occupational injuries among aides and nurses in acute care

AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 52:953–964 (2009)

Occupational Injuries Among Aides andNurses in Acute Care

R.L. Rodrı́guez-Acosta, PhD,1,2 D.B. Richardson, PhD,1 H.J. Lipscomb, PhD,2�

J.C. Chen, PhD,1 J.M. Dement, PhD, CIH,2 D.J. Myers, ScD,2 and D.P. Loomis, PhD3

Background Occupational injuries are common among nursing personnel. Most epidemio-logic research on nursing aides comes from long-term care settings. Reports from acute caresettings often combine data on nurses and aides even though their job requirements andpersonal characteristics are quite different. Our objective was to assess risk of work-relatedinjuries in an acute care setting while contrasting injuries of aides and nurses.Methods A retrospective cohort of aides (n¼ 1,689) and nurses (n¼ 5,082) working in acutecare at a large healthcare system between 1997 and 2004 were identified via personnel records.Workers’ compensation filings were used to ascertain occupational injuries. Poissonregression was used to estimate rate ratios (RR) and 95% confidence intervals (95% CI).Results Aides had higher overall injury rates than nurses for no-lost work time (RR¼ 1.2,95% CI: 1.1–1.3) and lost work time (RR¼ 2.8, 95% CI: 2.1–3.8) injuries. The risk of aninjury due to lifting was greater among aides compared to nurses for both non-lost work timeand lost work time injuries. Injury rates among aides were particularly high in rehabilitationand orthopedics units. Most of the injuries requiring time away from work for both groups wererelated to the process of delivering direct patient care.Conclusions Our findings illustrate the importance of evaluating work-relatedinjuries separately for aides and nurses, given differences in injury risk profiles and injuryoutcomes. It is particularly important that occupational safety needs of aides be addressedas this occupation experiences significant job growth. Am. J. Ind. Med. 52:953–964,2009. � 2009 Wiley-Liss, Inc.

KEY WORDS: nurse’s aides; occupational injuries; acute care setting; healthcareworkers; injury risk

INTRODUCTION

Registered nurses and nursing aides are two of the

leading occupations in the United States, not only in the

healthcare industry but also across all industries [Jones,

2001]. Injuries are common among these workers and

their occupational injury rate is higher than in many

other occupational groups [US Bureau of Labor Statistics,

2007a]. Despite evidence suggesting that aides are at

increased risk of being injured at work compared to other

US healthcare workers, in research studies they are often

� 2009Wiley-Liss, Inc.

Contract grant sponsor: National Institute for Occupational Safety and Health; Contractgrant number: 3 R01OH008375-02S1.

*Correspondence to: H.J. Lipscomb, Division of Occupational and EnvironmentalMedicine, Department of Community and Family Medicine, Duke University Medical Center,2200West Main Street, Suite 400, Durham, NC 27705. E-mail: [email protected]

Accepted 3 September 2009DOI10.1002/ajim.20762. Published online inWiley InterScience

(www.interscience.wiley.com)

1Department of Epidemiology, School of Public Health,University of North Carolina at Cha-pel Hill, Chapel Hill, North Carolina

2Division of Occupational and Environmental Medicine, Department of Community andFamily Medicine, Duke University Medical Center, Durham, North Carolina

3Department of Environmental Sciences, School of Public Health, University of Nevada,Reno, Nevada

Currently with the Centers for Disease Control and Prevention, National Center for Zoono-tic,Vector-Borne, and Enteric Diseases, Division of Vector-Borne Infectious Diseases - Den-gue Branch, San Juan, PR 00920. At the time of data analyses, Dr. Rodriguez was a doctoralcandidate at the UNC School of Public Health and a research analyst at Duke UniversityMedical Center.

combined with the nurses. Particularly in acute care, research

in the US has largely focused on comparisons of injury

experiences among different types of nurses (e.g., registered

nurses vs. licensed practical nurses). In other instances, the

word ‘‘nurse’’ refers to a combination of RNs, licensed

vocational nurses, nurses, orderlies, and technicians [Seago,

2000]. Currently, limited research is available that specifi-

cally includes or compares the injury experience of aides

with other nursing care personnel.

Unionized aides have been the focus of several

Scandinavian studies by Eriksen et al. [Eriksen et al.,

2003, 2004a,b; Eriksen, 2003a,b, 2005, 2006; Eriksen and

Bruusgaard, 2004]. These reports, based on analyses of

cross-sectional survey data, looked at a variety of issues

including self-reported pain, fatigue, sickness absence, and

social support. Research specifically examining injury

experiences of aides in the hospital setting in Canada and

Sweden has shown that these workers have a higher risk of

work-related injury than nurses [Engkvist et al., 2000;

Alamgir et al., 2007]. Aides have also been reported to

have poorer health than many other occupational groups,

including registered nurses [Eriksen, 2003a].

Aides, orderlies, and attendants consistently rank among

the occupations reporting the most cases of workplace

injuries and illness; they also have among the highest number

of events requiring time away from work beyond the day of

injury [Hoskins, 2006]. Over two decades ago aides in the US

were reported as having one of the highest rates of disabling

back disorders [Jensen, 1987]; a recent report of hospital

personnel documents that aides are among the occupational

groups with the highest rates of musculoskeletal injury and

lost work days [Pompeii et al., 2008].

Differences in training, duties, and job demands between

nurses and aides point to the importance of examining,

comparing, and contrasting their injury experiences. For

example, aides bear responsibility for many of the more

physically taxing patient care activities such as bathing, bed-

making, toileting, and turning tasks [US Department of

Health and Human Services, 2004; US Bureau of Labor

Statistics, 2006]. Aides have minimal educational require-

ments and their jobs are lower wage positions with limited

opportunity for professional advancement. There are striking

racial and ethnic differences between these predominantly

female workers in the United States [Yamada, 2002; US

Department of Health and Human Services, 2006] with aides

consistently over-represented by women of color. These

demographic and class differences, as well as differences in

work exposures, likely differentially influence the overall

health status and make results of previous research combin-

ing these occupational groups difficult to interpret accurately

and perhaps misleading.

To address the lack of research knowledge that clearly

differentiates the work-related injury experiences of nurses

and aides in hospital settings in the US, we conducted

analyses of occupational injuries among a historical cohort of

nursing staff in a major university hospital system. The

specific goals of our analyses were: (1) to explore factors

associated with work-related injuries or illnesses within each

of these occupational groups employed in acute care, (2) to

contrast characteristics of work-related injury experiences of

nurses and aides, and (3) to compare factors associated with

reported work-related injury/illness experience between

aides and nurses. The analyses drew upon a comprehensive

system for injury surveillance allowing us to examine

injury incidence within a dynamic cohort of nursing staff,

accommodating time-varying explanatory variables includ-

ing tenure of employment and age. The research reported in

this manuscript is part of an ongoing study to evaluate

changes in the rate of patient handling injuries among these

nursing staff after the introduction of lift equipment at Duke

University Health System.

MATERIALS AND METHODS

Data Sources

Data for these analyses came from the Duke Health

and Safety Surveillance System (DHSSS), a comprehensive

system for health, injury, and hazard surveillance for all

employees from Duke University and Health System.

The DHSSS links information from Human Resources,

employee health benefits, industrial hygiene, hazardous

waste management, emergency preparedness, occupational

medicine, workers’ compensation, health promotion, and

private healthcare claims on an individual basis while

protecting data privacy [Dement et al., 2004b].

The current analyses used Human Resources data to

identify all aides and nurses employed in inpatient units, as

well as the emergency room and anesthesia/post-anesthesia

care units at Duke University Hospital, a large tertiary care

medical center, and Durham Regional Hospital, a large

affiliated community hospital. All reported occupational

injuries or illnesses were ascertained from workers’ com-

pensation records regardless of injury/illness severity. Data

coding as performed by workers’ compensation staff was

used throughout this study. Early in the analyses we looked at

text descriptions of injury events to improve on data coding

and found out that in many instances, even combining

the employees’ and supervisors’ text descriptions, not

enough information was provided to allow us to create more

refined categories or improve coding accuracy. Analyses

were limited to accepted workers’ compensation claims. The

workers’ compensation database provided data on type and

nature of injury/illness, body part affected, place where

injury/illness happened, type of medical care received,

lost time from work beyond the day of the injury, and

compensation received by the employee. Data were available

from 1997 to 2004 for Duke University Hospital and from

954 Rodrı́guez-Acosta et al.

2000 to 2004 for Durham Regional Hospital following the

addition of this community hospital to the Duke University

Health System.

Human Resources records provided demographic data

(age, race, and gender) and employment information (hire

date, termination date, job tenure, work location, job title,

and hours worked per week). Nursing staff were classified

by groups of hospital units serving patients with similar

types of medical/surgical conditions and acuity. We used

administrative data to obtain additional information about

hospital units including primary patient population, defined

as: pediatric, adult, or mixed (adults and children), and

usual duration of shifts, defined as: 8 hr, 12 hr, or mixed (any

combination of hours).

The current research was approved by the Duke

University Health System Institutional Review Board.

Data Analyses

Descriptive statistics were generated to define the

cohort of aides and nurses, separately, by distributions of

age, gender, race/ethnicity, length of employment in this

setting, and hospital unit of employment. Yearly injury rates,

expressed as injuries per 100 full-time equivalents (FTEs),

were calculated separately for aides and nurses. Factors

associated with injuries within each occupational group

were explored based on age, gender, job tenure, and unit

of employment. Analyses next focused on comparisons

between the two occupational groups. Reported injuries were

described by type of injury/illness (nature), cause of injury/

illness, body site affected, and number of days lost beyond

the day of the injury for aides and nurses separately. Lastly,

we compared factors associated with work-related injury

experience between aides and nurses. In each of the analyses,

findings were further stratified by claims resulting in no-

lost time and those that did result in lost time from work.

Workers classified as working in the float pool (those who

work on different units depending on the hospitals’ needs)

were excluded from analyses addressing unit of employment.

Injury/illness events were stratified by occupational

group and then examined by age group (categorized as:

�29, 30–39, 40–49, 50–59, and 60þ years), gender, race

(categorized as Black, White, and Other), hospital unit of

employment, job tenure, usual duration of shifts, and patient

population in order to calculate stratum specific rates and rate

ratios (RRs). Poisson regression methods for ungrouped data

[Loomis et al., 2005] were used to estimate injury rates, RR,

and 95% confidence intervals (95% CI) using SAS PROC

GENMOD [SAS Institute, Inc., 1999]. Rate denominators

were expressed in terms of FTEs in order to account for the

number of employment hours at risk contributed by each

worker. FTEs were selected because available data allowed

the calculation of person-time by taking into account

hours worked per week and the duration of employment by

follow-up year. This led to a better estimation of hours

worked and in turn to more accurate rate calculations

[Dement et al., 2004a]. Poisson regression model fittings

were implemented by specifying the log (FTE) as the offset

variable or the denominator for rates. Explanatory variables

of interest included in the multivariable models were: age,

race, gender, job tenure (years of employment), and hospital

unit of employment. To avoid over controlling in our

analyses, patient population and shift duration were not

included in multivariate analyses due to their strong

relationships to type of work unit.

RESULTS

Population Characteristics

A total of 1,689 aides and 5,082 nurses worked in acute

care at the health system between 1997 and 2004. At time of

entry into the cohort, aides were slightly younger (mean

age 32.1, range 17–74 years) than nurses (mean age 34.7,

range 18–75 years). Fifty-four percent of the aides and

18% of the nurses were Black. The majority of the aides and

nurses were women (86% and 90%, respectively). Average

duration of employment at Duke University Health System

was 2.7 years for aides and 5.4 years for nurses.

Rates of Injury Among Aides andNurses Over Time

Injury rates by year of follow-up and lost time status

for aides and nurses are presented separately in Figure 1. For

no-lost work time injuries, we observed higher rates among

aides for all study years but 1999. Since the year 2002 rates

for both aides and nurses have been steadily decreasing. The

risk of lost work time injuries was also higher among aides

over the study period. We observed a decrease in risk of injury

for aides from 1998 to 2000 with a slight decline again in

2004; among nurses injury rates did not follow a specific

pattern although the greatest reduction in risk (65%) was

observed in 2004 compared to 1997.

Factors Associated With Work-RelatedInjury Within Each Occupational Group

Among aides the most striking factor associated with

injury risk was the unit on which they worked (Table I).

Specifically, the rehabilitation and orthopedic units were

particularly high-risk areas for both no-lost time and

lost time injuries. Younger aides and those with less job

tenure were slightly more likely to have no-lost time injuries

while the reverse was true of lost time injuries.

Similarly, the unit of work was the most prominent factor

associated with injury risk among nurses. However, the risk

of an injury not requiring time away from work was greater in

Occupational Injuries in Hospital Nursing Staff 955

FIGURE 1. Unadjusted injury rates by year of follow-up and lost time for nurse’s aides and Nurses, Duke University Health System,

NorthCarolina,1997^2004.

TABLE I. Unadjusted and Adjusted Rate Ratios (RR) and 95% Confidence Intervals (95% CI) ofWorkers’ Compensation Injuries AmongAides byDemographicand Employment Characteristics and LostTime Status,Duke University Health System,North Carolina,1997^2004

No-lost time injuries Lost time injuries

Unadjusted RR 95%CI Adjusted RRa 95%CI Unadjusted RR 95%CI Adjusted RRa 95%CI

Age group�29 1.2 0.9^1.6 1.2 0.9^1.6 0.8 0.4^1.6 0.8 0.3^1.830^39 1.1 0.8^1.4 1.0 0.8^1.4 0.7 0.4^1.5 0.7 0.3^1.540^49 1.0 0.8^1.4 1.0 0.7^1.3 1.1 0.5^2.2 1.0 0.5^2.150þ 1.0 1.0 1.0 1.0

GenderFemale 0.8 0.7^1.0 0.9 0.7^1.1 0.9 0.5^1.8 1.0 0.5^1.9Male 1.0 1.0 1.0 1.0

RaceNon-White 0.8 0.7^0.9 0.8 0.7^1.0 0.9 0.6^1.5 0.9 0.5^1.5White 1.0 1.0 1.0 1.0

Hospital unitEmergency room 1.2 0.8^1.9 1.1 0.7^1.8 1.7 0.5^5.5 1.6 0.5^5.5Floating 1.1 0.7^1.8 1.1 0.7^1.8 1.6 0.5^5.7 1.7 0.5^6.0Intensive/critical care 1.8 1.2^2.8 1.8 1.2^2.7 2.2 0.7^7.1 2.3 0.7^7.5Obstetrics/gynecology 1.8 1.1^3.0 1.8 1.1^3.0 1.0 0.2^5.4 1.0 0.2^5.6Orthopedics 3.2 2.0^5.0 3.1 2.0^5.0 3.1 0.8^11.4 3.0 0.8^11.6Other medical units 1.6 1.1^2.3 1.6 1.1^2.4 1.6 0.5^4.6 1.6 0.5^4.7Psychiatry 1.6 0.9^2.7 1.6 0.9^2.8 0.6 0.1^5.3 0.5 0.1^4.8Rehabilitation 3.6 2.2^5.9 3.4 2.1^5.7 6.3 1.8^22.5 6.7 1.9^24.0Stepdown 1.5 1.0^2.2 1.5 1.0^2.2 1.4 0.5^4.2 1.3 0.4^4.2Neonatal/pediatrics 1.0 1.0 1.0 1.0

Tenure<5 1.4 1.1^1.7 1.2 0.9^1.6 0.8 0.4^1.4 0.8 0.4^1.55^<10 1.4 1.0^1.8 1.2 0.9^1.6 0.8 0.4^1.6 0.7 0.3^1.510þ 1.0 1.0 1.0 1.0

aAdjusted for gender, race, age group, hospital unit, and tenure.

the intensive/critical care and psychiatry units, while for lost

work time injuries the risk was greater in the orthopedics and

rehabilitation units (Table II). Female nurses were at higher

risk of injury than their male counterparts, but the same was

not true for aides. Race did not significantly influence injury

risk of either group of workers.

Characteristics of Injuries to Aides andNurses, Respectively

Leading causes, nature, and body parts injured are

contrasted for aides and nurses in Tables III and IV for no-

lost time and lost time injuries, respectively. In both tables we

limit results to leading causes of nature of injury and body

part affected due to sparse data in the remaining categories.

Among no-lost work time injuries (Table III), being struck

by/against (e.g., needles, struck by patient) led to the highest

injury risk among aides and nurses (7.8 and 11.2 injuries per

100 FTEs) followed by lifting (5.5 and 2.2 injuries per

100 FTEs). Struck by injuries among nurses were more likely

to result from needles, while struck by injuries among aides

were more likely to result from patient or equipment contact.

Aides had a higher risk of injury due to lifting (RR¼ 2.4, 95%

CI: 2.1–3.1) and exertion (RR¼ 2.1, 95% CI: 1.7–2.7) than

did their nursing counterparts.

Lifting was the leading cause of lost work time injury

(Table IV) for aides (1.4 injuries per 100 FTE) as well as for

nurses (0.4 injuries per 100 FTE). Aides had a higher risk

of lost work time injury due to lifting (RR¼ 3.4, 95% CI:

2.2–5.3) and exertion (RR¼ 3.1, 95% CI: 1.8–5.5) than did

nurses. Furthermore, aides with injuries requiring time

away from work averaged more lost days from work than

nurses, with a mean of 178 days (median¼ 20, standard

deviation¼ 422) versus 89 days (median¼ 21, standard

deviation¼ 212) for aides and nurses, respectively (t-test

P-value¼ 0.05).

TABLEII. UnadjustedandAdjustedRateRatios (RR)and95%Confidence Intervals (95%CI)ofWorkers’Compensation InjuriesAmongNursesbyDemographicand Employment Characteristics and LostTime Status,Duke University Health System,North Carolina,1997^2004

No-lost time injuries Lost time injuries

Unadjusted RR 95%CI AdjustedRRa 95%CI Unadjusted RR 95%CI AdjustedRRa 95%CI

Age group�29 1.4 1.2^1.6 1.4 1.2^1.6 0.4 0.2^0.7 0.4 0.2^0.930^39 1.3 1.1^1.4 1.2 1.1^1.4 0.7 0.4^1.1 0.8 0.4^1.440^49 1.2 1.0^1.4 1.2 1.0^1.3 1.1 0.7^1.8 1.2 0.8^2.050þ 1.0 1.0 1.0 1.0

GenderFemale 1.2 1.1^1.4 1.4 1.2^1.7 2.1 0.9^4.7 2.2 1.0^5.1Male 1.0 1.0 1.0 1.0

RaceNon-White 0.9 0.8^1.0 0.9 0.8^0.9 1.3 0.9^1.9 1.0 0.7^1.5White 1.0 1.0 1.0 1.0

Hospital unitEmergency room 1.5 1.2^1.9 1.7 1.4^2.1 2.0 0.7^5.3 1.9 0.7^5.2Floating 1.1 0.9^1.4 1.2 0.9^1.5 2.3 0.9^5.9 2.1 0.8^5.3Intensive/critical care 2.3 2.0^2.7 2.5 2.1^2.9 2.3 1.1^5.1 2.3 1.1^5.1Obstetrics/gynecology 1.7 1.4^2.1 1.9 1.5^2.3 2.1 0.8^5.5 1.8 0.7^4.7Orthopedics 2.0 1.5^2.6 2.3 1.7^3.0 9.9 4.2^23.6 8.3 3.5^20.0Other medical units 1.9 1.6^2.2 2.1 1.8^2.4 2.6 1.2^5.5 2.3 1.1^4.9Psychiatry 2.1 1.5^2.9 2.7 2.0^3.8 5.4 1.7^17.5 4.3 1.3^14.3Rehabilitation 1.6 1.0^2.6 2.2 1.4^3.6 9.5 2.9^30.8 8.6 2.5^29.3Stepdown 1.6 1.4^1.9 1.7 1.5^2.0 2.7 1.3^5.8 2.7 1.2^5.7Neonatal/pediatrics 1.0 1.0 1.0 1.0

Tenure<5 1.2 1.1^1.3 1.1 1.0^1.3 0.7 0.5^1.0 1.2 0.7^1.95^<10 1.1 0.9^1.2 1.0 0.9^1.1 0.8 0.5^1.2 1.0 0.6^1.710þ 1.0 1.0 1.0 1.0

aAdjusted for gender, race, age group, hospital unit, and tenure.


TABLE III. Injury Characteristics of No-Lost WorkTimeWorkers’ Compensation Injuries* Among Nurse’s Aides and Nurses, Duke University Health System,North Carolina,1997^2004

Nurse’s aides Nurses

RRb 95%CIInjuries Ratesa 95%CI Injuries Ratesa 95%CI

Cause of injury*Struckby/struck against 176 7.8 6.7^9.0 1,233 11.2 10.6^11.8 0.7 0.6^0.8Lifting 125 5.5 4.6^6.6 246 2.2 2.0^2.5 2.4 2.1^3.1Exertion 98 4.3 3.5^5.2 223 2.0 1.8^2.3 2.1 1.7^2.7Fall/slip 47 2.1 1.6^2.8 184 1.7 1.4^1.9 1.2 0.9^1.7Miscellaneous 36 1.6 1.1^2.2 111 1.0 0.8^1.2 1.6 1.1^2.3

Nature of injury*Sprain/strain 194 8.6 7.4^9.9 352 3.2 2.9^3.5 2.7 2.3^3.2Pain/inflammation 119 5.3 4.4^6.3 453 4.1 3.7^4.5 1.3 1.0^1.6Bloodandbodyfluidsexposure 73 3.2 2.6^4.1 684 6.2 5.8^6.7 0.5 0.4^0.7Contusion (bruise) 60 2.6 2.1^3.4 179 1.6 1.4^1.9 1.6 1.2^2.2Skin disease/dermatitis 29 1.3 0.9^1.8 115 1.0 0.9^1.3 1.2 0.8^1.8Puncture 20 0.9 0.6^1.4 273 2.5 2.2^2.8 0.4 0.2^0.6

Bodypart*Arm/hand 174 7.7 6.6^8.9 1,004 9.1 8.6^9.7 0.8 0.7^1.0Back 173 7.6 6.6^8.9 408 3.7 3.4^4.1 2.1 1.7^2.5Head 71 3.1 2.5^4.0 434 3.9 3.6^4.3 0.8 0.6^1.0Legs 49 2.2 1.6^2.9 202 1.8 1.6^2.1 1.2 0.9^1.6Neck/shoulder 45 2.0 1.5^2.7 105 1.0 0.8^1.2 2.1 1.5^3.0Unspecified 22 1.0 0.6^1.5 139 1.3 1.1^1.5 0.8 0.5^1.2

*Only leading causes of injury, nature of injury, and body part affected per occupational group are presented.aRates per100 FTEs.bNurse’s aides versus nurses.

TABLE IV. Injury Characteristics of LostWorkTimeWorkers’ Compensation Injuries* Among Nurse’s Aides andNurses,Duke University Health System,NorthCarolina,1997^2004


RRb 95%CIInjuries Ratesa 95%CI Injuries Ratesa 95%CI

Cause of injury*Lifting 32 1.4 1.0^2.0 46 0.4 0.3^0.6 3.4 2.2^5.3Exertion 20 0.9 0.6^1.4 31 0.3 0.2^0.4 3.1 1.8^5.5Struckby/struck against 6 0.3 0.1^0.6 12 0.1 0.1^0.2 2.4 0.9^6.5Fall/slip 5 0.2 0.1^0.5 20 0.2 0.1^0.3 1.2 0.5^3.2

Nature of injury*Sprain/strain 49 2.2 1.6^2.9 68 0.6 0.5^0.8 3.5 2.4^5.1Pain/inflammation 17 0.8 0.5^1.2 33 0.3 0.2^0.4 2.5 1.4^4.5Contusion (bruise) 5 0.2 0.1^0.5 12 0.1 0.1^0.2 2.0 0.7^5.8

Bodypart*Back 44 1.9 1.5^2.6 57 0.5 0.4^0.7 3.8 2.5^5.6Arms/fingers 10 0.4 0.2^0.8 15 0.1 0.1^0.2 3.2 1.5^7.2Legs 9 0.4 0.2^0.8 25 0.2 0.2^0.3 1.8 0.8^3.8Neck/shoulder 8 0.4 0.2^0.7 18 0.2 0.1^0.3 2.2 0.9^5.0

*Only leading causes of injury, nature of injury, and body part affected per occupational group are presented due to small numbers.aRates per100 FTEs.bNurse’s aides versus nurses.


We observed differences by occupational title in the

nature of the injuries and the body parts involved. Sprains and

strains accounted for the highest risk of injury among nurse’s

aides for no-lost work time injuries as well as for lost work

injuries (8.6 and 2.2 injuries per 100 FTEs, respectively).

Blood and body fluid exposures accounted for the highest risk

of no-lost work time injuries among nurses (6.2 injuries per

100 FTEs). When comparing both occupational groups we

observed that the RR of injury was highest among aides for

injuries that resulted in sprains/strains, contusions, and pain

and inflammation. On the other hand, their risk of injury was

lower for puncture injuries and blood and body fluids

exposures.

Regarding body parts affected, similar risk ratios

comparing aides to nurses were observed for no-lost

work time injuries to the back (RR¼ 2.1, 95% CI: 1.7–2.5)

and neck/shoulder (RR¼ 2.1, 95% CI: 1.5–3.0) (Table III).

For injuries requiring workers to lose work time (Table IV)

the RRs were higher for back (RR¼ 3.8, 95% CI: 2.5–5.6)

and arm/fingers (RR¼ 3.2, 95% CI: 1.5–7.2) related injuries.

Among aides as well as nurses, the majority of the reported

lost work time injuries were the result of patient handling

activities (73% and 63%, respectively).

Factors Associated With Work-RelatedInjuries Between Aides and Nurses

Injury rates of aides and nurses are compared across

demographic strata and characteristics of employment in

Tables V and VI, respectively, for no-lost work time injuries

and lost work time injuries. Adjustment for age, race,

gender, tenure, and unit of employment had minimal impact

on estimated RRs; for this reason and simplicity the crude

RRs are displayed in Tables Vand VI. Injury rates for events

that did and did not result in lost time from work were higher

for nurse’s aides compared to nurses; the magnitude of

the risk was greater for aides with lost work time injuries

(RR¼ 2.8, 95% CI: 2.1–3.8), although estimates are less

precise.

For no-lost work time injuries (Table V), risk among

both occupational groups was highest among workers less

than 30 years of age. However, when examining the risk

between occupational groups, the greatest difference

between aides and nurses for any age category was noted

among those 60 and older (RR¼ 2.4, 95% CI: 1.2–4.8).

For both, aides and nurses, workers 60 years and over have

the highest risk of injury resulting in lost time from work.

Aides under 29 years and younger had the highest RR

(RR¼ 5.3, 95% CI: 2.7–10.3) compared to their nursing

counterparts (Table VI).

Regarding gender, the risk of no-lost work time injury

was greater among male aides than female aides. There

were minimal differences in the risk comparing female aides

to female nurses (RR¼ 1.1, 95% CI: 1.0–1.2), but the risk of

injury was higher for male nurse’s aides compared to their

nursing counterparts (RR¼ 1.6, 95% CI: 1.3–2.1) (Table V).

A similar risk pattern was observed for lost work time injuries

(Table VI). However, the magnitude of the risk for women

more than doubled when we compared rates of injuries with

lost work time among aides and nurses (RR¼ 2.7, 95% CI:

2.0–3.6). Male aides showed higher risk of lost work time

injuries than male nurses as well.

Rates of no-lost work time injury (Table V) were highest

among White aides. RR estimates comparing aides to nurses

did not differ by race. On the other hand, we observed that

among those with lost work time injuries White aides had

three times the risk of injury (RR¼ 3.3, 95% CI: 2.1–5.2)

compared to White nurses, and Black aides had 2.5 (95% CI:

1.6–3.9) times the risk of injury compared to Black nurses

(Table VI).

Tenure of employment was a modest predictor of injury

risk for no-lost work time injuries (Table V). Among aides,

the rate of injury declined monotonically with tenure of

employment; the rate was nearly 30% higher among those

employed less than 5 years when compared to those

employed 10 or more years. Among nurses, a similar pattern

of decreasing injury rates with tenure was observed; those

employed less than 5 years had nearly a 20% higher rate of

injury when compared to those employed 10 or more years.

The risk of lost work time injuries increased with tenure

among nurses’ aides as well as nurses. Aides had a greater

risk of injury compared to nurses in each tenure category

(Table VI).

Among aides we observed the lowest risk of no-lost

work time injury in the neonatal and pediatric units (Table V)

and of lost work time injury in psychiatry (Table VI). For

nurses, the highest risk of no-lost work time injury was

observed in the intensive and critical care units while risk of

lost work time injuries was higher in orthopedic units. The

risk of occupational injury not involving time away from

work (Table V) did not vary between aides and nurses

working in the emergency room (RR¼ 1.0, 95% CI: 0.7–

1.4), intensive and critical care (RR¼ 1.0, 95% CI: 0.8–1.3),

other general medical/surgical units (RR¼ 1.0, 95% CI: 0.9–

1.2), psychiatry (RR¼ 0.9, 95% CI: 0.6–1.5), and stepdown

(RR¼ 1.1, 95% CI: 0.9–1.4) units. Significantly higher rates

were seen among aides in the rehabilitation (RR¼ 2.8, 95%

CI: 1.5–5.0) and orthopedics (RR¼ 2.0, 95% CI: 1.3–2.9)

units. The risk of lost work time injury (Table VI) was higher

for aides across all hospital units, except for psychiatry

(RR¼ 0.5, 95% CI: 0.1–4.1).

Rates of injury among aides and nurses were consis-

tently higher among those working with adult patients for

both no-lost work time and lost work time injuries. When

comparing aides to nurses for both classifications of injuries,

we observed that their risk was higher across all patient

population categories with pediatrics accounting for the

highest RR of injury.


DISCUSSION

We utilized data from a dynamic 8-year historical cohort

to increase our understanding of occupational injuries among

aides and nurses employed in acute care at a major US

medical center and an affiliated community hospital. Differ-

ences were noted in patterns of injury risk both within

and between work groups. Our results showed that sprains

and strains and the poorly defined classification of pain/

inflammation ranked as the leading types of injury among

aides and nurses for injuries with and without time lost from

work. We observed that among cases whose injuries did not

TABLE V. No-LostWorkTime Injuries: Stratified Crude Rates,* Rate Ratios (RR), and 95% Confidence Intervals (95% CI) Comparing Nurse’s Aides and Nurses,Duke University Health System,North Carolina,1997^2004

Injuries

Nurse’s aides

Injuries

Nurses

RRa 95%CIFTEs Rate* 95%CI FTEs Rate* 95%CI

Age group�29 185 644.9 28.7 24.8^33.1 715 2,878.1 24.8 23.1^26.7 1.2 1.0^1.430^39 183 727.3 25.2 21.8^29.1 766 3,443.9 22.2 20.7^23.9 1.1 1.0^1.340^49 137 572.0 24.0 20.3^28.3 624 2,945.4 21.2 19.6^22.9 1.1 0.9^1.450^59 63 275.0 22.9 17.9^29.3 285 1,469.9 19.5 17.4^21.9 1.2 0.9^1.560þ 11 45.6 24.1 13.4^43.6 29 288.2 10.1 7.0^14.5 2.4 1.2^4.8

GenderFemale 475 1,913.6 24.8 22.7^27.2 2,235 10,000.6 22.3 21.4^23.3 1.1 1.0^1.2Male 104 351.2 29.6 24.4^35.9 186 1,024.9 18.1 15.7^21.0 1.6 1.3^2.1

RaceBlack 376 1,591.9 23.6 21.3^26.1 401 2,112.2 19.0 17.2^20.9 1.2 1.1^1.4White 191 630.4 30.3 26.3^34.9 1,869 8,250.3 22.7 21.6^23.7 1.3 1.2^1.6Other 12 42.5 28.2 16.0^49.7 151 662.9 22.8 19.4^26.7 1.2 0.7^2.2

Hospital unitb

Emergency room 48 244.4 19.6 14.8^26.1 153 763.0 20.1 17.1^23.5 1.0 0.7^1.4Intensive/critical care 68 226.3 30.1 23.7^38.1 585 1,924.5 30.4 28.0^33.0 1.0 0.8^1.3Obstetrics/gynecology 31 103.1 30.1 21.1^42.7 182 808.6 22.5 19.5^26.0 1.3 0.9^2.0Orthopedics 43 82.7 52.0 38.6^70.1 68 258.5 26.3 20.7^33.4 2.0 1.3^2.9Other medical units 156 609.5 25.6 21.9^29.9 576 2,313.6 24.9 22.9^27.0 1.0 0.9^1.2Psychiatry 22 86.0 25.6 16.9^38.9 44 159.0 27.7 20.6^37.2 0.9 0.6^1.5Rehabilitation 28 47.9 58.5 40.4^84.7 19 90.0 21.1 13.5^33.1 2.8 1.5^5.0Stepdown 116 474.8 24.4 20.4^29.3 424 1,963.5 21.6 19.6^23.8 1.1 0.9^1.4Neonatal/pediatrics 33 202.3 16.3 11.6^22.9 253 1,924.5 13.1 11.6^14.9 1.2 0.9^1.8

Patient populationb

Adult 396 1,397.6 28.3 25.7^31.3 1,513 6,014.0 25.2 23.9^26.5 1.1 1.0^1.3Pediatric 33 176.7 18.7 13.3^26.3 218 1,625.8 13.4 11.7^15.3 1.4 1.0^2.0Mixed 116 502.6 23.1 19.2^27.7 573 2,565.4 22.3 20.6^24.2 1.0 0.8^1.3

Shift durationb

12 hr 401 1,593.7 25.2 22.8^27.7 1,809 8,106.8 22.3 21.3^23.4 1.1 1.0^1.38 hr 51 146.6 34.8 26.4^45.8 65 284.4 22.9 17.9^29.1 1.5 1.1^2.2Mixed 93 336.6 27.6 22.5^33.9 430 1,814.0 23.7 21.6^26.1 1.2 0.9^1.5

Tenure<5 381 1,405.7 27.1 24.5^30.0 1,180 4,907.4 24.0 22.7^25.5 1.1 1.0^1.35^<10 114 432.1 26.4 22.0^31.7 494 2,362.5 20.9 19.1^22.8 1.3 1.0^1.510þ 84 427.0 19.7 15.9^24.4 747 3,755.5 19.9 18.5^21.4 1.0 1.0^4.2Total 579 2,264.8 25.6 23.6^27.7 2,421 11,025.5 22.0 21.1^22.9 1.2 1.1^1.3

FTE, full-time equivalent, based on a 40-hr workweek.*Rates per100 FTEs.aNurse’s aides versus nurses.bFloating workers not included in these analyses.


require them to lose time from work, aides had more than

twice the rate of back and neck/shoulder injuries than nurses.

Aides with injuries that required them to lose work time had

almost four times the rate of back injury, closely followed by

arm and hand injuries compared to nurses. These patterns are

not surprising and are consistent with national injury and

illness statistics [Hoskins, 2006] and with data from the

Occupational Health Supplement to the 1988 National

Interview Survey [Goldman et al., 2001] that lists nursing

aides, orderlies, and attendants as the highest risk group for

TABLEVI. LostWorkTime Injuries:StratifiedCrudeRates,*RateRatios (RR), and95%Confidence Intervals (95%CI)ComparingNurse’sAidesandNurses,DukeUniversity Health System,North Carolina,1997^2004


RRa 95%CIInjuries FTEs Rate* 95%CI Injuries FTEs Rate* 95%CI

Age group�29 19 644.9 2.9 1.9^4.6 16 2,878.1 0.6 0.3^0.9 5.3 2.7^10.330^39 20 727.3 2.7 1.8^4.3 35 3,443.9 1.0 0.7^1.4 2.7 1.6^4.740^49 23 572.0 4.0 2.7^6.1 50 2,945.4 1.7 1.3^2.2 2.4 1.4^3.950^59 10 275.0 3.6 2.0^6.8 20 1,469.9 1.4 0.9^2.1 2.7 1.3^5.760þ 2 45.6 4.4 1.1^17.6 6 288.2 2.1 0.9^4.6 2.1 0.4^10.4

GenderFemale 62 1,913.6 3.2 2.5^4.2 121 10,000.6 1.2 1.0^1.4 2.7 2.0^3.6Male 12 351.2 3.4 1.9^6.0 6 1,024.9 0.6 0.3^1.3 5.8 2.2^15.6

RaceBlack 52 1,591.9 3.3 2.5^4.3 28 2,112.2 1.3 0.9^1.9 2.5 1.6^3.9White 22 630.4 3.5 2.3^5.3 88 8,250.3 1.1 0.9^1.3 3.3 2.1^5.2Other 0 42.5 ^ ^ 11 662.9 1.7 0.9^3.0 G G

Hospital unitb

Emergency room 8 244.4 3.3 1.6^6.5 7 763.0 0.9 0.4^1.9 3.6 1.3^9.8Intensive/critical care 10 226.3 4.4 2.4^8.2 21 1,924.5 1.1 0.7^1.7 4.1 1.9^8.6Obstetrics/gynecology 2 103.1 1.9 0.5^7.8 8 808.6 1.0 0.5^2.0 2.0 0.4^9.2Orthopedics 5 82.7 6.0 2.5^14.5 12 258.5 4.6 2.6^8.2 1.3 0.5^3.7Other medical units 19 609.5 3.1 2.0^4.9 28 2,313.6 1.2 0.8^1.8 2.6 1.4^4.6Psychiatry 1 86.0 1.2 0.2^8.3 4 159.0 2.5 0.9^6.7 0.5 0.1^4.1Rehabilitation 6 47.9 12.5 5.6^27.9 4 90.0 4.4 1.7^11.8 2.8 0.8^10.0Stepdown 13 474.8 2.7 1.6^4.7 25 1,963.5 1.3 0.9^1.9 2.2 1.1^4.2Neonatal/pediatrics 4 202.3 2.0 0.7^5.3 9 1,924.5 0.5 0.2^0.9 4.2 1.3^13.7

Patient populationb

Adult 50 1,397.6 3.2 2.7^4.7 87 6,014.0 1.4 1.2^1.8 2.5 1.7^3.5Pediatric 4 176.7 2.3 0.8^6.0 8 1,625.8 0.5 0.2^1.0 4.6 1.4^5.3Mixed 14 502.6 2.8 1.6^4.7 23 2,565.4 0.9 0.6^1.3 3.1 1.6^6.0

Shift durationb

12 hr 49 1,593.7 3.1 2.3^4.1 88 8,106.8 1.1 0.9^1.3 2.8 2.0^4.08 hr 7 146.6 4.8 2.3^10.0 8 284.4 2.8 1.4^5.6 1.7 0.6^4.7Mixed 12 336.6 3.6 2.0^6.3 22 1,814.0 1.2 0.8^1.8 2.9 1.5^5.9

Tenure<5 44 1,405.7 3.1 2.3^4.2 47 4,907.4 1.0 0.7^1.3 3.3 2.2^4.95^<10 13 432.1 3.0 1.7^5.2 26 2,362.5 1.1 0.7^1.6 2.7 1.4^5.310þ 17 427.0 4.0 2.5^6.4 54 3,755.5 1.4 1.1^1.9 2.8 1.6^4.8Total 74 2,264.8 3.3 2.6^4.1 127 11,025.5 1.2 1.0^1.4 2.8 2.1^3.8

FTE, full-time equivalent, based on a 40-hr workweek.*Rates per100 FTEs.aNurse’s aides versus nurses.bFloating workers not included in these analyses.


back pain among female employees, with a back pain

prevalence of 18.8%.

Overall injury rates were greater for aides in the

rehabilitation, orthopedics, and intensive/critical care units

and were quite high. This pattern held for both no-lost work

and lost work time injuries. In a study of the risk of back

injury in a large teaching hospital, Goldman et al. [2001]

reported varying risk of injury by nursing work areas. In their

study intensive care, surgical, and orthopedics/neurology

units had the highest risk of back injury. These units also had

the greatest number of non-ambulatory patients requiring

more total body transfers and lifts. Consistent with our

findings, pediatric nurses’ risk was below all nursing- and

hospital-wide levels. Recent data from BLS report that

aides have the highest rates of work injuries that result in

lost days from work occurring at a rate of 465/10,000 FTEs

(or 4.65/100 FTEs comparable to the units we reported) [US

Bureau of Labor Statistics, 2007b]. Although the rates varied

some by year, this report is not dissimilar from what we

observed.

Through these analyses, we documented overall injury

rates that were higher for aides compared to nurses; the risk

of injury increased in magnitude when comparing aides to

nurses for lost work time injuries. This pattern held across all

covariates of interest. After adjustment for age, gender, race,

hospital unit, and tenure, differences in overall injury

risk between nurse’s aides and nurses remained. These

differences are not surprising and likely due to differences in

tasks performed, physical work conditions, and demands

[Schoenfisch et al., 2007] that were not available in these

surveillance data. Aides are responsible for more direct

patient handling tasks including bed making, bathing, and

toileting activities. Nurses may also be involved in such tasks

but a lesser percentage of their time involves heavier patient

handling activities.

Results presented here are based on accepted workers’

compensation claims. The injury data were coded through

the compensation office without any regular quality control

checks as is often case in compensation records; conse-

quently, there is likely some error involved. We also

acknowledge that anything which influences the filing of a

claim will affect our results including the possibility of

underestimating the true risk of injury. Differences in

reporting by hospital, occupation, and hospital unit could

influence the observed risk of injury. It is also important to

point out that especially among aides the highly physical

nature of their work, limited opportunities for performing

other tasks when injured, and fear of losing their jobs or

income may be an important factor in their decision to report

an injury. Return to work policies at these institutions, for

both nurses and aides, are increasingly emphasizing early,

modified return to work after injury. However, we acknowl-

edge that nurses often have more flexibility in altering the

physical nature of their work than do aides; they are also able

to adjust their work schedules more easily. Both may

influence the patterns we observed.

Literature addressing underreporting of injuries has

identified a wide range of factors that may play a role. For

example, a Canadian study found that of those eligible

for workers’ compensation benefits, 40% did not file a

claim [Shannon and Lowe, 2002]. Workers less likely to

submit claims included the less seriously injured and single

jobholders. Also, a study of Michigan workers found that

predictors of filing a claim were: greater severity of the

disorder, longer duration of employment, lower annual

income, worker dissatisfaction with co-workers, poorer

health status, activity restrictions, and type of physician

providing treatment (specialists—orthopedist and surgeons,

physical and occupational therapist, and family practitioner

compared to company physician) [Rosenman et al., 2000].

Other reasons for not reporting injuries presented in the

literature are safety incentives, fear of reprisal, desire not to

lose their usual job, and a belief that pain was a normal

sequence of work and aging [Pransky et al., 1999]. In the

current study we did not have adequate data to evaluate

underreporting and/or differential reporting.

It has been noted that national surveys and workers’

compensation databases lack key data for a more complete

assessment of injuries [Dembe et al., 2004]. For example, the

Bureau of Labor Statistics survey of injury and illnesses

contains demographic data, details about the injury, and

employment characteristics, but has minimal information

available about employees’ exposure histories, personal

circumstances, and individual-level data for analyses.

Currently, the DHSSS does not contain exposure data

related to physical or psychological demands for all

employees. Data on individual risk factors for injury

(e.g., smoking, exercise) or physical attributes (i.e.,

obesity), either of which could also have influenced our

findings, were not available. Analyses of data from a subset

of the hospital population demonstrated the effects of

obesity on worker’s compensation claims; however, among

high-risk groups, such as the aides in our report, the effects

of job were a stronger determinant of injury [Ostbye et al.,

2007].

Surveillance systems based on incident reports usually

lack information about members not experiencing injury

or illnesses, limiting researchers’ ability to compare the

exposure histories and personal characteristics of injured

and non-injured workers [Azaroff et al., 2002]. In our

study, Human Resources data complemented workers’

compensation data by providing demographic and work

history data for each employee in the system. This

combination allowed us to establish a well-defined cohort,

their reported work-related injuries and time at risk for injury

making longitudinal analyses including the calculation of

injury rates possible which we believe is the greatest strength

of our study.


CONCLUSION

These analyses revealed that injury risk in the hospital

acute care setting was greater for nurse’s aides relative to

nurses. Given that current employment projections for

nurse’s aides nationally [Dohm and Shniper, 2007] and in

North Carolina [North Carolina Employment Security

Commission, 2008] position aides as one of the top

occupations with the largest job growth, it is important that

we specifically address their occupational safety and health

needs in order to develop injury prevention strategies that are

appropriate to them. Increasing the availability of mechan-

ical lifts and other devices designed to lower physical

demands, training in the use of these technologies, and

regular assessments of patients’ lifting needs are steps that

may help lower exposures that are high among aides.

However, some of the factors associated with injury risk

were similar for both groups, particularly the unit or setting in

which they work. This documents the need for unit-specific

prevention efforts that acknowledge the specific challenges

and needs of patients being cared for and the staff responsible

for them.

ACKNOWLEDGMENTS

The authors would like to acknowledge Thomas R.

Konrad for his assistance in the earlier stages of this project.

Also, the National Institute for Occupational Safety and

Health for providing support for this project through grant

number: 3 R01 OH008375-02S1.

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