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OSHA 366 Portland State University Behavior Based Safety Discussion

Program Development
Improvement opportunities in hospital safety
By Don Nielsen and John Austin
FEW WORKPLACES ARE AS COMPLEX as hospitals. Not only do hospitals provide a multitude of
patient care services, they also require many support
services. Hospitals in the U.S. employ more than four
million workers—or about 3.4 percent of the total
U.S. workforce (USDoL). These workers are exposed
to a wide range of potential safety hazards In direct
patient care departments and support services
departments. The annual rate of injury among hospital workers is 7.7 per 100 full-time employees (BLS).
The leading causes of injury in these settings are
overextension, falls, contact with objects, exposure to
harmful solutions and environmental hazards.
Many hospitals have developed general (and in
some cases specific) guidelines for preventing accidents and injuries, but these guidelines typically do
not require employees to demonstrate mastery of safe
behavior. Behavioral approaches to safety have shown
substantial improvement of specific safe behaviors in
various settings, but few behavior-based research
studies have been conducted in hospital facilities; this
suggests an opportunity for additional investigation
and application. This article identifies potential causes
of injuries and offers some suggestions for reducing
injuries using behavioral approaches.
The Hospital Setting
Hospital medical staff provide patient care
around the clock. Their services range from emergency procedures to scheduled activities, from fairly
routine tasks to complex procedures. Some patients
display difficult and even combative behaviors,
which can hinder the provision of these services.
Further complicating the picture are severe staff
shortages being reported by hospitals nationwide.
Examination of hospital safety history reveals
several national efforts to address hospital employee
safety and health problems. In 1958, a report by the
American Medical Assn. and American Hospital
Assn. identified the basic elements of occupational
health for hospital workers (AMA). In addition, the
groups reported that hospitals should serve as examples of job safety. In June 1972, NIOSH complet-
ed a survey of health programs and services for hospital workers. The survey identified three key deficiencies in U.S. hospitals.
1) Only half of the hospitals had regular employee safety and health education programs.
2) Ordy 39 percent had employee immunization
programs for infectious disease control.
3) Only 18 percent of the hospitals trained employees about potential hazards and at-risk activities
Currently, protection of hospital workers is accomplished through a hodgepodge of approaches. Hospitals are regulated or accredited by various local,
state and federal government agencies such as local
zoning boards, state health departments, state licensing boards. Joint Commission on Accreditation of
Healthcare Organizations, American Osteopathic
Assn., OSHA, U.S. Nuclear Regulatory Commission,
Food and Drug Administration and
Federal Aviation Administration. As a Don Nielsen, M.A., is a researcher
result, no single set of safety and health in the fields of behavioral safety and
regulations is applied to hospitals and performance management who is
their employees [NIOSH(a)]. Some man- pursuing a Ph.D. at Western Michigan
datory standards, such as the Needle University (WMU). He holds a B.A. in
Stick Safety and Prevention Act, require Psychology from Winona State
hospitals to identify and make use of University, as well as an M.A. in
safer medical devices (Pugliese and Counseling Psychology and an M.S.
Bartley 30). However, hospital employee in Behavior Analysis, both from WMU.
safety programs have primarily been John Austin, Ph.D., is an associate
developed using information from professor of psychology at WMU,
NIOSH and the Centers for Disease where he teaches courses in
Control and Prevention [CDC(a); (b)].
performance management and
Patient care involves a broad spec- consults with businesses on behavioral
trum of services—delivered by various safety and performance improvement
departments—designed to maximize a systems. He has a B.A. from the
patient’s health and recovery. These University of Notre Dame and an
departments include surgery, intensive M.S. and Ph.D. from Florida State
care, acute care, nursing, radiology and University. Austin is co-editor of the
laboratory. Potential hazards to work- Journal of Organizational Behavior
ers in these areas include radiation Management, an editorial board
exposure, needlesticks, and exposure to member of the Journal of Applied
chemicals and hazardous bodily fluids. Behavior Analysis and director
Hospital support services include of the OBM Network. FEBRUARY 2005 PROFESSIONAL SAFETY 33
complete a specific task, with the expectation that they will continue to execute the
task in that manner when unsupervised.
Typically, these training programs do not
require employees to demonstrate mastery
of the specific task being trained.
Hospital Rate
Training (called performance-based
instruction) is most effective when carried
out in three phases: guided observation,
guided practice and demonstration of
Contact with Objects
mastery (Brethower and Smalley). Guided
Harmful Substances/Environments 0.15
observation uses examples or demonstrations that show why something is done,
Source: BLS.
what is accomplished and how. Through
guided practice, leamers practice processmaintenance, housekeeping and food services. es that produce specific results and receive feedback
Workers in these departments face exposure to sol- while they do so. Demonstration of mastery requires
vents, mechanical malfunctions, steam bums and elec- employees to show that they can perform these tasks
trical hazards. Housekeeping employees are exposed and generate the products/services accomplished
to various solvents and disinfectants that may result in by their work. Instead of using aU three steps, hospirashes or irritation. They are also exposed to hepatitis tal training programs typically include only one
and other diseases from hypodermic needles that step—guided observation. In the authors’ experihave not been properly discarded. Food service work- ence, this often entails only discussion of or modelers face potential cuts from sharp kitchen objects, ing how to accomplish a task.
bums from hot surfaces and falls on sHppery floors.
Hospital workers are similar to workers in other
AO hospital workers face common risks and hazards
such as strain and overextension, slips, trips and falls, settings in that many likely engage in at-risk behavior
potential contact with used needles and exposure to in part because such behe /ior may be easier and may
save time. In general, risk taking is rarely punished
hazardous bodily fluids.
and is often rewarded with convenience (Geller 115).
The annual rate of injury among hospital workers Hospital safety programs, like those in other work
is 7.7 per 100 full-time employees (FTEs) (BLS). The settings, typically focus on the outcomes of unsafe
leading causes of injury are overextension (often practices rather than on safe practices. Other efforts
resulting in back injury), sUps/trips/faUs, contact have focused on identifying factors that correlate with
with objects, exposure to harmful solutions and occupational safety, such as personality characterisenvironmental hazards such as exposure to conta- tics assumed to be associated with injury (Grindle, et
gious diseases. Table 1 displays the incidence rate al 29-68). As a result, it is difficult to pinpoint the speper 100 equivalent FTEs for these leading causes cific behaviors needed to improve safety and reduce
(BLS). Treatment typically ranges from minor first injuries in these settings. Therefore, hospitals need to
aid to major medical treatment with possible chron- develop safe environments and nurture safe worker
ic disabling conditions or even death.
behavior rather than merely respond to injuries.
Typical hospital safety programs feature several Many hospitals need a safety process that focuses on
elements: 1) enlistment of administrative support; the safe behavior of hospital employees, requires
2) hazard identification; 3) periodic inspection and employees to demonstrate mastery of safe behavior
monitoring of safety and industrial hygiene; 4) infor- and helps maintain safe behavior.
mal interviews of workers; and 5) environmental
evaluation [NIOSH(a)]. Administrative support
helps ensure that all departments are involved in Behavioral Approaches
safety. Hazards are identified via walkthrough to Safety Improvement
inspections and from information gleaned from
Studies conducted using a behavioral approach to
MSDS. Periodic inspection and monitoring is gener- safety—applying the principles of applied behavior
ally conducted by the many regulatory agencies that analysis—have reported improvement of specific safe
oversee hospitals. Informal interviews of workers behaviors and reduced injury occurrence. In a metaand environmental evaluations usually focus on analysis of 73 applications in varying industries, one
problems once they have occurred.
study reported a 20 to 25 percent year-over-year
The types and rates of occurrence of hospital work- decrease in injuries for the first five years after impleer injuries have been identified at the national level menting a behavioral approach to safety (BCrause, et al
through the collection of work-related injuries and iU- 1-18). A literature review by Sulzer-Azaroff and
nesses data for OSHA. As a result, hospitals have Austin found that 32 of 33 behavioral safety studies
developed guidelines to prevent accidents and resulted in substantial decreases in injury rates (21).
injuries. However, based on the authors’ experience in
In a classic example of the behavioral approach to
more than one hospital, safety training for hospital occupational safety, behaviorally defined and reinworkers often involves a “show and go” approach— forced safe practices resulted in occupational injury
that is, workers are shown an appropriate method to reduction (Komaki, et al 434-445). This investigation
Incident Rate per 1OO FTEs
provided workers with information and practice on
how to discriminate between particular safe and
unsafe behavior related to injury, graphs depicting
results of the safe behavior and verbal feedback from
supervisors. These activities resulted in a substantial
and immediate increase in safe behavior. When the
behavioral program was discontinued, safety behavior returned to preintervention levels.
A behavioral approach to safety has been used in
various other occupational settings as well: with roofing crews (Austin, et al 49-75); in a paper miU (Fellner
and Sulzer-Azaroff 3-24); in a soft drink bottling facility (WilUams and Geller 135-142); with delivery drivers (Ludwig and Geller 253-261); in an electronics
components facility (Streff, et al 3-14); in an open-pit
mine (Fox, et al 215-224); in a residential facility for
persons with developmental disabilities (Alavosius
and Sulzer-Azaroff 151-162); and in a hospital emergency room (DeVries, et al 705-711).
A review of the literature revealed that few behavior-based research studies have been conducted in
hospitals. A handful of studies have been completed
in healthcare-related settings (e.g., Babcock, et al;
DeVries, et al; GeUer, et al; Mayer, et al). Because of
the limited research in this area, this appears to be an
opportunity for additional investigation and application. Using a behavioral approach to increase safe
behaviors and reduce injury among hospital workers
would likely enhance the quality of life for these
workers. It would also likely result in fewer lost
workdays and would save time and money—^both
for workers and the hospitals that employ them.
Areas of Opportunity
To improve hospital safety, practitioners must
focus on behaviors that lead to the common injuries
incurred by hospital workers—overextension, slips,
needlesticks and contact with bodily fluids.
Within the category of overextension, back strain
is the most frequently reported injury and accounts
for approximately half of all reported injuries and
illnesses in the healthcare industry (BLS). Back
injury causes include a) task performance by a worker who is unfit or unaccustomed to the task; b) postural stress; and c) work that approaches the limit of
a worker’s strengths [NIOSH(a)]. Specific causes
among hospital workers include assisting or lifting
patients, raising or lowering beds, lifting or moving
heavy objects, and pushing or pulling carts. NIOSH
recommends that programs designed to prevent
back injury contain the following elements:
•use of mechanical devices to lift patients;
•use of wheels and other devices to move heavy
•adequate staffing to prevent workers from lifting heavy patients or equipment alone;
•education and close supervision to ensure proper lifting or moving [NIOSH(a)].
Hospital workers also need to gain competency in
specific safe behaviors. Providing employees with
written instructions alone generally results in short-
lived improvements (Shook, et al 206-215).
Therefore, building behavioral competency in addition to providing information to
employees is critical.
Individualized feedback has been used
to build behavioral competency among
healthcare workers (Alavosius and SulzerAzaroff 151-162). That study was designed
to establish safe behaviors associated with
patient transfer or positioning. Participants
first received instructions on how to execute the behaviors properly, then received
either densely scheduled (many times each
day) or intermittently scheduled (a couple
of times each week) feedback about their
lifting performance. Under both schedules,
feedback continued until participants had
demonstrated mastery of the behavior.
Dense feedback allowed participants to
master the target behavior within two or
three workdays. Those who received inter- ffl(l§f;Qyl
mittent feedback took longer to demon^

strate mastery. However, both approaches
resulted in similar patterns of behavior
change maintenance.
Practitioners interested in improving
proper lifting, patient transfer and/or
positioning could use techniques similar
to those used in the Alavosius and Sulzer-Azaroff
study. Practitioners could:
1) Identify and create a checklist of observable
actions that must occur, including an explanation of
why they need to occur for employees to avoid
overextension and/or back injuries.
2) Observe (or have employees self-monitor) and
accurately record these actions during actual work
3) Make sure employees understand and can
demonstrate the safe actions specified on the checklist, then deliver frequent supportive and guidance
feedback to employees immediately after they complete work activities.
Many organizations will benefit from training
employees to conduct observation and feedback sessions with coworkers. Clearly, delivering feedback
involves an elaborate set of skills and this fact should
not be ignored. However, how to deliver effective
feedback is beyond the scope of this article.
safety training
programs for
hospital workers
use a ”show
and go”
and do not
require employees
to demonstrate
specific task
heing trained.
SWps, Trips & Falls
Slips, trips and falls in hospital settings are generally the result of hazards such as wet floors, stairway
and hallway obstructions, or faulty ladders. This
category is the second-leading cause of injury
among hospital workers. Preventive measures
might include housekeeping procedures to keep
floors dry, keep halls and stairways clear, provide
good lighting in halls and stairways, and use ladders
properly [NIOSH(a)]. Practitioners seeking to remedy sUps, trips and falls would, for example:
1) identify and create a checklist of safe environmental conditions that would reduce or eliminate
slips, trips and falls. FEBRUARY 2005 PROFESSIONAL SAFETY
at the global
level the
appear the
same, at the
level, each
must be
2) Observe (or have employees selfmonitor) and accurately record these conditions in all work areas.
3) Make sure workers and supervisors
understand and can produce the safe working conditions specified on the checklist,
then deliver frequent feedback to employees and supervisors immediately after they
establish safe working conditions.
Systems support is one issue to address
when considering these conditions. Before
behavior can change, the relevant equipment, processes and other systems must be
in place to enable safe behavior. Expecting
people to behave safely when appropriate
systems are not in place could produce
frustration and failure.
Needlesticks generally affect direct care
and housekeeping employees. Reports
suggest that healthcare workers suffer
between 600,000 and 800,000 needlestick
injuries each year in the U.S. (Baran 66).
Hospital workers incur about 30 needlesticks per 100 hospital beds per year
(EPINet). Needlesticks generally occur as
a result of uncapped needles during
preadministration, puncture during patient administration or puncture during needle disposal.
Approximately 38 percent of needlesticks occur during use and 42 percent occur after use and before disposal [CDC(a) 21-25]. Engineering controls have
been the primary method of minimizing employee
exposure to these injuries (Pugliese and Bartley 26).
Engineering approaches eliminate the use of needles
where alternatives are available and have resulted in
the use of safer needle devices as well [NIOSH(c)].
A behavioral approach would target the safe use
and disposal of needles. Practitioners interested in
addressing this area could:
1) Create a checklist of observable actions that
must occur for the safe handling of needles during
preadministration, recapping, passing and transferring needles, needle disposal and use of safety
equipment where appropriate.
2) Observe (or have employees self-monitor) and
accurately record these actions during actual work
3) Make sure employees understand and can
demonstrate the safe actions specified on the checklist, then deliver frequent supportive and guidance
feedback to employees immediately after they complete work activities.
Contact with Bodily Fluids
Contact with potentially dangerous bodily fluids
is generally the result of contact with blood and
blood products, other bodily fluids or tissue.
Potential consequences of contact with contaminated bodily fluids include exposure to hepatitis C
virus, human immunodeficiency virus and hepatitis
B virus [NIOSH(a); (c)]. In 1983, CDC identified a set
of universal precautions. Revised in 1987, these standard precautions serve as guidelines to help healthcare workers avoid contact with potentially
dangerous bodily fluids [CDC(b)].
Hospitals typically have specific programs that
identify three categories of potential exposure:
1) tasks that involve exposure to blood, bodily fluids
or tissues; 2) tasks that involve no exposure to blood,
bodily fluids or tissue, but may require performing
implanned category one tasks; and 3) tasks that
involve no exposure to blood, bodily fluids or tissue
and category one tasks are not a condition of
employment [NIOSH(a); (c)]. Efforts to reduce exposure in this area focus on educating healthcare workers about the danger of contact and the proper use of
PPE. Specific PPE use is generally tailored to the task
at hand. For example, protection for category one
tasks would include the use of appropriate gloves;
for situations where splashes may occur, protective
eyewear or faceshields would be worn.
A behavioral study used a feedback intervention
to increase glove wearing by nurses in a hospital
emergency department (DeVries, et al 705-711).
Using a multiple baseline design to evaluate the
effects across four participants, a substantial increase
in glove wearing was observed for situations in
which contact with fluids was probable. The potentially hazardous situations were cleaning instruments, cleaning a laceration, giving an injection,
phlebotomy, inserting a catheter, and obtaining or
transporting specimens. Staff nurses received individual feedback to inform them of the percentage of
contact opportunities in which they wore gloves.
In a similar study, a feedback intervention was
implemented to increase the frequency of nurses
giving feedback to nursing assistants about increasing glove use to avoid contact with bodily fluids in a
head-injury treatment center (Babcock, et al 621627). The authors reported an increase in both the
feedback provided to nursing assistants and in glove
use by these employees. Practitioners wishing to use
similar techniques could:
1) Identify and create a checklist of observable
actions that must occur for employees to avoid contact with potentially harmful body fluids.
2) Observe (or have employees self-monitor) and
accurately record these actions during actual work
3) Make sure employees understand and can
demonstrate the safe actions specified on the checklist, then deliver frequent supportive and guidance
feedback to employees immediately after they complete work activities.
Customize at the Implementation Level
Although these behavioral solutions to common
injuries in hospitals may look the same, in reality each
situation is different. (Zertainly, each of these safety
efforts would incorporate data coUection, feedback
and praise. However, in each case, the practitioner wiU
be monitoring different activities. Thus, although the
solutions at the global level appear the same, at the
implementation level, each safety intervention must
CDC(b). “Update: Universal Precautions for Preventing of
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Daniels, A.C. Performance Improvement: Improving Quality and
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be customized. Exactly which behaviors are measured, how often and the logistics of that measurement
will differ dramatically in each case. Acceptable formats for feedback, posting of feedback and frequency
of feedback will vary based on work characteristics.
Furthermore, how employees talk to each other when
delivering praise will differ in each work culture and,
therefore, must be customized in each setting. FEBRUARY 2005 PROFESSIONAL SAFETY
For this week, I choose Confined Spaces. I am familiar with confined spaces, have gone through several
trainings and have even developed a few confined space programs for some of my facilities. Without
knowledge, the average person could look at an area and think that it is safe to enter into that area. For
example, industrial ovens, most people would think that as long as they are not turned on, they are safe.
However, it is not just the heat that is a danger to a person. You have to take air readings to make sure
that there is no gas present, you have to take temperature readings to make sure it’s cool enough to enter
the space. Also, we have an added danger because of chemical vapors inside of the oven, so we only
allow our employees 15 minutes of entry time, and we have meters used to measure air quality. We have
an entrant monitor who completes paperwork on when the employees enter when they leave, air quality
readings, and we have the gas sources locked out. My advice is if you’re in an industrial setting, and
you’re not familiar with a room or area complete a confined space assessment.
I have linked an article about a man that was trapped and killed inside an oven, there were several
failures, but if they would have had the oven locked out and a confined space program then the employee
would be alive today. I have employees that work inside of ovens, and there are areas where they can
climb into and you can’t see them and a person could assume that the oven is clear, but that is why we
have so many safety steps in place, to prevent that from happening.
This week’s article I have chosen to write about is Behavior-Based Safety: Improvement opportunities in
hospital safety. First, I would like to say that I respect Safety Professionals who work in hospitals because
it would seem they must manage nearly every form of safety hazard. I chose to read this article because I
have been having difficulty differentiating behavior-based safety from well established training. Even after
reading this article to me behavior-based safety seems to be a subset of well-established safety training.
The primary idea of behavior-based safety I pulled from this article is to identify, observe, and verify the
desired behavioral performance. The article suggested to make a checklist of observable tasks to be
performed to avoid injury. This list then should be used to observe and accurately record the workers
performance. After observation feedback should be discussed with the worker to verify that they
understand where they need to improve. These steps should be repeated until the worker adequately
displays the desired safety behaviors. A system should also be in place to periodically verify retention to
ensure continued competence.
For this week’s discussion, I decided to chose the article Behavior-Based Safety. The article explains how
to discriminate based on safe and unsafe behaviors and feedback from supervisors. The idea is the
relationship between administrative and other works to make sure all workers are working safely. This
article focuses on the health care setting but also mentions other occupational settings, such as roofingcrews and paper mills. The whole point is to improve safety, so it’s important for administrative to
understand behaviors that lead to common injuries in the work place. When I worked as a nurse while in
the program at my local college, before I realized nursing wasn’t for me, the lifting and needle sticking
was a big thing at the hospital I worked at. Often times nurses would injure their back by practicing unsafe
lifting, and needle-sticking was something I was concerned about because it’s so easy to do if you don’t
take your time. It’s important to use these behavioral approaches by administration to remain safe.

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