TNAI JOURNAL

Workplace tension and abuse are significant contributing factors behind nurses exiting workplaces - and even leaving the profession. Abuse can take many forms, from inappropriate interpersonal communication to sexual harassment and even violence. According to the US Bureau of Labor Statistics, nurses and other personal care workers suffer 25 injuries annually resulting in days off from work for every 10,000 fulltime workers. That’s 12 times the rate of the overall private sector. Fifty percent of nurses surveyed by the Massachusetts Nurses Association (MNA) and the University of Massachusetts said they had been punched at least once in a two-year period. Some reported being strangled, sexually assaulted or stuck with contaminated needles. In a 2006 survey by the Emergency Nurses Association, a national group, 86 percent of respondents said they had experienced violence in the previous three years, and a fifth said they encountered it frequently. Every year, November 25 has been marked as the International Day against Violence against Women. This article aims to familiarise the nurses about the problems in their workplace and helping them to find solutions. The author is Lecturer, Sri Gokulam College of Nursing, Salem (Tamil Nadu).	Psychological Problems Moving from “Novice to Expert” One of the challenges for beginning nurses is pressure to function as an expert without adequate knowledge and skills. Janice (2004) identified six different roles which nurses perform while they move from the sate of being a Novice to Expert: (i) The helping role (ii) The teaching - coaching function (iii) The diagnostic and monitoring function (iv) Effective management of rapidly changing situation (v) Administering and monitoring therapeutic interventions and regimens (vi) Monitoring and ensuring the quality of health care practice and organisational work-role competencies. Reality Shock One problem confronted by the new graduates is the seeming impossibility of delivering quality care within the constraints of the system as it exists. The person undergoing such stress is less able to perceive the entire situation and to solve problems effectively. Burnout Burnout is a form of chronic stress related to one’s job. It can be identified by feelings of hopelessness and powerlessness, and is accompanied by a decreased ability to function both on the job and in personal life. Burnout is more frequent in nurses who work in particularly stressful areas of nursing. It also occurs when staffing is inadequate or interpersonal relationships are strained.	The main causes for burnout are conflict between ideals and reality, practicing nursing in areas that have high mortality rates, inadequate staffing, staying overtime, skipping breaks and lunch and running throughout the shift. Discrimination Discrimination relates to treating others differently based on stereotypes about groups of people. Discrimination may occur regarding racial or ethnic background, gender or sex, sexual orientation, and / or age. Men in nursing have expressed concern about sex discrimination. They are not allowed to care for women clients, or restrictions are placed on them in terms of obtaining consent from each client. Female nurses care for male clients in all situations. This has been accepted because women are commonly seen in nursing and the public associates mothering role with nursing. Mandatory Overtime Mandatory overtime is another way that hospitals deal with poor staffing. It creates a loss of control for the nurse over the ability to schedule non-work activities, including essential family functions.This also puts safe patient care at risk because of nurse’s fatigue and subsequent loss of ability to concentrate and make good decisions. Floating Nurses are sometimes required to ‘float’ from the area in which they normally practice to another nursing unit. It reduces

nurse’s competence and also affects quality nursing care. Physical Problems Harassment and Violence Violence includes a range of behaviour from verbal abuse, threats, and unwanted sexual attacks to physical assault and at the extreme, homicide. According to Occupational Safety and Health Administration (OSHA), two thirds of non-fatal workplace assaults happen in health and social services facilities, the majority of these are assaults by clients on nursing staff, and more in psychiatric mental health setting than in other settings. The World Health Organisation has identified violence as a worldwide problem, which threatens the effective delivery of health care (WHO, 2002). Both men and women may be the objects of sexual harassment. Sexual harassment is a concern in nursing. Harassers in the health care workplace may be clients, coworkers, or physicians. The most dangerous settings for violence are psychiatric units and nursing homes, where patients are often confused, disoriented or suffering from mental ailments, as well as emergency rooms, where long waits for care can anger patients, and the people with them. Infection as an Occupational Hazard Transmission of infection is a major concern for the nurses when caring for infected clients. The hidden danger for nurses lies in those clients who have not been diagnosed as having an infection and for whom specific infection-control measures have therefore	not been prescribed. Needle Stick Injuries Needle stick injuries especially those with large-bore needles (e.g. bone-marrow aspiration needles) continue to be the most frequent source of infection transmission. Hazardous Chemical Agents Nurses working in operation rooms should seek information regarding anaesthetic gases that can increase the risk of foetal malformation and spontaneous abortion in pregnant women who are exposed to them on a regular basis. Chemotherapeutic agents used in the treatment of cancer are extremely toxic and nurses who work in setting where such agents are prepared and administered should seek additional education regarding their administration, not only in relation to the client’s safety but also personal safety. Contact with any medication, especially antibiotics, during preparation and administration may cause the nurse to develop sensitivity leading to hand-rash, for example. Some medications are absorbed through the skin and may produce an undesirable effect. Cleansing agents and disinfectants used in the hospital may also be hazardous if used improperly. Back Injuries Nursing includes providing direct care to incapacitated individuals, hence back injuries are a common occupational hazard. Bioterrorism Most biological attacks will be covert, meaning that there will be no warning. Therefore, it is	important that nurses should know and understand what bioterrorism is and how to identify a potential event because health care workers in hospitals and clinics may have the first opportunity to recognise the covert event. An alert nurse can save lives, including her own. Anthrax, botulism, plague and smallpox are considered the four top agents for potential bioterrorism because plague and small pox can be spread (person-to-person) and botulism and anthrax can be disseminated to a population via airborne release. Solutions for Psychological Problems One way of meeting the challenges to reality shock is to assess themselves as they have developed theoretical knowledge for safe practice, use of the nursing process, self awareness, communication skill, delegation, documentation, skill proficiency, work ethics, speed of functioning, interpersonal skills and cultural sensitivity. Mentor relationship is the important one to cultivate. Orientation programmes provided by experienced nurse as a preceptor to the new graduates will help the new graduates to overcome the reality shock. Nurse internships or residencies in some settings have been created to provide a planned and organised transition time during which the new graduate participates in a formal programme, including classes, seminars and rotations to various units of the hospital.

Burnout can be prevented by paying attention to one’s own physical health maintaining a balanced programme of rest, nutrition and exercise, rotating out of a high-stress area, reviewing positive aspects of nursing - caring, thoughtful doing, life long learning and conducting sessions of group discussion. All nurses need to recognise and welcome diversity in the nursing profession. When we see discrimination occurring, we need to speak up as agents for change. These efforts help nursing to move forward as a profession that welcomes and provides opportunities for all. Solutions for Physical Problems Individual should take steps to stop sexual harassment by giving clear, direct verbal messages indicating that the behaviour in question is unwanted, unpleasant and must stop. If clear, direct messages are not successful, the individual then should report the matter in writing to an immediate supervisor. Health care institutions should work with law enforcement professionals when abusive or assaultive behaviour occurs to assure that appropriate action can be taken. Nurses need to seek information about what devices are available to participate knowledgeably in decisions regarding needle system and devices. Designing needles with a protective	plastic housing, needleless intravenous connection and syringes with needle that retracts immediately after use will help in protection from injury. All hospitals should have an infection control officer, usually an RN, who has the expertise to guide the staff in planning appropriate infection - control procedure. Universal precautions have been mandated by OSHA for use with all clients in all settings to protect staff from blood-borne pathogen. OSHA has developed standards that require employers to pay for Hepatitis B immunisation for the employees. The employer is responsible for providing the equipment needed to maintain safety when handling chemical agents. Nurses must take personal responsibility for their own safety regarding these agents. Employers are now required by OSHA to maintain a list of all chemicals used in the work environment, along with information on their possible effects, and the appropriate treatment if individuals are accidentally exposed to them. Nurses should follow the instructions of body mechanics - lifting, transfer, posture and other back saving strategies to prevent back injury. Mechanical lifting devices provide a means of moving clients without danger to staff. Nurses in emergency department may need	additional personal protective equipment for potential exposure to patients with nuclear contamination, chemical toxins, and biological threats. Yearly training on the proper methods of decontamination and use of personal protective equipments such as respirators are essential to make sure that emergency room nurses know how to prevent self contamination. Lastly, nurses need to pay attention to the threat level for terrorist attacks and know what to look for. Hospitals and other Health Care Organisations are believed to be a likely target for attack. References 1. Carol J Huston (2006). Professional Issues in Nursing: Challenges and Opportunities; Philadelphia: Lippincott Williams and Wilkins, A Wolters Kluwer Company, Ch 10 -14; pp 203-263 2. Christmas K (2007). Workplace abuse: finding solutions. Nursing Econ, Nov-Dec; 25(6): pp 365-367 3. Claborn and Zerwekh (2006). Nursing Today-Transition and Trends 5th edn. Missouri: Saunders and Elsevier Publishers, Ch 25; pp 588-600 4. Janice Rider Ellis, Celia Love Hartley (2004). Nursing in Today’s World - Trends, Issues and management, 8th edn. Philadelphia: Lippincott Williams and Wilkins, A Wolters Kluwer Company, Ch 10 -12; pp 433-450 5. Kalpana Sharma (2008). Not born to rule. India Together, 2 August 6. Violence against nurses: The public needs to know this not ok. Oread Daily, 9 July 2008