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Fire, Safety and OSHA Training for the CNA and HHA

2 Contact Hours
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This peer reviewed course is applicable for the following professions:
Certified Nursing Assistant (CNA), Home Health Aid (HHA), Licensed Nursing Assistant (LNA), Medical Assistant (MA), Medication Aide
This course will be updated or discontinued on or before Monday, July 1, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥90% of participants will know the actions to take to avoid workplace hazards.


After completing this continuing education course, the participant will be able to:

  1. Discuss OSHA standards.
  2. Identify actions to prevent hazardous chemical exposure.
  3. Identify actions to prevent musculoskeletal disorders.
  4. Identify the steps of RACE and other important Fire Hazard & Safety actions.
  5. Identify actions to prevent bodily safety concerns.
  6. Identify actions to avoid injury in workplace violence.
  7. Identify actions to avoid injury in the home care setting.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Fire, Safety and OSHA Training for the CNA and HHA
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Jeanna Winchester (PhD)

An Introduction to OSHA

Occupational Safety and Health Administration (OSHA) is part of the United States Department of Labor. OSHA covers most private-sector employers and their workers, in addition to some public-sector employers and workers.1

Employers must comply with the General Duty Clause of the OSHA Act of 1970. This clause requires employers to keep their workplaces free of serious recognized hazards. OSHA covers most private-sector employers and workers. Federal OSHA does not cover state and local government workers. Still, they do have protections in states that operate their programs.1

Employers are required to meet OSHA standards. These standards include 1:

  • Follow all relevant OSHA safety and health standards
  • Find and correct safety and health hazards
  • Inform employees about chemical hazards through training, labels, alarms, color-coded systems, chemical information sheets, and other methods
  • Notify OSHA within 8 hours of a workplace fatality or within 24 hours of any work-related inpatient hospitalization, amputation, or loss of an eye
  • Provide required PPE (PPE) at no cost to workers
  • Keep accurate records of work-related injuries and illnesses
  • Post-OSHA citations, injury and illness summary data, and the OSHA Job Safety and Health "It's the Law" poster where they are visible to all employees
  • Not retaliate against any worker for using their rights under the law

A Note About Employer Responsibility & PPE (PPE) in the New Viral Outbreak Era

With the emergence of novel viral outbreaks, such as COVID-19 from the coronavirus category of viruses, it is important to know that employers must pay for most types of required PPE (e.g., PPE), under American law.1

"There is No Such Thing as an Accident, only a Failure to Recognize the Hand of Fate," Napoleon Bonaparte.2

Every time an individual decides to leave the comfort and control of their home environment and enter the workplace, there are risks. Every American needs to know their rights under American law. Employees have the right to1:

  • Working conditions that do not pose a risk of serious harm
  • Receive information and training (in a language that the workers can understand) about chemical and other hazards, methods to prevent harm, and OSHA standards that apply to their workplace
  • Review records of work-related injuries and illnesses
  • Obtain copies of test results performed to find and measure hazards in the workplace
  • File a complaint asking OSHA to inspect their workplace if they believe there is a serious hazard or that their employer is not following OSHA rules
  • Request that identity remains confidential
  • Use their rights under the law without retaliation. If an employee is fired, demoted, transferred, or retaliated against in any way for using their rights under the law, they can file a complaint with OSHA. This complaint must be filed within 30 days of the alleged retaliation
  • Report any incident or hazard to your immediate supervisor

While OSHA may not be able to protect every worker from every possible accident or scenario, OSHA standards are created to establish a system from which risk, hazard, and responsibility may or may not be applicable. Specifically, OSHA standards are rules that describe how employers are legally required to follow to protect their workers from hazards.1

Standards protect workers from a wide range of serious hazards. These standards limit the amount of hazardous chemicals workers can be exposed to, require the use of certain safe practices and equipment, and require employers to monitor certain workplace hazards.1

Examples of OSHA worker safety standards include1:

  • Requirements to provide fall protection
  • Prevent trenching cave-ins
  • Prevent exposure to some infectious diseases
  • Ensure the safety of workers who enter confined spaces
  • Prevent exposure to such harmful substances as asbestos and lead
  • Put guards on machines
  • Provide respirators or other safety equipment
  • Provide training for certain dangerous jobs

Few workplaces are as complex as a healthcare facility. Such complex situations provide a lot of potential health and safety hazards.1 When compared with the total civilian workforce, healthcare workers have a greater percentage of workers' compensation claims for sprains and strains, infectious and parasitic diseases, dermatitis, hepatitis, mental disorders, eye diseases, influenza, and toxic hepatitis.1

The list of potential hazards includes radiation, toxic chemicals, biological hazards, heat, noise, dust, and stress.1 The risks and exposures for blood and body fluids are important but not included in this course. Information about the risks and exposures to blood and body fluids is available in a separate course entitled OSHA: Occupational Exposure to Blood and Body Fluids at

Hazardous Chemicals

All healthcare and home care facilities are required to have detailed information about the chemicals that are at the worksite. This information is in a standard format called a Material Safety Data Sheet (MSDS).3

The Material Safety Data Sheet (MSDS)

A typical MSDS will include the following sections3:

  1. Product and Company Identification
  2. Hazards Identification
  3. Composition/Information on Ingredients
  4. First Aid Measures
  5. Fire-Fighting Measures
  6. Accidental Release Measures
  7. Handling and Storage
  8. Exposure Controls/Personal Protection
  9. Physical and Chemical Properties
  10. Stability and reactivity
  11. Toxicological Information
  12. Ecological Information
  13. Disposal Considerations
  14. Transport Information
  15. Regulatory Information
  16. Other Relevant Information for that chemical

The MSDS should be readily available to every worker. Access to the MSDS allows every worker to educate himself about the chemicals at the worksite.3

Chemicals may exert either acute or chronic effects on workers. The effects depend on the extent (concentration and duration) of exposure, the route of exposure, and the physical and chemical properties of the substance.3 The effects of a substance may also be influenced by the presence of other chemicals and physical agents or by an individual's use of tobacco, alcohol, or drugs.3

When you are exposed, the substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals metabolize rapidly, others are not and might be excreted unchanged or stored in the fatty tissues (solvents), lungs (dust and fibers), bone (lead and radium), or blood (soluble gases).3

Toxic substances can enter the body through several routes, including the intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures.3 Inhalation and skin exposure are the most likely.3

Some substances can also damage the skin or eyes directly without being absorbed. Not all substances can enter the body through all routes. Inorganic lead, for example, can be inhaled or swallowed, but it does not penetrate the skin.3

Exposure routes for antineoplastic (cancer drugs) and other hazardous drugs are inhalation (breathe it in), skin absorption, ingestion (swallow it), and injection.3 Although exposure to hazardous drugs and antineoplastics can put the healthcare worker at risk, there are guidelines for handling these drugs safely.3

The National Institute of Occupational Health and Safety (NIOSH) released new guidelines in 2016 about the handling of antineoplastic (cancer drugs) and other hazardous drugs.3

The pharmacist or registered nurse is responsible for following special steps to handle hazardous drugs. Hazardous drugs are mixed in special locations to prevent contamination. Do not enter the area where hazardous drugs are being mixed.

There should be specific procedures that the CNA or HHA is trained to follow before working with patients treated with hazardous drugs. The special procedures may include3,4:

  • Handling body fluids, clothing, dressings, linens, and other materials contaminated with body fluids
  • Special handling of hazardous wastes and contaminated materials separately from other trash
  • Decontaminating and cleaning clinical areas where hazardous drugs are used
  • Clean up spills immediately while using appropriate safety precautions and PPE unless the spill is large enough to require an environmental services specialist
  • Transporting infectious, chemical, or hazardous waste containers
  • Removing and disposing of PPE used during the handling of hazardous drugs or waste
  • Review procedures and information resources for hazardous drugs handled
  • Be familiar with and be able to recognize sources of exposure to hazardous drugs
  • Wash hands with soap and water immediately before using and after removing personal protective clothing, such as disposable gloves and gowns

Following these guidelines and understanding responsibilities may be the difference between an injury or fatality and a safe employee experience.

Musculoskeletal Disorders (MSDs)

"The Injuries We Do and Those We Suffer Are Seldom Weighed in the Same Scales," Aesop5

Nursing aides, orderlies, and attendants have the highest rates of musculoskeletal disorders (MSDs). The rate is more than seven times the average for all industries. The average incidence rate for MSD cases with days away from work increased by four percent, while the MSD incidence rate for nursing aides, orderlies, and attendants increased by ten percent.3,5,6

These injuries are largely due to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring and repositioning patients and working in extremely awkward postures.3,5,6

Nearly half of all compensation claims for healthcare workers involved back injuries.3,5,6

The most common causes of all work-related back pain are3,5,6:

  • Job performance by a worker who is unfit or unaccustomed to the task
  • Postural stress
  • Work that approaches the limit of a worker's strength

Factors that contribute to these causes of back pain are:

  • Understaffing
  • The lack of regular training programs in proper procedures for lifting and other work motions
  • Inadequate general safety precautions

Written guides and programs for preventing back injuries are available for all workers. The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks biomechanically (body movement) stressful. The secondary approach is to train workers on how to perform stressful tasks while minimizing the biomechanical forces on their backs and how to maintain flexibility and strengthen the back and abdominal muscles.3,5,6

To prevent back injury, workers should3,5,6:

  • Use proper lifting techniques
  • Request help. When in doubt about whether a task may strain the back, a worker should request help rather than take a chance
  • Use back exercises to strengthen the back muscles and help prevent back injuries. A physician or physical therapist should be consulted

Patient transfers are particularly hazardous for healthcare workers. The following fundamental points should be emphasized to prevent back injuries during transfers3,5,6:

  1. Communicate the plan of action to the patient and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves
  2. Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles
  3. Ensure good footing for the workers and patients (patients should wear slippers that provide good traction)
  4. Maintain eye contact and communication with the patient. Be alert for trouble signs
  5. If help is needed, request that a coworker stand by before attempting the transfer

Accident hazards such as wet floors, stairway obstructions, and faulty ladders should be reduced. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Workers should be instructed to use the handrail on stairs to avoid undue speed and to maintain an unobstructed view of the stairs ahead of them. Request help to manage a bulky load.3,5,6

The consequences of work-related musculoskeletal injuries among CNAs and HHAs are substantial. Along with higher employer costs due to medical expenses, disability compensation, and litigation, injuries are also costly regarding chronic pain and functional disability, absenteeism, and turnover. Approximately 20% of nurses who leave direct patient care positions do so because of risks associated with the work. Many healthcare workers who experience pain and fatigue can be less attentive, less productive, more susceptible to further injury, and can be more likely to affect the health and safety of others.3,5,6

Case Study

David, a float CNA, was educated on how to use the newest lift equipment and techniques to use when transferring patients from their wheelchairs to their beds and visa-versa. He constantly encouraged the staff he worked with to ask for assistance when handling residents who were unable to help themselves or required more than one person to assist them in moving. Before using any lifting equipment, he made sure all lines and hooks were secure and the equipment functioned safely and properly. Especially in the secured units where many of the patients have dementia or Alzheimer's disease, he instructed the staff to always work as a cohesive team. The individual at the head of the patient is designated to be in charge, and they would discuss the process they would use ahead of time. Patients are told what will be done and why before staff transfer them. Questions are answered at the patient's level of understanding.

This approach is time-consuming and may seem redundant. However, these steps can prevent injuries.

A major point to remember is that the better healthcare workers care for their own bodies and protect themselves from diseases and injuries, the more patients they can help daily. Taking care of yourself is just as important as caring for your patients. There are many ways to be injured in the healthcare workspace, and the savvy healthcare worker knows how to work with those risks while protecting their health & safety!

Healthcare Facility Fires & Other Fire-Related Disasters

Healthcare facility fires and disasters are especially dangerous because workers must protect themselves and evacuate large numbers of patients.7 Almost one-third of healthcare facility fires originated within patient rooms or worker quarters. Matches and smoking is the most frequent cause.7 Other causes are malfunctioning or misused electrical equipment, including hot plates, coffeepots, and toaster ovens.7

Deaths during healthcare facility fires are overwhelmingly due to inhaling the toxic products of combustion rather than direct exposure to the fire. Another obvious fire hazard is the use of oxygen within patient areas. Oxygen increases the combustion of fire. Fires can occur in an oxygen-enriched atmosphere because of patient smoking, electrical malfunctions, and the use of flammable liquids. Procedures should be developed and strictly enforced to prevent fire hazards within patient areas where oxygen is used. When entering a new work area, look around and find fire alarms, fire extinguishers, exit signs, and oxygen cut-off valves.7

One way to remember fire safety is the acronym RACE7:

  • R: rescue
  • A: alarm
  • C: contain the fire (if possible)
  • E: extinguish or evacuate

When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling, forming a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gases. Never hesitate to sound the alarm with any suspicion of fire, but never yell fire. That will only create panic. Call out the facility's code for fire. Call the switchboard to report the fire and pull the fire alarm. When calling the switchboard, be sure to stay on the phone long enough to ensure they have the correct information.7

Healthcare units are separated by heavy fire doors that close automatically when the alarm is sounded to keep the fire from spreading. Additional measures to take to confine a fire include:

  • Closing doors, windows, and all vertical openings like the laundry chute
  • Stuffing wet towels under doors to keep smoke out
  • Shutting off oxygen supplies if directed to do so

Usually, someone in charge is designated to decide when to turn off oxygen supplies.7

If a fire is small and confined, you may be able to extinguish it. If a patient's clothes are on fire, wrap the patient tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug or cut the electricity as soon as possible.7

If a fire cannot be extinguished and smoke, fumes, or flames threaten patient safety, you may have to evacuate (move patients out of danger). Evacuate ambulatory patients first. Stay calm and give clear directions. Evacuate horizontally (sideways) as long as you can. Then, evaluate vertically (up and down) to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you trapped inside the elevator.7

Fire extinguishers come in different classes for use on fires of different sources. The extinguisher has small pictures on the label that help you identify the type of fire source material the canister will extinguish. Class A puts out fires involving ordinary combustibles (cloth, wood). Class B extinguishers smother fires involving flammable liquids or gases. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires. To use an extinguisher, pull the pin, aim the nozzle at the base of the fire, and squeeze the trigger while you make sweeping strokes.7

For anyone at a healthcare site, having clear and explicit directions for fire safety, as well as disseminating that knowledge to other colleagues at that site, is critical to everyone's safety. Fires can get out of control very quickly. The more informed the staff is, and the more frequently the staff practices important fire safety protocols, the more lives will be saved should a terrible situation occur!

Flammable and Combustible Liquids, Vapors, and Gases

A major hazard in all healthcare facilities is the widespread use and storage of flammable and combustible liquids. Many liquids have flammable or combustible vapors and can be ignited by a spark from a motor, friction, or static electricity. Handling and storage directions must be followed.7

Compressed gas cylinders are under pressure and are flammable, so they must be handled with extreme care. An exploding cylinder can have the same destructive effect as a bomb. The proper handling of compressed gas cylinders requires training. Storage areas for compressed gas cylinders should be well-ventilated, fireproof, and dry.

Cylinders should not be stored near steam pipes, hot water pipes, boilers, highly flammable solvents, combustible wastes, unprotected electrical connections, open flames, or other potential heat sources or ignition. Cylinders should be labeled appropriately. The valve protection cap should not be removed until the cylinder is secured and ready for use.7

Acetylene, ethylene oxide, methyl chloride, and hydrogen are flammable, as are the anesthetic agents, cyclopropane, diethyl ether, ethyl chloride, and ethylene. Although oxygen and nitrous oxide are labeled as nonflammable, they are oxidizing gases that will aid combustion.7

Before opening, a healthcare facility cannot correctly estimate the patient load, number of machines, and required safety checks. Over time, minor repairs, haphazard extensions, and replacements might cause some wires to come in contact with each other or create a short circuit, which may cause a very high current flow through wires and cause fire.8

Electrical Equipment

Violating standards and procedures to use electrical equipment are the most frequently cited causes of electrical fires.1,8 Thorough electrical maintenance records should be kept, and considerable effort should be devoted to electrical safety, particularly in areas where patient care is involved. Equipment and appliances that are frequently ungrounded or incorrectly grounded include:

  • Three-wire plugs attached to two-wire cords
  • Grounding prongs that are bent or cut off
  • Ungrounded appliances resting on metal surfaces
  • Extension cords with improper grounding
  • Cords molded to plugs that are not properly wired
  • Ungrounded, multiple-plug devices that are often found in office areas and at nurses' stations
  • Personal electrical appliances brought by the workers from home (radios, coffeepots, fans, electric heaters) that are not grounded, have frayed cords, poor insulation, or are otherwise in poor repair

As a healthcare worker, you can be the eyes and ears of the facility! If you are in a patient's room and something just does not look right, it is more important to ask and investigate. Whenever possible, take a look at your patient's room and report anything suspicious, in terms of electrical equipment or wiring, to the person in charge! Electrical fires and other hazardous events are largely out of our control. Still, we can be on the lookout in the hopes of preventing a terrible situation from occurring.

Bodily Safety Concerns for the Healthcare Worker

"I am Oz, the Great and Terrible." L. Frank Baum9

Disaster plans should be prepared for natural events (e.g., tornadoes, earthquakes, and hurricanes), gas leaks, and bomb threats. The plans should be written and readily available. Supervisory workers will initiate the disaster plan and designate tasks to workers. Workers are responsible for knowing the alarm code for a disaster and the exit routes.

Reproductive Hazards (Infertility, miscarriage, birth defects, low birth weight)

Up to 4 million women employed in healthcare and home care facilities may be exposed to hazards to a normal pregnancy. However, there is no clear evidence that exposure conditions in healthcare facilities have resulted in an excess rate of birth defects among the children of healthcare workers.10

Studies support more general associations between employment in healthcare facilities or laboratories and an increased risk of adverse pregnancy effects. The primary effect is spontaneous abortion.10

In addition to many of these drugs being cytotoxic (destructive action on cells), the majority are hazardous to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breastfeeding. The substance may be present in breast milk. These drugs represent an occupational hazard to healthcare workers. They should always be handled with the use of recommended engineering controls and PPE, regardless of their route of administration.10

Chemical and Physical Agents that are reproductive hazards in the healthcare workplace10


Observed effect

Cancer treatment drugs (e.g., methotrexate)

Infertility, miscarriage, birth defects, low birth weight

Ionizing radiation (e.g., X-rays and gamma rays)

Infertility, miscarriage, birth defects, low birth weight, developmental disorders, childhood cancers

Strenuous physical
labor (e.g., prolonged standing, heavy lifting)

Miscarriage late in pregnancy, premature delivery

Infectious Reproductive Hazards for women in the Healthcare workplace10
DiseaseObserved effectsPreventive Measures


Birth defects, low birth weight, developmental disorders

Good hygienic practices such as handwashing

Hepatitis B virus

Low birth weight


Human immunodeficiency virus (HIV)

Low birth weight, childhood cancer

Practice universal precautions

Human parvovirus B19


Good hygienic practices such as handwashing

Rubella (German measles)

Birth defects, low birth weight

Vaccination before pregnancy if there is no prior

Varicella-zoster virus (chickenpox)

Birth defects, low birth weight

Vaccination before pregnancy if there is no prior

Workers with immunity through vaccinations or earlier exposures are not generally at risk from diseases such as hepatitis B, human parvovirus B19, German measles, or chickenpox. However, pregnant workers without prior immunity should avoid contact with infected children or adults. Workers should also use good hygienic practices such as frequent handwashing to prevent the spread of infectious diseases and universal precautions.11

PPE (PPE) and engineering controls for working with reproductive-hazardous drugs in healthcare settings10
 ActivityDouble chemo-therapy glovesProtective gownEye/face protectionRespiratory protection

Drugs and metabolites in body fluids

Disposal and cleaningYesYesYes, if the liquid that could splash

Yes, if inhalation potential

Drug-contaminated waste

Disposal and cleaningYesYesYes, if the liquid that could splash

Yes, if inhalation potential




Skin Hazards

Skin injuries and diseases account for a large proportion of all occupational injuries and diseases. Skin injuries in the healthcare environment include cuts, lacerations, punctures, abrasions, and burns. Skin diseases and conditions of healthcare workers include dermatitis, allergic sensitization, infections such as herpes, and skin cancer. Chemicals can directly irritate the skin or cause allergic sensitization. Physical agents can also damage the skin, and skin that has been chemically or physically damaged is vulnerable to infection.11

The most common and often the most easily preventable of all job-related health problems are skin reactions (dermatitis).11 The skin is the body's natural defense system: it has a rough, waxy coating, a layer of protein, keratin, and an outer layer of dead cells to help prevent chemicals from penetrating the tissues and being absorbed into the blood.11

Many chemicals cause irritation on contact with the skin, irritant contact dermatitis by dissolving the protective fats or keratin protein layer, dehydrating the skin, or killing skin cells. Symptoms of this kind of irritation are red, itchy, peeling, dry, or cracking skin. Some chemicals are not irritants under normal conditions, but they will irritate skin that has already been damaged by sunburn, scratching, prolonged soaking, or other means. Tars, oils, and solvents can plug the skin pores and hair follicles, causing blackheads, pimples, and folliculitis (inflammation of hair follicles).11

Some persons become sensitized to chemicals days, months, or even years after their first exposure. This allergic reaction does not occur in every worker who contacts the chemical. Symptoms are red, itchy, and blistering skin, like poison oak or ivy reaction, and maybe much more severe than the direct irritation described in the previous subsection.11

The association between basal and squamous cell carcinomas and ultraviolet radiation has been well established. The association between skin cancer and exposure to other agents is less well documented. Still, ionizing radiation and antineoplastic drugs have been implicated. Other evidence indicates that malignant transformation of cells damaged by chronic allergic contact dermatitis may occur.11

The skin can be damaged by a variety of microorganisms, including bacteria, fungi, viruses, and parasites. Herpes simplex is the most common dermatologic infection among healthcare workers.11

Relatively simple precautions can greatly reduce skin hazards. Effective measures include work practices and engineering controls (procedure steps that prevent exposure) that limit solvent exposure, the use of PPE, the substitution of less irritating chemicals, the use of non-powdered gloves, and the institution of a good hygiene program.11


Job stress refers to the harmful physical and emotional responses that occur when the job requirements do not match the worker's capabilities, resources, or needs. Job stress can lead to poor health and even injury.12,13 Healthcare work often requires coping with some of the most stressful situations found in any workplace.12,13

Healthcare workers must deal with life-threatening injuries and illnesses complicated by complex hierarchies of authority and skills, dependent or demanding patients, and patient deaths; all of these contribute to stress.12,13 Other important stress factors include job specialization, discrimination, concerns about money, lack of autonomy, work schedules, ergonomic factors, and technological changes.12,13

The increasing size and bureaucracy of many healthcare facilities may depersonalize the environment and leave many workers feeling isolated, fatigued, angry, powerless, and frustrated.12,13 These feelings may be expressed as apathy, loss of self-confidence, withdrawal, or absenteeism. Failure to recognize and treat the sources of stress results in workers who suffer burnout.12,13

Factors commonly mentioned as causes of stress by all categories of healthcare workers are12,13:

  • Understaffing
  • Role conflict and ambiguity
  • Inadequate resources
  • Working in unfamiliar areas
  • Excessive noise
  • Lack of control (influence, power) and participation in planning and decision-making
  • Lack of administrative rewards
  • Under-utilization of talents and abilities
  • Rotating shift work
  • Exposure to toxic substances
  • Exposure to infectious patients

Stress has been associated with loss of appetite, ulcers, mental disorders, migraines, difficulty sleeping, emotional instability, disruption of social and family life, and the increased use of cigarettes, alcohol, and drugs. Stress can also affect worker attitudes and behavior. Some frequently reported consequences of stress among healthcare workers are difficulties in communicating with very sick patients, maintaining pleasant relations with coworkers, and judging the seriousness of a potential emergency.12,13

Understanding stress in the healthcare workplace could be vital in preventing a harmful, dangerous, or violent situation from erupting.

Workplace Violence

Workplace violence is a serious concern for the approximately 15 million healthcare workers in the United States.14 OSHA does not require employers to implement workplace violence prevention programs. Still, it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards.14

The circumstances of healthcare and home care facility violence differ from the circumstances of workplace violence in general. Violence most often relates to robbery in other workplaces, such as convenience stores and taxicabs. Violence in healthcare and home care facilities usually results from patients and occasionally from their family members who feel frustrated, vulnerable, and out of control.14

Common risk factors for healthcare and home care facilities violence include the following14:

  • Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses
  • Working when understaffed-especially during mealtimes and visiting hours
  • Transporting patients
  • Long waits for service
  • Overcrowded, uncomfortable waiting rooms
  • Working alone
  • Poor environmental design
  • Inadequate security
  • Lack of staff training and policies for preventing and managing crises with potentially volatile patients
  • Drug and alcohol abuse
  • Access to firearms
  • Unrestricted movement of the public
  • Poorly lit corridors, rooms, parking lots, and other areas

Violence may occur anywhere in healthcare or home care facilities, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units. Studies indicate that violence often takes place during times of high activity and interaction with patients. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or tobacco or alcohol use.14

Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mentation.14 Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia. Watch for signals that may be associated with impending violence14:

  • Verbally expressed anger and frustration
  • Body language, such as threatening gestures
  • Signs of drug or alcohol use

Note how your coworkers behave. If a colleague's demeanor or behavior has changed for the worse, notify the person in charge.14 For example, slamming equipment around is red-flag behavior. Learn from their history. If a patient has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for this patient. Let security know if you feel threatened or if you find or suspect that the patient is carrying a weapon. Notify your nursing supervisor, manager, and healthcare facility security if you suspect a patient will be violent. In a home care situation, leave and call the police if needed.  Keep your patient informed. Help relieve patient tension and anxiety by informing them about when examinations/treatments will be performed and what is happening.14

Be Alert14:

  • Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor
  • Be vigilant throughout the encounter
  • Do not isolate yourself with a potentially violent person
  • Plan your exit
  • Watch your surroundings

Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door. When you are with an upset patient or coworker, avoid areas of the room that do not have an accessible exit. If you go to an isolated part of your facility, let others know where you are going and when you expect to return. Consider asking for an escort.

Observe your surroundings and note anyone who is not wearing a staff ID and is lingering where they should not be. Ask politely if you can help and notify security if you are unsatisfied with the answer. Call security and provide a full description if you would rather not approach someone.

Evaluate the way you wear equipment to be sure it cannot be used as a weapon against you. For example, consider that a stethoscope or ID badge without a breakaway necklace can be used to choke you. Carry your stethoscope in a pocket and use an ID badge necklace that has a breakaway feature. If you wear a necktie, opt for a clip-on style. If your hair is long, wear it in a way that is not easy to pull, and do not wear dangling jewelry.14

Dos & Do Nots in Violent Situations

In the presence of a potentially violent person, DO14:

  • Plan a clear exit route
  • Keep 5 to 7 feet between you and them; never turn your back or let them get between you and the exit
  • Keep your voice calm and quiet
  • Acknowledge that they have a right to their feelings
  • Assume that they have a valid concern and address it
  • Try to meet reasonable demands
  • Offer alternatives when possible:
    • For example, tell an angry patient that although they cannot order take-out pizza, you will see if you can get them an early dinner
    • Tell an angry colleague that you see that they are angry and that you would like to work with them and your manager to resolve the situation
  • Call for backup or security if a situation grows increasingly tense
  • Ensure that they have access to bathrooms, a phone, a TV, and something to read
  • Track equipment:
    • Return it to its rightful place
    • When you take an item into a patient's room, dispose of it properly or take it with you when you leave

In the presence of a potentially violent person, DO NOT:

  • Ignore the agitated person or avoid them
  • Threaten or demand obedience
  • Argue or become defensive or judgmental
  • Laugh, move suddenly, make threatening gestures, or invade their personal space
  • Try to handle a dangerous situation alone
    • Call security or initiate your facility's violence prevention protocol

Take these steps if you cannot defuse the situation quickly14:

  • Remove yourself from the situation
  • Call security for help
  • Report any violent incidents to your management

In the presence of a weapon, maintain behavior that helps diffuse anger14:

  • Present a calm, caring attitude
  • Do not match the threats
  • Do not give orders
  • Acknowledge the person's feelings (for example, "I know you are frustrated")
  • Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly)

You can make all the difference in violent situations! Staying calm and following these quick tips just might diffuse a violent situation from deteriorating into a worse one.

Hazards in the Home

The demand for home care services is escalating in step with the aging population, resulting in an ever-growing number of paid caregivers providing in-home services for individuals with illnesses and disabilities.

CNAs and HHAs have identified multiple types of home hazards.15 Homes can harbor a variety of hazards, including throw rugs, pests, tobacco smoke, mold, sharps, inadequate lighting, cluttered hallways and rooms, and inaccessible bathrooms.15

Despite high rates of work-related injuries and the identification of a variety of hazards, scant research describes hazards by specific locations in the home. Hazards also negatively affect job performance, job satisfaction, and health.15 In the only published study describing particular locations in the home of injuries incurred by HHC providers, researchers found that 60% of HHAs injuries occurred inside patient homes, with the most common locations being the bedroom (24%), bathroom (18%), and kitchen (9%).15

Half of the injuries were associated with patient handling, 8% with specific objects (e.g., needles, pets), 8% with cleaning, 4% with lifting objects, 2% with trash disposal, and 28% were not specified. Patient handling tasks that resulted in injury included moving patients in bedding, bathing, and transferring patients.15

Recommendations to reduce exposure to trip/slip/lift hazards include making changes in the work environment (e.g., removing throw rugs, securing cords, providing adequate lighting), using assistive devices such as transfer or gait belts, participating in ergonomics training, and wearing sturdy shoes with slip-resistant soles.15

Water and grease spills were described frequently on kitchen floors; tight spaces and missing equipment in bathrooms; clutter, tight spaces, and lifting hazards in the bedroom; electrical cords and oxygen tubing in the living room; and clutter in the hallway.15

Pet droppings were key biohazards in the kitchen and living room; human waste was commonly noted as bathroom and bedroom hazards.15 The rooms in patients' homes where HHAs work varied by type of healthcare worker and patient needs. For example, nurses may not go into a patient's bedroom or kitchen if patient care is provided in the living room.15

By contrast, home health aides are often in all rooms if they provide cleaning, meal preparation, and personal care services. A key implication of these findings is that healthcare agencies should provide tailored training addressing the hazards HHC providers will likely encounter by room.15


Many healthcare workers must constantly deal with exposure to neoplastic and hazardous drugs. New drugs are developed every year, and each has specific side effects. Fortunately, organizations such as NIOSH, CDC, and DHHS are constantly updating important information, telling us how to be safe, along with the side effects of new chemical agents. Healthcare workers in all departments need to know where their MSDS book is located and have easy access to it. Educators must constantly update their safety manuals and educate workers on all shifts and in all departments. In today's volatile world, healthcare workers and others need to stay informed on how to handle fires and be prepared for disasters, both man-made and natural.

Knowing how to use equipment that can prevent injuries, along with practicing utilizing this equipment, is necessary. Workplace violence is everybody's concern. The key to success is to learn to listen effectively, know when to speak and what to say, respect everybody's personal distance, and show genuine concern for all those you are in contact with. People need to feel valued and appreciated and know the consequences of their actions. Administrators are responsible for ensuring healthcare workers are protected from injuries while at work and enforcing the consequences when a patient, relative, or coworker physically or mentally abuses a worker.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
No TestDescribe how this course will impact your practice.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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