as 11 HC recipients in Massachusetts. All focus groups and interviews were audio-recorded, transcribed, and coded with NVIVO software. RESULTS: Major OSH concerns were musculoskeletal disorders from client care tasks and verbal abuse. Performing tasks beyond specified job duties may be an OSH risk factor. HC aides' safety and clients' safety are closely linked. Client handling devices, client evaluation, care plan development, and training are key interventions for both aides' and clients' safety. CONCLUSIONS: Promoting OSH in HC is essential for maintaining a viable workforce.

Long-term care in the United States and Finland: policy lessons to be learned.

Gerontological nurses are crucial members of long-term care (LTC) policy development teams as they work toward the provision of quality, equitable, seamless, and affordable LTC for all. When developing LTC policies in the United States, it is useful to explore such services in other countries. This policy brief provides an overview of LTC services in Finland to examine possible policy lessons for U.S. LTC service and delivery. Finland provides LTC to its older adult population under a universal program whereby services are provided as part of their universal health care and social services coverage. The U.S. system provides LTC primarily under Medicaid along with some coverage financed under Medicare. The challenges in the U.S. system include fragmented LTC delivery and financing, increasing LTC costs, and maintaining quality of care. Although difficult to compare the LTC costs in these two countries, available data suggest that Finland spends less on LTC the older adult population.

Sharps injuries and other blood and body fluid exposures among home health care nurses and aides.

OBJECTIVES: We quantified risks of sharp medical device (sharps) injuries and other blood and body fluid exposures among home health care nurses and aides, identified risk factors, assessed the use of sharps with safety features, and evaluated underreporting in workplace-based surveillance. METHODS: We conducted a questionnaire survey and workplace-based surveillance, collaborating with 9 home health care agencies and 2 labor unions from 2006 to 2007. RESULTS: Approximately 35% of nurses and 6.4% of aides had experienced at least 1 sharps injury during their home health care career; corresponding figures for other blood and body fluid exposures were 15.1% and 6.7%, respectively. Annual sharps injuries incidence rates were 5.1 per 100 full-time equivalent (FTE) nurses and 1.0 per 100 FTE aides. Medical procedures contributing to sharps injuries were injecting medications, administering fingersticks and heelsticks, and drawing blood. Other contributing factors were sharps disposal, contact with waste, and patient handling. Sharps with safety features frequently were not used. Underreporting of sharps injuries to the workplace-based surveillance system was estimated to be about 50%. CONCLUSIONS: Sharps injuries and other blood and body fluid exposures are serious hazards for home health care nurses and aides. Improvements in hazard intervention are needed.

Sharps injuries and bloodborne pathogen exposures in home health care.

Home health care is one of the fastest growing industries in the United States. Approximately 20,000 provider agencies deliver home health care services to 7.6 million individuals with acute illness, long-term health conditions, permanent disability, or terminal illness. The home health care setting poses many challenges that likely increase the risk of sharps injuries. Home health nurses face unique challenges in preventing and reporting sharps injuries in the home. This article examines the nature of and risk factors for sharps injuries in the home health care setting, the scope of the problem, the legislative and regulatory framework relevant to sharps injuries, and the role of occupational health nurses in promoting a culture of safety to prevent sharps injuries and bloodborne pathogen exposures.

There's no place like home: a qualitative study of the working conditions of home health care providers.

OBJECTIVE: Home health care (HHC) is one of the fastest growing US industries. Its working conditions have been challenging to evaluate, because the work environments are highly variable and geographically dispersed. This study aims to characterize qualitatively the work experience and hazards of HHC clinicians, with a focus on risk factors for bloodborne pathogen exposures. METHODS: The researchers conducted five focus group discussions with HHC clinicians and ten in-depth interviews with HHC agency managers and trade union representatives in Massachusetts. RESULTS: HHC clinicians face serious occupational hazards, including violence in neighborhoods and homes, lack of workstations, heavy patient lifting, improper disposal of dressings or sharp medical devices, and high productivity demands. CONCLUSIONS: The social context of the home-work environment challenges the implementation of preventive interventions to reduce occupational hazards in HHC.