Which external/environmental factors would the nurse identify as affecting an individual’s safety?

INTRODUCTION

A safe environment is something many of us take for granted. Florence Nightingale highlighted the importance of ensuring that patients were safe when she stated in her instructions to nurses, Notes on Nursing (Nightingale 1860), that nursing should ‘Do the patient no harm’. She also offered advice on the design of hospital wards in an attempt to ensure an optimum environment for hospital patients (Nightingale 1863). Over 140 years later, the Department of Health, in conjunction with the National Patient Safety Agency, has reiterated Florence Nightingale’s ideal, while recognizing that ‘no harm’ may be optimistic. The report An Organisation with a Memory (Department of Health 2000), which was the outcome of an expert group on learning from adverse events in the National Health Service, has become one of the building blocks of safety and risk management in the NHS in the UK. This report was preceded by a US report entitled To Err is Human: Building a Safer Health System (Institute of Medicine 2000), which had a major influence on the development of safety within health care, both in the USA and internationally. However, to view the promotion of a safe environment as simply something nurses can do for their patients is simplistic. This perspective alone fails to recognize the sociological components of maintaining a safe environment, that is the need for patients (and nurses) to be aware of potential threats to health within their personal environments and to behave in a safe manner. Nursing has a responsibility to understand and promote both the concept of maintaining patient safety in care environments and the notion of safe patient behaviour through health promotion.

In some ways, Clinical Governance was merely a renaming and collation of a number of initiatives designed to (directly or indirectly) improve the quality of clinical care in the NHS, such as clinical audit, risk management, continuing professional development, etc. However, it did impose new requirements, which involved the application of far greater structure and rigour to such initiatives than was previously the case. Looking back, more than 10 years on, it is fair to say that clinical quality is higher up the agenda than ever before, though whether this can be attributed primarily to the Clinical Governance initiative as opposed to, for example, wider societal pressure is open to debate.

Although patients have always featured as a prime concern with regard to health and safety, the safety of nurses at work has not always received the same attention. The last century saw many legislative attempts at improving the health of the worker in society, though many people, including health service workers, were not given legal protection while at work until the last decade or so. For many, the establishment of the Health and Safety at Work etc. Act 1974 was the first opportunity for ensuring safe working premises and practices. The NHS became subject to the new law but avoided the need for implementation because of Crown immunity. After well publicized incidents of poor standards, this immunity was finally lifted by the NHS (Amendment) Act 1986.

Today, the provision and maintenance of an optimum environment for both patients and healthcare staff is a major concern. Laws, regulations, local procedures and policies at European, national and local levels offer guidance for safe practice. Nurses have a responsibility to ensure that the workplace is a safe place for themselves and their patients. Some nurses, in particular occupational health nurses and those who represent unions with regard to health and safety, have additional responsibility to ensure that the workplace is a safe place for all employees.

This chapter explores issues in the provision of a safe environment for patients and carers. It presents a broad overview, since other chapters in this book contain sections that focus on specific areas of safety such as handling and moving (see Ch. 6), infection control (see Ch. 5) and medicines (see Ch. 10). Food safety is addressed under nutrition (see Ch. 8) and stress arising from multiple external environmental sources is explored under stress, relaxation and rest (see Ch. 9). The functions and maintenance of the body in dealing with environmental threats are addressed under homeostasis (see Ch. 7).

OVERVIEW

Subject knowledge

The concept of ‘environment’ and the meanings of internal and external environment are explored. Threats to safety that are either part of the natural world or human-made are outlined. In relation to psychosocial knowledge, our interaction with the world around us is considered and there is discussion about the basic human needs for maintaining safety and well-being. Behavioural issues are addressed, with a particular reference to factors that may compromise safety. These factors include theories of risk behaviour and individual and societal non-compliance in maintaining a healthy environment.

Care delivery knowledge

Ways to facilitate an optimum environment for patients are explored in relation to the planning of safe care for the individual as well as the need to minimize hazards in the care environment. Emphasis is placed on risk assessment and on incident and ‘near miss’ reporting and investigating, as the key components of effective risk management.

Professional and ethical knowledge

This section touches on interprofessional team working but addresses in more depth the requirement for nurses to maintain professional and statutory requirements. There is a review of the many external agencies that set standards for the management of risk in the NHS today. Consideration is given to some ethical dilemmas within risk management which may provide a stimulus for further discussion and deliberation.

Personal and reflective knowledge

Throughout the chapter you will be encouraged to apply information reflectively through exercises and by considering examples. In this final section case studies from the four branches of nursing help you reflect further and apply the knowledge you have gained. You may find it helpful to read one of these before you start the chapter and use it as a focus for your reflections while reading.

SUBJECT KNOWLEDGE

BIOLOGICAL

A SAFE ENVIRONMENT

For the purposes of this chapter, the internal environment can be described as the functions and workings of the human body. The body’s ability to maintain a homeostatic (stable) internal environment is essential to well-being (see Ch. 7). The essential consideration of the internal environment in relation to health and safety is concerned with its interaction with the external environment and the effects which may result. The external environment is the world surrounding the human body. In order to function, the human body has essential requirements, which must be met externally. Conversely, the actions of individuals can influence the safety and ambience of the external environment for all who live in it. Both environments are highly dependent upon one another for their own maintenance.

Basic needs of human life

The basic requirements of living are well known. Physiological needs include:

Without these basic needs, higher order psychological needs such as belonging and esteem cannot easily be achieved (Maslow 1970). Over many thousands of years of development, however, an increasingly complicated way for meeting basic needs has developed. This has resulted in our modifying the external environment to suit our needs.

Table 3.1 illustrates how individuals interact within the external environmental system. It demonstrates how components essential for life support are taken from the external environment and how the two environments interact through activities of living. Waste and residues are contributed to the external environment as a by-product of human existence.

Table 3.1 The environmental system (adapted from Purdom & Walton 1971)

Throughout life activities, individuals may find threats to safety, both to and from the external environment. These are also summarized in the categories outlined in Table 3.1.

POTENTIAL HAZARDS IN MEETING BASIC REQUIREMENTS FOR LIVING

Air

The air that we breathe usually contains 21% oxygen and 78% nitrogen, with the other 1% being made up of trace gases such as carbon dioxide, xenon and neon. If the oxygen concentration were to drop below 16%, anoxia would develop resulting in effects on the brain and other body functions. If the oxygen level decreased further to 6%, life could not be sustained and immediate loss of consciousness results from exposure to a zero oxygen atmosphere.

Air can also act as a vehicle for microorganisms, allergens, waste gases and dust, all of which enter the body via the lungs (Harrington & Gill 1992). These pollutants may cause damage or illness if present in sufficient quantity or if an individual develops an allergic response to them. Air quality is particularly compromised in large urban areas when the temperature rises and there is little wind movement. Threats to health have been acknowledged in the increasing rates of respiratory disease, especially in young children (Brunekreef et al., 1997, Clancy et al., 2002 and Karol, 2002). There is evidence to suggest that children exposed to lead in exhaust fumes arising from the increased use of the car in our society have exhibited symptoms (such as decreased intelligence) consistent with the expected neurological sequelae identified in those with high levels of lead exposure via other sources such as contaminated drinking water (Maas et al 2002).

Water

In developing countries and in areas affected by war or disaster the greatest risk to the population may be contamination of the drinking water, resulting in life-threatening infections such as cholera and amoebic dysentery. In developed countries, most residents have access to water purification systems that have been in place for many decades (Ineichen 1993). Preoccupation with contamination of water supplies among the wealthier population in the UK has spawned a large water bottling industry. This development in the provision of water for drinking, however, is not without problems, as it is not suitable for everyone. Small babies cannot physically manage the increased mineral content found in many bottled waters due to renal immaturity. Care is required in educating parents about the provision of water for consumption by infants and young children.

In nursing, there are occasions when water must be sterile. This is especially important when water is being used for the preparation of feeds for those who are immunosuppressed as a result of illness. Infants require sterile feeds because they have not developed resistance to infective organisms. Sterile water is also essential where water is used to irrigate wounds or in the preparation of medication via infusion, to protect patients from absorbing harmful contaminants.

Food

For dietary provision to be considered safe, it must be free from contaminants such as harmful bacteria (e.g. Salmonella, Escherichia coli) or diseases (e.g. bovine spongiform encephalopathy) (Irani & Johnson 2003) which may be passed to humans. Additionally, food should be in adequate supply, and this is not always the case in the developing world or in some instances in developed countries such as the UK. Within nursing, providing adequate nutrition for clients is important to promote healing and recovery. Health promotion is also important to prevent malnutrition and obesity.

Decision-making exercise

What information about ‘sterile’ feed preparation would you need to offer Julie, a new mother, who wishes to bottle-feed her baby?

• How would she ensure that the feeding implements are sterile?

• How would she ensure that the water she is using is safe for her baby?

• Where would you obtain information to give to Julie?

Although the main impact of nutrition on health is discussed in greater detail in Chapter 8, it is important to recognize that modern systems for developing food sources need to be monitored closely. Contamination of food at any stage in the external food chain processing will be a potential threat to the well-being of the internal environment.

Shelter

Shelter is essential for survival, providing protection from excessive heat and cold, from the weather and from other environmental hazards. However, shelter should be safe for the resident and should not itself be contributory to disease. These two aspects are surprisingly difficult to achieve within the home and institutional setting.

Evidence-based practice

Poor housing has been linked to poor health. Specifically, Howden-Chapman et al (2007) showed that insulating existing houses led to a significantly warmer, drier environments, resulting in improved self-rated health, reduced self-reported wheezing, days off school and work, and visits to general practitioners as well as a trend for fewer hospital admissions for respiratory conditions. On a more general note, the World Health Organization’s Regional Office for Europe has undertaken a large study to evaluate housing and health in seven European cities. Survey tools were used to obtain information about housing and living conditions, health perception, and health status from a representative sample of city populations. Preliminary results reported in 2003 revealed important potential links between housing and health (Bonnefoy et al 2003). The completed study will likely generate recommendations about mental health and housing; poverty, housing, and health; noise and health; allergies and housing; perceptions of housing conditions and associated perceptions of health; and immediate-environment conditions and health status.

Care institutions are often work settings and there is an increasing interest in how the design of individual workplace buildings can have an effect on the health of the individual workers within the building (Raw & Goldman 1996). Sick building syndrome (SBS) has been linked to a group of symptoms developed by people in certain buildings, notably office blocks. Symptoms of SBS include physical and behavioural problems such as irritation of the eyes, nose, throat and skin, headaches, lethargy and lack of concentration. Features of the buildings that appear to cause problems are associated with air conditioning systems, office layouts, windows and light, furnishings and decorations (Raw & Goldman 1996).

ENVIRONMENTAL HAZARDS

Biological hazards

Biological hazards are concerned primarily with the entry of disease-producing infectious agents into the body, thus causing a risk to the stability of the internal environment. Such organisms include bacteria, viruses and fungi as well as parasites, which may additionally carry harmful pathogens.

Chemical hazards

Chemical hazards are not new: the gaining of knowledge by our predecessors into which plants were safe to eat and which liquids were safe to drink must have been fraught and littered with many accidents. Even though our ancestors may not have known the finer physiological details of any particular poison, they would have learnt to avoid it. Chemical agents may be synthetic or derived from natural substances and can affect the internal or the external environment beneficially or detrimentally. The most important consideration related to chemical hazards is regarding knowledge about the substance and the judicious application of this knowledge in using chemical substances safely and effectively. It is important to consider the impact of improper use or exposure to substances by patients.

Landrigan & Garg (2002) describe the potential chronic effects of toxic environmental exposure on children’s health. Children have unusual patterns of exposure to environmental chemicals, and they have vulnerabilities that are quite distinct from those of adults. Increasingly, children’s exposure to chemicals in the environment is understood to contribute to the causation and exacerbation of certain chronic, disabling diseases in children including asthma, cancer, birth defects and neurobehavioral dysfunction. The protection of children against environmental toxins is a major challenge to modern society (Landrigan & Garg 2002). There is also a nursing role in the management and education of the public in maintaining a safe home environment for themselves and their families.

Physical hazards

Physical hazards are all around us and may cause disease, disability or fatality, and are manifest in many different ways. Certain dusts can be dangerous to the internal environment if they are inhaled and then absorbed, while other powders can be used therapeutically in the form of inhalers. Temperature in the external environment can also be a physical hazard. Extreme external temperatures can lead to a loss of the internal homeostatic balance (see Ch. 7). Contact with an extreme hot or cold source can cause extensive physical damage (burning) and, potentially, death.

Electromagnetic radiation, which includes X-rays, ultraviolet and infrared light and microwaves, can cause skin burns, an elevation in temperature and fatality with prolonged exposure. Understanding the dangers related to uncontrolled exposure to these radiations is vital for nurses since controlled ionizing radiation such as X-rays and gamma rays can also be used beneficially to produce radiographic pictures and in the treatment of neoplastic disease (cancer).

Human inventions such as equipment and machinery can cause accidents as well as offering intended benefits. Modern machinery, including all nursing equipment, is continually being made safer as it is evaluated through use. Equipment that is used inappropriately or without regard to the manufacturer’s instructions may provide a hazard to safety, even if it is functioning correctly technically. In the community, everyday machinery such as motor vehicles, drills or gardening equipment can be dangerous if not used appropriately.

Accidents

Some accidents can be prevented if carers are aware of hazards and can offer health and safety education. Patients need to clearly understand the outcomes of risky behaviour and the implications that may arise. This requires imaginative education for the most vulnerable groups, to communicate information in a way that can be easily understood and accepted.

PSYCHOSOCIAL

PSYCHOLOGICAL AND SOCIAL HAZARDS

Psychological and social hazards are closely linked to human interactions with the environment. The next section explores the influence of psychosocial factors in the promotion of a safe and healthy environment.

There are many ways in which individuals strive to understand risks in their daily lives and many factors influencing how they may act in the light of such perceptions (Bloor 1995). Fallowfield (1990) suggests that quality of life, and therefore ultimately perceived health and well-being, is directly related to the quality of the environment in which life exists. The environment must also satisfy physiological, psychological and sociological needs. Fallowfield (1990) further identifies four areas where the perception of life quality is paramount:

• psychological – related to the perception of mental well-being

• social – related to involvement in social activities

• occupational – related to functional ability to achieve work (paid or voluntary)

• physical – related to pain, comfort, sleep, physical ability.

These areas are useful for exploring factors associated with determining life quality. However, it should be remembered that the way you view something may be very different from the way another person perceives it. Culture, social class, gender, age, level of education and emotional state should be acknowledged. Toxic effects from drugs and general level of health are also important. Finally, there may be differences in the perception of priorities between patients and their carers. A knowledge of these differences can be critical in facilitating the provision of appropriate care.

PSYCHOLOGICAL STRESS

Stress can alter an individual’s perceived environment, which can ultimately become hazardous. The main issues associated with psychological stress and its effects on the internal environment are addressed elsewhere (see Ch. 9). However, it is important to consider how the effects of stress on an individual can impact on his or her immediate external environment.

RISK PERCEPTION

Risk perception is different from the knowledge of a danger, as it does not necessarily cause people to worry. Risk perception may result from the personal orientations that guide an individual to make commitments consistent with one specific political culture and inconsistent with others. At the same time cultures may select those individuals who support their way of life. Individuals may choose what to fear in supporting their preferred way of life (Royal Society Study Group 1992). For example, a religious sect propounding a particular set of beliefs may attract new members who are sympathetic to the views of that sect. Gabe (1995) identifies that in this sense risk cannot be objectively ‘measured’, but must be viewed as a social construct. This draws from the original anthropological work by Douglas (1966), which addressed questions about why different cultures select different risks for particular attention using beliefs to rationalize behaviour. Given that such interpretations of risk perception are valid, then points of cultural difference are extremely important in nursing. If a patient has different social expectations and selects different risks from the nurse’s social expectation then a true assessment could be difficult and treatment could fail to meet the expectations of both parties. There may even be open conflict between the patient and health professional. For instance, Jehovah’s Witnesses can present a challenge because they may refuse to receive blood transfusions. Where patients are severely ill and unable to give informed consent to treatment or where children require urgent blood transfusion, nurses may then face moral dilemmas in respecting the cultural beliefs of such individuals while acting in their best interest to maintain their safety.

Within the hospital setting most patients are away from their known environment and are therefore unable to perceive risks in what amounts to an ‘alien’ environment. It is the responsibility of the nurse to ensure that individuals are aware of hazards wherever possible and are protected by either their own action or action on their behalf by the nurse. The nurse’s role is to ensure the safety of the environment by assessing the potential risks and facilitating action for change.

Risk – the possibility of injury or loss – must be in the minds of all who deliver health care, in every clinical episode and in the planning of all healthcare delivery. The roots of risk management lie in risk assessment and implementation of ensuing preventative action and in the reporting, analysis, investigation and prevention-planning of incidents. Therefore, there are two aspects to risk management: one is forward looking, trying to identify issues and circumstances with the potential to go wrong, and act before they do go wrong. The other is backward looking, trying to learn from incidents by thoroughly investigating the causes and aiming to prevent recurrence.

A key principle in both the To Err is Human and the Organisation with a Memory reports was that when things do go wrong, the most likely and accurate underlying causes are related to ‘systems failures’ rather than the failures of individuals. It is of course possible that incidents where safety has been compromised are due to reckless or thoughtless actions by individuals, but evidence from research into ‘human factors’ (the study of all aspects of the way humans relate to the world around them) predominantly points to individuals being as much victims of failings within the design of systems and processes than the causes of such failings. The National Patient Safety Agency (NPSA) in the UK, which was established as a result of the Organisation with a Memory report, promotes the principle of systems failures being at the heart of most incidents in much of its work.

PSYCHOSOCIAL HAZARDS IN THE WORK ENVIRONMENT

So far, there has been an emphasis upon individual responsibility within personal environments, with some discussion about people’s behaviour when interacting within the healthcare environment. It is, however, important to recognize that the organization has influence in creating a healthy environment. According to Cox & Griffiths (1996: 128) a ‘safe’ environment might be relatively easy to define, but perceptions of a ‘healthy’ work environment are usually narrowly focused on physical threats to health. These authors argue that healthy work can be defined as ‘work that does not threaten but which helps maintain and enhance physical, psychological and social well-being’.

A ‘hazard’ has been defined as an event or situation that has the potential to cause harm (Cox & Griffiths 1996). Besides physical hazards referred to in the previous section, the International Labour Organization (1986) has defined psychosocial hazards arising from interactions between job content, work, organizational, management and environmental conditions, and the employee’s competencies and needs. Those interactions that can be defined as hazardous influence the health of employees through their ‘perceptions’ and ‘experiences’ of these conditions (International Labour Organization, 1986 and Cox et al., 1995). Exposure to psychosocial hazards in particular is often chronic and cumulative, except when a particular acute, traumatic incident occurs. Table 3.2 outlines the common psychosocial hazards associated with the work environment and the conditions that define the potential level of hazard for the individual employee.

Table 3.2 Psychosocial hazards in the work environment (from Cox & Griffiths 1996)

The synergistic nature of the physical and psychosocial hazard in the work environment is also important. Interactions can occur between the different types of hazard and their consequent effects on the health of the individual (Levi 1984). Stress in the workplace, from whatever cause, may inadvertently lead to risk taking behaviour by the individual worker.

MANAGEMENT OF HAZARDS AND DANGERS

When dealing with safety issues in the workplace environment, there have been three common approaches (Landy 1989):

1 The ‘engineering’ approach assumes that by modifying the environment or the equipment used, safety can be enhanced and accident rates reduced. Modifying the environment should include both physical and psychosocial factors.

2 In the ‘person psychology’ approach the psychologist attempts to identify particular individual characteristics that might lead a worker to be more accident-prone or to take risks. Within this particular approach the focus is on training programmes that will highlight individual behaviour and attempt to influence change in unsafe behaviour.

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