Practical nurses' health and safety in nursing homes.
Abstract: Purpose: Practical nurses (PNs) rated their general and emotional health and their employers' attention to their health and safety. These components were examined in relationship to work setting and intention to leave for the purpose of exploring workforce issues involving these important care providers of frail elders.

Design/Methods: A relicensure survey mailed to all PNs in one rural state included the Minimum Data Set for nurse workforce supply plus questions from the Health and Retirement Survey. Data were analyzed using Kruskal-Wallis nonparametric ANOVA, t-test, and chi-square tests.

Results: Of the state's working PNs, 813 responded, (71%) and 34% (n=269) reported nursing home employment. Overall, age and work role were not significantly associated with self-rated general health (p=0.14 and p=0.12). Males reported poorer general (p=0.09) and emotional (p=0.004) health. PNs working in nursing homes rated their general and emotional health lower than PNs in other settings (p<0.001). Of the PNs in nursing homes, 28% reported they were likely to leave their position within one year, versus 19% in other work settings (p=0.003). PNs with higher evaluations of their employer safety practices were less likely to leave.

Implications: Understanding PNs perceived general/emotional health and perceptions of workplace health/safety efforts can inform interventions to reduce turnover.

Key words: Practical nursing, nursing home, health status, workplace health promotion, safety management, and turnover.
Article Type: Report
Subject: Practical nurses (Practice)
Practical nurses (Health aspects)
Practical nurses (Safety and security measures)
Occupational health and safety (Management)
Nursing homes (Human resource management)
Authors: Palumbo, Mary Val
McLaughlin, Vicki
McIntosh, Barbara
Rambur, Betty
Pub Date: 12/22/2011
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Winter, 2011 Source Volume: 34 Source Issue: 3
Topic: Event Code: 200 Management dynamics; 260 General services; 280 Personnel administration Computer Subject: Company business management; Company personnel management
Product: Product Code: 8043120 Nurses, Practical; 8000500 Employee Health & Safety; 8050000 Nursing & Rest Homes; 8366000 Homes for Aged NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners; 62 Health Care and Social Assistance; 623 Nursing and Residential Care Facilities; 623312 Homes for the Elderly SIC Code: 8051 Skilled nursing care facilities; 8052 Intermediate care facilities; 8059 Nursing and personal care, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 304051561

Aging Population And Nursing Home Care

According to a recent National Nursing Home Survey (CDC, 2009) there currently are 16,100 nursing homes in the United States with 1.7 million beds operating at an 86% occupancy rate. Moreover, with an aging population predicted to steadily increase in the decades ahead, nursing homes are expected to experience an increase of more than 300 percent in the number of residents over 85 years (Administration on Aging, 2009). The question "Who will care for the elderly?" has been raised but has not been adequately answered (Kovner, Mezey, & Harrington, 2002). It is reasonable to predict, however, that a substantial amount of hands-on nursing care will continue to be provided by those with more health care training than family, but less than the most highly trained and expensive care offered by registered nurses, advanced practice nurses, and physicians. Specifically, practical nurses (Licensed Practical Nurses or Licensed Vocational Nurses, depending upon the area of the country) are a key component in providing long term care and elder care in the US and often supervise the care provided by licensed or certified nursing assistants (LNA or CNAs, name also area dependent). The practical nurse has completed a non-degree nursing program (usually less than two years) and is licensed to provide routine care.

In the last decade, the PN " hours per resident day" has increased from 51% to 62% across all sizes of nursing homes while the Registered Nurse (RN) "hours per resident day" has decreased approximately 20% in medium and large facilities (Seblega, et al., 2010). It is therefore highly likely that PNs will continue their role in the care for the elderly, particularly in the nursing home setting (Skillman, Andrilla, Patterson, Tieman, & Doescher, 2010). Moreover, this trend may actually accelerate as the population ages, particularly if RN and physician career choices don't favor work with the elderly in nursing homes. (Cohen, 2009; Houde & Melillo, 2009; Lee, Reuben, & Ferrell, 2005; Levy, Palat, & Kramer, 2007). While the role of PNs is increasingly important, they have received less attention than other segments of the nursing workforce. This study explored PN's perceptions of their own general and emotional health, as well as the PNs' opinion of their employers' attention to their health and safety. These factors were analyzed in relationship to intention to leave their position.

Aging Nursing Workforce And Nurses ' Health

There have been no studies specifically addressing PN health; therefore, it is important to look to all segments of the nursing workforce for cues. Nurses are an aging workforce, and recent economic conditions may have delayed retirement for many nurses (Buerhaus, Auerbach, & Staiger, 2009). Uncertainty about the future, coupled with possible changes in family income and benefit package availability, may be driving this continued labor force participation. In addition, fewer females chose nursing careers in the 1980s and 1990s, which means that the nurse workforce is older than ever before (Buerhaus, Staiger, & Auerbach, 2000; Janiszewski, 2002). At the same time, assigned work roles and organizational expectations have not evolved to recognize the contemporary nursing workforce as knowledge workers. Nurse job descriptions, for example, often include specific physical demands such as, "must lift 50 pounds" even if this is not a necessary element of the actual job. Undoubtedly, providing nursing care can be a physically demanding job. As a case in point, one study found that nurses on a medical surgical floor walked four to five miles on a 12 hour shift (Welton, Decker, Adam, & Zone-Smith, 2006). Yet, the physical nature of the work doesn't not seem to create a corollary health benefit demonstrated in weight control or other healthy behaviors according to one hospital based study (Zapka, Lemon, Magner, & Hale, 2009). The combination of an aging workforce, the potential for delayed retirement, the physical nature of nurses' work, and the compelling need for the PN raises questions about the health and safety of the PN. This is particularly true in the nursing home setting where where our most impaired elders reside and providing care is particularly physically demanding.

Emotional health is another critical interrelated component of overall health, and Faragher, Cass, and Cooper's (2005) meta-analysis of 485 studies found job dissatisfaction has been most strongly associated with mental/psychological problems. Increasing staff/patient ratios (Seblega, et al., 2010) and increased acuity in the nursing home resident (Feng, Grabowski, Intrator, & Mor, 2006) can add to job stress. Additionally, job stress can be exacerbated in the workplace by work pace, schedule, job security, noise, poor supervision and the nature of client (Sundstrom, Town, Rice, Osborn, & Brill, 1994). This stress has particularly significant consequences for both the employee and employer (de Jonge, Bosma, Peter, & Siegrist, 2000; Silva, de Souza, Borges, & Fischer, 2010; Weyers, Peter, Boggild, Jeppesen, & Siegrist, 2006). Specifically, burnout, the depletion of physical and mental resources, builds gradually and manifests itself in symptoms such as irritability, discouragement, exhaustion, cynicism, entrapment, and resentments (Maslach & Leiter, 2008). For nurses, the negative consequences of burnout caused by overwork and job stress have been well documented for decades as a cause of turnover, absenteeism, reduced productivity, and medical errors (E. M. Chang, Hancock, Johnson, Daly, & Jackson, 2005; McNeely, 2005; Tyler, Carroll, & Cunningham, 1991).

Staff Health and Safety in Nursing Homes

Staff caring for frail elders need to feel personally safe in order to keep their residents safe and foster a "safety climate" (Wisniewski, et al.). Safety initiatives for nursing home staff should be very visible to all employees. However, in 2003, the Occupational Safety & Health Administration (OSHA) was so concerned about the high rate of musculoskeletal injuries in nursing home employees that ergonomic guidelines were issued for the industry (OSHA, 2009). There is also concern about violence towards nursing staff in long term care settings, and there is evidence that PNs are more at risk than RNs (Astrom, Bucht, Eisemann, Norberg, & Saveman, 2002; Gerberich, et al., 2005; Nachreiner, et al., 2007).

In one study of nurses working in 42 large U.S. hospitals, researchers measured the safety climate with survey questions such as "to what extent does the nurse manager on this unit emphasizes safety," and they found that "safety climate predicted medication errors, nurse back injuries, urinary tract infections, (and) patient satisfaction" (Hofman & Mark (2006). The extent to which employers recognize employee stressors and provide perceived support has also long been associated with productivity, reduced absenteeism, and retention (Chang, Rosen, & Levy, 2009; Fornes, Rocco, & Wollard, 2008). This safety climate thus becomes critically important in the effort to maintain a stable nursing home workforce. Evidence is clear that staff shortages and turnover in the nursing home environment, have a detrimental effect on resident care (Bostick, Rantz, Flesner, & Riggs, 2006; Kim, Kovner, Harrington, Greene, & Mezey, 2009). Therefore, this study investigated a statewide workforce of Practical Nurses with specific attention to personal characteristics such as age, gender, work roles, and employment setting in relationship to Practical Nurses' perceptions about personal self-health (general and emotional) and employer practices in regards to health and safety. The data were segmented to identify differences between PNs working in nursing homes and those working in other settings.

The specific hypotheses tested are as follows:

1. (a) PNs' perceived general and emotional health will vary by practice setting

1. (b). PNs' perception of employer safety and health practices will vary by practice setting

2. Age, gender, work role, and practice setting will predict PNs' perceived:

(a) General Health

(b) Emotional Health

3. Age, gender, work role, and practice setting will predict PN's perception of their employer's:

(a) Safety practices

(b) Health practices

4. PNs' age, gender, perceived general health, perceived emotional health, perceptions of employer safety practices, and perceptions of health practices will predict their self-reported intention to leave their principle position within 12 months.


In January 2010, a mail survey was sent to all Vermont Licensed Practical Nurses with their relicensure material. The survey used the Minimum Data Set as recommended for nurse supply studies (Forum of State Nursing Workforce Centers, 2009). Four additional questions were included: 1. Would you say your health is excellent, very good, fair, or poor? 2. What about your emotional health - how good you feel or how stressed, anxious, or depressed you feel? Is it excellent, very good, good, fair, or poor? 3. To what extent does your employer implement practices to maximize your safety on the job? (All the time, Most of the time, Some of the Time, Seldom, Never). 4. To what extent does your employer implement practices to maximize your general health? (All the time, Most of the time, Some of the Time, Seldom, Never).

The rationale for these additions was their consistency with those on the national Health and Retirement Survey (National Institute on Aging, 2007). Intention to leave was measured by self-report on the following question: "How likely are you to leave your principal position in the next twelve months?" Answer choices were on a Likert scale, as follows: very likely, somewhat likely, somewhat unlikely, and very unlikely. Content validity was established by a statewide expert panel of nurses representing a variety of settings. The study was reviewed and approved by the Institutional Review Board at the University of Vermont and the Vermont Board of Nursing prior to implementation.

Statistical Methods

Descriptive statistics were used to examine background variables. For Hypothesis 1a and 1b, significant associations between health and safety self-ratings and independent variables were determined using a Kruskal-Wallis analysis of variance (ANOVA) on the five-point rating scale for each health and safety question. Comparisons between levels of significant variables were made using a Bonferroni adjusted level of significance to account for all multiple comparisons (alpha adjusted by the total number of cross-classifications). To address Hypotheses 2 and 3, a logistic regression model was developed using each of the four health and safety questions (self-rated general health and emotional health and perceived employer initiatives for safety and health) as the dependent variables and age, gender, work role, and setting as independent variables. The model assessed the probability of an "excellent" self-rating versus any other response. For Hypothesis 4, logistic regression was used with a dichotomous measure of intention to leave ("very likely" or "somewhat likely" versus "very unlikely" or "somewhat unlikely") as the dependent variable and age, gender, and perceived general health, perceived emotional health, perception of employer safety practices, and perception of employer health practices as independent variables. Additional analysis regarding PNs in nursing homes also used descriptive statistics and logistic regression to determine significant factors associated with PN's intention to leave.


Eight hundred and thirteen (n=813) PNs responded to the mailed survey (71% response rate). The majority of respondents (34%, n = 269) were employed in nursing homes. Demographic characteristics of this population are provided in Table 1.

The individual factors associated with PN self-rated general and emotional health (Hypothesis 1a) are summarized in Table 2. The only statistically significant factor associated with self-rated general health was work setting. PNs working in a nursing homes rated their general health significantly lower than PNs in other settings (p<0.001). Specifically, only 16% of PNs in nursing homes rated general health as "excellent" versus 24% of PNs in other settings. Along with work setting, age and gender were significant factors associated with self-rated emotional health. Nurses in the youngest age group (<30 years) reported significantly worse emotional health than older nurses. Males were significantly less likely to report "excellent" or "very good" emotional health than females (39% versus 56%). As with general health, PNs in nursing homes reported significantly worse emotional health than PNs in other work settings (p<0.001). Nine percent (9%) of PNs in nursing homes rated their emotional health as "excellent" compared to 19% of PNs in other work settings.

Factors associated with PNs perception of their employer's health and safety practices (Hypothesis 1b) are summarized in Table 3. Again, work setting is a significant factor in the PN's survey response. PNs in nursing homes reported significantly lower ratings for employer practices to promote general health and safety (p<0.001 health; p<0.001 safety).

A multivariate analysis was used to determine the factors predicting PN's perceived general and emotional health and employer health and safety practices (Hypotheses 2 and 3). The model compared a rating of "excellent" on the health or safety questions versus all other responses. The analysis confirmed that when adjusting for other factors, employment setting was significant in predicting both self-rated general health and emotional health (p=0.007 general health, p=0.005 emotional health). No other factors (age, gender, or work role) were significant in this analysis. A similar analysis was used to determine the factors predicting PN's perception of their employer's health and safety practices. Again, employment setting was the only significant predictor of an "excellent" rating in employer health practices (p<0.001) and employer safety practices (p<0.001). Nurses in all other settings rated employer practices significantly higher than did nurses in nursing homes.

A similar analysis determined the significant predictors for PN's self-reported intention to leave their current nursing position (Hypothesis 4). This analysis found that after adjusting for age and gender, a rating of "excellent" for employer safety practices was significant in predicting intention to leave. PNs who rated their employer's safety practices as "excellent" were significantly less likely to report that they were "very likely" or "somewhat likely" to leave their current position (p<0.001). These results are summarized in Table 4. Age and gender were also significant predictors of intention to leave. Older PNs and female PNs were less likely to report intention to leave (p=0.009 age; p=0.005 gender).

PNs In Nursing Homes

PNs in nursing homes reported significantly lower general and emotional health and significantly worse perceptions of employer health and safety practices than PNs in other work settings. In addition, PNs in nursing homes were significantly more likely to report an intention to leave their current position than their counterparts in other work settings. Twenty eight percent (28%) of PNs in nursing homes reported that they were "very likely" or "somewhat likely" to leave their principal position in the next 12 months, versus 19% of PNs in other work settings (p=0.003), and 16% of PNs in nursing homes reported that they were "very dissatisfied" or "somewhat dissatisfied" with their principal position, versus only 4% of PNs in other work settings (p<0.0001).

Table Five provides a comparison of general demographic information for PNs in nursing homes versus other work settings. PNs in nursing homes had significantly fewer years experience working as a PN or in their current position, and were significantly more likely to be enrolled in a nursing education program.

PNs reporting "very likely" or "somewhat likely" to leave their current position were able to provide a reason for their response. When these reasons were collapsed into three categories: career advancement (position change, promotion, return to school), situational (family responsibilities, health/illness, relocation, retirement), and job dissatisfaction (co-worker relationship, supervisor relationship, job assignment, job stress, management, salary/benefits), there were no significant differences in the reason for leaving between PNs in nursing homes and those in other work settings. About 47% of each group reported a situational reason for leaving (p=0.749), and about 63% of each group reported a job dissatisfaction reason (p=0.376). Respondents could choose more than one reason for leaving.

Additional analysis was performed on only the PNs in nursing homes to understand any significant predictors for those reporting "very likely" or "somewhat likely" to leave. Not surprisingly, nurses enrolled in education programs were significantly more likely to report an intention to leave. After controlling for these individuals the analysis found that gender, years in current position, and major work activity were all significant in predicting intention to leave. These results are summarized in Table 6.

Of the significant variables listed above, years in current position was significantly different between PNs in nursing homes and other work settings. Further analysis is recommended to determine if intention to leave is better predicted by work setting (nursing home versus other) or years in current position.


These data suggest that there is considerable work that must be done to ensure that PNs in nursing homes are healthy, both physically and mentally, and perceive there is employer support and concern regarding their health and safety. This climate is essential for their retention and continued ability to meet growing demand. In the future. Hypothesis 1 was confirmed; self-rated emotional and physical health varied by setting, with PNs in long term reporting less favorable general and emotional health. Moreover, the youngest age cohort perceived their emotional health less favorably, as did men. The latter finding is at odds with many other studies that suggest that in general, women rate their emotional health lower than men (Koopmans, et al., 2010; Needham & Hill, 2010; Seedat, et al., 2009). This finding may indicate that the male PNs working in the nursing home may be an important group for further qualitative study regarding their health.

Although a directional association between employee health and nurses' work setting cannot be ascertained within the current study design, this study raises interesting areas of further inquiry. It is possible, for example, that PNs with poorer perceived health self-select to work in the nursing home setting, and these perceptions create a cascade of outcomes. Specifically, health self-perceptions (particularly less than optimal emotional health self-perceptions) may influence PNs impressions of their entire work environment and role and create a less favorable overall response from nursing home PNs. Alternately, the nursing home may be an environment that, when compared to other PN work settings, is less focused on health and safety. Regardless of causation, however, these findings matter; PNs with less positive perceptions of employer health and safety initiatives reported greater intention to leave their position (hypothesis 4). Taken as a whole, these findings may offer corporate administrators, facility administrators, direct staff management, and policymakers a hopeful strategy for retention. Perception is a powerful element in workplace and life satisfaction, and senior level administrators clearly need to emphasize their concern for PNs health and safety and assure that this concern is palpable throughout the organization. Moreover, a solid launching platform is necessary to underscore what is needed is currently in place. Implementation of basic health and safety measures is required by law, for example, but simply may not be recognized by PNs. Fostering understanding of measures that have been taken may require enhanced and ongoing communication, as well as specific, strategically placed awareness initiatives. In addition, highlighting success, for example, a poster declaring 12 consecutive months without a staff injury, provides a constant visual reminder of employer values. In an early study, the use of safety posters increased safety behavior by more than 20% (Lanier & Sell, 1960). Other initiatives to foster a culture of safety might include: 1) forming a management/employee team to address safety, 2) incorporating highly visible and interactive communication and collaboration on safety matters, 3) creating a shared vision of safety excellence, 4) assigning critical safety functions to specific individuals or teams, and 5) making it clear that identifying and correcting workplace safety problems is a continuous effort (Smith, 2004). Together with training and evaluation, these actions provide environmental prompts that underscore the value of PN's health and safety.

Additional modest initiatives may offer substantial rewards. Specifically, given the known and likely ongoing fiscal challenges of the nursing home setting, a reasonable next step is an assessment of current staff health and safety concerns followed by a systematic assessment of organizational readiness for health/safety promotion programming. These efforts should reflect the unique nature, challenges, and opportunities of the nursing home setting. Fortunately, such measurement tools exist. Faghri et al (2010), for example, used six nursing homes to validate the Worksite Health Promotion Readiness Checklist, therefore establishing an instrument useful for this setting. Faghri et al also notes other, less universal instruments targeted for specific baseline measures, which may be useful for organizations undertaking discrete health initiatives. These include the Checklist of Health Promotion Environments at Worksites (CHEW) (Oldenburg, Sallis, Harris, & Owen, 2002), which is designed to access worksite environmental features. HeartCheck (Golaszewski & Fisher, 2002), which is focused on employer support for heart health and WorkCheck (Golaszewski, Barr, & Pronk, 2003) which is designed to measure and effect organizational support for employee health. These more focused instruments are essential tools for any organization wishing to follow The Wellness Councils of America (WELCOA) "Seven Benchmarks of Success", given WELCOA's schematics that includes data collection in two of the seven domains. Notably, this organizing framework identifies administrative support as the key initial impetus to organizational health improvement, followed by a process by which to create community by-in. The WELCO Seven Benchmarks of Success are: 1. Capture senior level support 2. Create a cohesive wellness team 3. Collect data 4. Craft an operating plan 5. Choose appropriate interventions 6. Create supportive environments and 7. Carefully evaluate outcomes (Spyke, 2011). Clearly, although the impetus for organizational change to optimize health and safety of employees must start at the level of senior administration, these recommendations and others (BLR HR and Employment Law News, 2010) reinforce the need for a "Culture of Health" that permeates the organization, involving all. Therefore, initiatives will only resonate with the staff if they resonate with their own deep concerns. In that vein, it is reasonable to look at two of the most commonly reported areas nursing workforce trauma, back injuries and assault.

With the incidence of back injury and assault remaining stubbornly high among healthcare employees, adoption of safe patient handling (Waters, et al., 2006) and conflict management recommendations (Levin, Hewitt, Misner, & Reynolds, 2003) must be a part of any safety program in the nursing home environment. This latter study found that even if programs addressing PN safety are in place, PN's perception of the employer's concern is lacking. Similarly, Faghri et al, (2010) also found that in some cases the administrator had a different perception of health and safety offerings than nursing leadership. The extent to which either of these align with the rank and file staff is unknown, and variations by gender, age, ethnicity, and race have not been fully elucidated.

Clearly, health and safety promotion in the nursing home environment is a complex undertaking that requires resources, commitment, constant attention, and steadfastness over time in order to obtain tangible, sustainable results. Moreover, because safety concerns may not be monolithic, each organization should start with an employee assessment to determine what factors or conditions lead to perceptions of safety gaps, and determine if these vary by age, gender, organizational culture, and geographic location of the facility. Concerns about the safety of the parking lot, for example, require a very different organizational strategy than concerns about horizontal bully activities or back injuries. Thus, identifying PN's perceptions should be the first step toward organizing a strategic and well received safety program. Furthermore, these individuals may become even more important, as existing PNs exit the nursing home workplace for retirement or opportunities in other, more positively received areas in healthcare and demand accelerates to meet needs of aging Baby Boomers. Nursing homes that adopt a longer planning horizon have greater potential to retain a competitive advantage.

Finally, although health and safety initiatives that go beyond the required protections may be costly, they are projected to have a sound return on investment by decreased accidents and turnover. Implementation of extensive wellness programming would thus be best enabled by state and federal reimbursement policies that adequately reflect what is necessary to keep a healthy and satisfied workforce caring for our elders and others nursing homes.

At the same time, it is also important to recognize that previous studies testing health and safety interventions have found mixed results. In the nursing home setting, for example, Tveito and Eriksen (2009) found no change in sick days with a nine month wellness intervention. In contrast, other studies found that evidence for the cost effectiveness of work-based wellness offerings (Erfurt, Foote, & Heirich, 2006; Goetzel & Ozminkowski, 2008; Harris, Lichiello, & Hannon, 2009; Mills, Kessler, Cooper, & Sullivan, 2007; Pelletier, 2001). One other example (Palumbo et al, 2010), involved registered nurses over 49 years old working in the hospital setting attending weekly Tai Chi classes. In this randomized control design pilot study, participants were less likely to take sick days compared to the control group and in contrast to their own sick days from the previous year.

The current study's findings suggest additional research is needed to better understand the unique needs of PNs in nursing homes and tailor effective empirically based interventions tailored to meet gender and age cohort needs. Such efforts are difficult given the number and complexity of the interacting factors that can contribute to a nurse's perceptions of employer attention to health and safety on the job, the nurses' health self-perception, and career intentions. However, the interrelationship between physical and emotional health has been widely acknowledged (Tosevski & Milovancevic, 2006), as has been the relationship between health and job satisfaction. A meta-analysis of 485 studies, for example, found job satisfaction was most strongly associated with mental/psychological problems: burnout (corrected r = 0.478), self esteem (r = 0.429), depression (r = 0.428), and anxiety (r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287) (Faragher, et al., 2005). The extent to which the PNs in nursing homes mirror other populations is unknown. Thus, the current study offers a modest beginning toward understanding a population largely ignored in previous studies, yet critical to the care of the nation's infirm elders.

This study was limited by its setting, one rural US state that lacks substantial ethnic diversity. Moreover, the use of the relicensure process through the State Board of Nursing raised some limitations in instrumentation, as only questions approved by the Board were included. Despite these limitations, this study offers an analysis of a substantial proportion of these key caregivers in an entire US state. Moreover, the State does offer considerable diversity in social class and income. These factors, along with its small size, make it an important research laboratory. Further studies of PNs in other geographic regions are warranted for the purpose generating evidence-based practice intervention to improve health and safety of this important caregiving population. Specific interventions should be tested in studies that are designed with experimental control.


Administration on Aging. (2009). Aging into the 21st Century. 1-5. Retrieved from growth/aging21/ health.aspx#Nursing

Astrom, S., Bucht, G., Eisemann, M., Norberg, A., & Saveman, B. (2002). Incidence of violence towards staff caring for the elderly. Scand J Caring Sci, 16(1), 66-72.

BLR HR and Employment Law News. (2010). Get employees engaged in wellness by creating a strong 'culture of health'. Retrieved from Engaged-in-Wellness-By-Creating-Stro/

Bostick, J. E., Rantz, M. J., Flesner, M. K., & Riggs, C. J. (2006). Systematic review of studies of staffing and quality in nursing homes. J Am Med Dir Assoc, 7(6), 366-376.

Buerhaus, P. I., Auerbach, D. I., & Staiger, D. O. (2009). The recent surge in nurse employment: causes and implications. Health Aff (Millwood), 28(4), w657 668.

Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2000). Implications of an aging registered nurse workforce. Journal of the American Medical Association, 283(22), 2985-2987.

CDC. (2009). The National Nursing Home Survey:2004 Overview (No. 167). Hyattsville, Maryland.

Chang, C., Rosen, C., & Levy, P. (2009). The relationship between perceptions of organizational politics and employee attitudes, strain, and behavior: A meta-analytic examination. The Academy of Management Journal, 52(4), 779-801.

Chang, E. M., Hancock, K. M., Johnson, A., Daly, J., & Jackson, D. (2005). Role stress in nurses: review of related factors and strategies for moving forward. Nursing and Health Science, 7(1), 57-65.

Cohen, S. A. (2009). A review of demographic and infrastructural factors and potential solutions to the physician and nursing shortage predicted to impact the growing US elderly population. JPublic HealthManagPract, 15(4), 352-362.

de Jonge, J., Bosma, H., Peter, R., & Siegrist, J. (2000). Job strain, effort-reward imbalance and employee wellbeing: a large-scale cross-sectional study. Soc Sci Med, 50(9), 1317-1327.

Erfurt, J. C., Foote, A., & Heirich, M. (2006). The cost effectiveness of worksite wellness programs for hypertension control, weight loss, smoking cessation and exercise. Personnel Psychology, 45(1), 5-27.

Faghri, P., Kotejoshyer, R., Cherniack, M., Reeves, D., & Punnett, L. (2010). Assessment of a Worksite Health Promotion Readiness Checklist. Journal of Occupational and Environmental Medicine., 52(9), 893-899.

Faragher, E. B., Cass, M., & Cooper, C. L. (2005). The relationship between job satisfaction and health: a meta-analysis. Occup Environ Med, 62(2), 105-112.

Feng, Z., Grabowski, D. C., Intrator, O., & Mor, V. (2006). The effect of state medicaid case- mix payment on nursing home resident acuity. Health Serv Res, 41(4 Pt 1), 1317-1336.

Fornes, S. L., Rocco, T., & Wollard, K. (2008). Workplace commitment: A conceptual model developed from intergrative review of research. Human Resource Development Review, 7(3), 339-357.

Forum of State Nursing Workforce Centers. (2009). National Nursing Workforce Minimum Datasets: Supply. 1-9. Retrieved from Supply Dataset.pdf

Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H., Nachreiner, N. M., Geisser, M. S., et al. (2005). Risk factors for work-related assaults on nurses. Epidemiology, 16(5), 704-709.

Goetzel, R. Z., & Ozminkowski, R. J. (2008). The health and cost benefits of work site health- promotion programs. [Review]. Annu Rev Public Health, 29, 303-323.

Golaszewski, T., Barr, D., & Pronk, N. (2003). Development of assessment tools to measure organizational support for employee health. American Journal of Health Behavior., 27(1), 4354.

Golaszewski, T., & Fisher, B. (2002). Heart check: the development and evolution of an organizational heart health assessment. American Journal of Health Promotion., 17(2), 132-153.

Harris, J. R., Lichiello, P. A., & Hannon, P. A. (2009). Workplace health promotion in Washington State. Prev Chronic Dis., 6(1), A29. Epub 2008 Dec 2015.

Hofman, D. & Mark, B (2006) An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. Personnel Psychology, 50 (9), 847-869.

Houde, S. C., & Melillo, K. D. (2009). Caring for an Aging Population. J GerontolNurs, 1-5.

Janiszewski, G. H. (2003). The nursing shortage in the United States of America: an integrative review of the literature. Journal of Advanced Nursing 43(4), 335-343..

Kim, H., Kovner, C., Harrington, C., Greene, W., & Mezey, M. (2009). A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies. J GerontolB Psychol Sci Soc Sci, 64(2), 269-278.

Koopmans, P. C., Roelen, C. A., Bultmann, U., Hoedeman, R., van der Klink, J. J., & Groothoff, J. W. (2010). Gender and age differences in the recurrence of sickness absence due to common mental disorders: a longitudinal study. BMC Public Health, 10, 426.

Kovner, C., Mezey, M., & Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging society. Health Affairs, 5(Sept-Oct), 78-89. Laner, S. & Sell, R.J. (1960) An experiment on the effect of specially designed safety posters. Occupational Psychology 34, 153-169.

Lee, M., Reuben, D. B., & Ferrell, B. A. (2005). Multidimensional attitudes of medical residents and geriatrics fellows toward older people. J Am Geriatr Soc, 53(3), 489-494.

Levy, C., Palat, S. I., & Kramer, A. M. (2007). Physician practice patterns in nursing homes. J Am Med Dir Assoc, 8(9), 558-567.

Levin, P. F., Hewitt, J. B., Misner, S. T., & Reynolds, S. (2003). Assault of long-term care personnel. J Gerontol Nurs, 29(3), 28-35.

Maslach, C., & Leiter, M. P. (2008). Early predictors of job burnout and engagement. Journal of Applied Psychology, 93(3), 498-512.

McNeely, E. (2005). The consequences of job stress for nurses' health: time for a check-up. Nurs Outlook, 53(6), 291-299.

Mills, P. R., Kessler, R. C., Cooper, J., & Sullivan, S. (2007). Impact of a health promotion program on employee health risks and work productivity. Am J Health Promot., 22(1), 45-53.

Nachreiner, N. M., Hansen, H. E., Okano, A., Gerberich, S. G., Ryan, A. D., McGovern, P. M., et al. (2007). Difference in work-related violence by nurse license type. J Prof Nurs, 23(5), 290-300.

National Institute on Aging. (2007). Growing Older in America: The Health and Retirement Study. Washington, DC: US Department of Health and Human Services

Needham, B., & Hill, T. D. (2010). Do gender differences in mental health contribute to gender differences in physical health? Soc Sci Med._2010 Oct;71(8):14729.

Oldenburg, B., Sallis, J., Harris, D., & Owen, N. (2002). Checklist of Health Promotion Environments at Worksites (CHEW): development and measurement characteristics. Am J Health Promot., 16(5), 288299.

OSHA. (2009). Guidelines for nursing homes: ergonomics for the prevention of musculoskeletal disorders. US Department of Labor. Retrieved from finalnhguidelines.pdf

Palumbo, M. V., Wu, G., Shaner-McRae, H., Rambur, B., & McIntosh, B. (2010). Tai Chi for older nurses: A workplace wellness pilot study. Applied Nursing Research. Retrieved from 4YV7PXJ1/2/f15b1b6a8cfe9f5d7c5be617ed3a6aad

Pelletier, K. R. (2001). A review and analysis of the clinical- and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1998-2000 update. Am J Health Promot., 16(2), 107-116.

Seblega, B., Zhang, N., Unruh, L., Breen, G., Seung Chun Paek, & Wan, T. (2010). Changes in nursing home staffing levels, 1997 to 2007. Med Care Res Rev, 67(2), 232-246. Epub 2009 Aug 2011.

Seedat, S., Scott, K. M., Angermeyer, M. C., Berglund, P., Bromet, E. J., Brugha, T. S., et al. (2009). Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry, 66(7), 785795.

Shoaf, L. (1988). Improving the life-style of long-term-care employees. Nursing Homes Senior Citizen Care., 37(4), 20-24.

Silva, A. A., de Souza, J. M., Borges, F. N., & Fischer, F. M. (2010). Health-related quality of life and working conditions among nursing providers. Rev Saude Publica, 44(4), 718-725.

Skillman, S. M., Andrilla, C. H., Patterson, D. G., Tieman, L., & Doescher, M. P. (2010). The licensed practical nurse workforce in the United States: one state's experience. Cah Sociol Demogr Med, 50(2), 179-212.

Smith, S. (2004) Breakthrough safety management. Occupational Hazards. (June) 43.

Sofie, J., Belza, B., & Young, H. (2003). Health and safety risk at a skilled nursing facility. Nursing assistants' perceptions. J Gerontol Nurs, 29(2), 13-21.

Spyke, B. (2011). How healthy is your bottom line? The Greater Lansing Business Monthly. Retrieved from is-your-bottom-line.html

Sundstrom, E., Town, J. P., Rice, R. W., Osborn, D. P., & Brill, M. (1994). Office noise, satisfaction, and performance. Environment and Behavior, 26(2), 195-222.

Tosevski, D. L., & Milovancevic, M. P. (2006). Stressful life events and physical health. Curr Opin Psychiatry, 19(2), 184-189.

Tveito, T. H., & Eriksen, H. R. (2009). Integrated health programme: a workplace randomized controlled trial. JAdv Nurs, 65(1), 110-119. Epub 2008 Nov 2014.

Tyler, P. A., Carroll, D., & Cunningham, S. E. (1991). Stress and well-being in nurses: a comparison of the public and private sectors. Int JNurs Stud, 28(2), 125-130.

Waters, T., Collins, J., Galinsky, T., & Caruso, C. (2006). NIOSH research efforts to prevent musculoskeletal disorders in the healthcare industry. Orthop Nurs, 25(6), 380-389.

Welton, J. M., Decker, M., Adam, J., & Zone-Smith, L. (2006). How far do nurses walk? Medsurg Nurs, 15(4), 213-216.

Weyers, S., Peter, R., Boggild, H., Jeppesen, H. J., & Siegrist, J. (2006). Psychosocial work stress is associated with poor self-rated health in Danish nurses: a test of the effort-reward imbalance model. Scand J Caring Sci, 20(1), 26-34.

Wisniewski, A. M., Erdley, W. S., Singh, R., Servoss, T. J., Naughton, B. J., & Singh, G. Assessment of Safety Attitudes in a Skilled Nursing Facility. Geriatric Nursing, 28(2), 126-136.

Zapka, J. M., Lemon, S. C., Magner, R. P., & Hale, J. (2009). Lifestyle behaviours and weight among hospital-based nurses. J Nurs Manag, 17(7), 853860.


University of Vermont


University of Massachusetts



University of Vermont
Table 1: Demographic characteristics of PN respondents

                                                   % of PN
Characteristics              (Total N = 813)     Respondents

Sex (female)                       751               94%

Age - Mean (std)           49 years (11 years)

Work Setting

Nursing home                       269               34%

Hospital                           105               13%

Ambulatory/Outpatient              94                12%

Independent Practice               91                11%

Assisted Living Facility           47                6%

Home Health Agency                 43                5%

Other                              164               19%

Work Role

Direct Patient Care                571               70%

Nurse Manager                      88                11%

Teaching/Instruction               27                3%

Other/Unknown                      56                16%

Table 2: Factors associated with PN's self-rated general
and emotional health

                                  % rating
                                 health as"      P
                   Number of    very good or   value
Factor            respondents    excellent"      +

Age group                                      0.319

<30 years             44            70%

30-39 years           84            67%

40-49 years           127           75%

50-59 years           195           67%

60-64 years           70            66%

65+ years             25            64%

Gender                                         0.089

Male                  62            59%

Female                751           70%

Major Activity                                 0.119

Direct patient        562           68%

Nurse Manager         88            74%

Teaching/             27            78%

Other/Unknown         127           67%

Setting                                        <0.001

Nursing home          268           59%

Hospital              103           66%

Ambulatory/           90            81%

Independent           89            83%

Assisted Living       47            68%

Home Health           42            69%

Other/Unknown         141           71%

                   % rating
                   health as       P
                  "very good"   or value
Factor            "excellent"      +

Age group                        0.003

<30 years             36%

30-39 years           45%

40-49 years           59%

50-59 years           55%

60-64 years           59%

65+ years             80%

Gender                           0.004

Male                  38%

Female                56%

Major Activity                   0.859

Direct patient        56%

Nurse Manager         52%

Teaching/             56%

Other/Unknown         57%

Setting                          <0.001

Nursing home          46%

Hospital              57%

Ambulatory/           67%

Independent           68%

Assisted Living       60%

Home Health           60%

Other/Unknown         55%

+ Kruskal-Wallis non-parametric analysis of variance (ANOVA) on
the five-point rating scale

Table 3: Factors associated with PN's perception of
employer's safety and health practices

                                   % rating
                                employer health
                                 practices as
                   Number of     "very good or      P
Factor            respondents     excellent"      value+

Age group                                         0.051

<30 years             42              57%

30-39 years           82              66%

40-49 years           126             73%

50-59 years           190             70%

60-64 years           67              67%

65+ years             25              92%

Gender                                            0.140

Male                  37              59%

Female                677             70%

Major Activity                                    0.577

Direct patient        551             69%


Nurse Manager         86              69%

Teaching/             25              76%

Other/Unknown         111             70%
Setting                                           <0.001

Nursing home          265             56%

Hospital              87              84%

Ambulatory/           88              78%

Independent           86              78%

Assisted Living       88              78%

Home Health           41              73%

Other/Unknown         143             71%

                     % rating
                  employer safety
                   practices as
                   "very good or       P
Factor              excellent"      value +

Age group                            0.065

<30 years               79%

30-39 years             83%

40-49 years             89%

50-59 years             88%

60-64 years             85%

65+ years               88%

Gender                               0.063

Male                    71%

Female                  86%

Major Activity                       0.424

Direct patient          85%


Nurse Manager           86%

Teaching/               80%

Other/Unknown           88%
Setting                             <0.001

Nursing home            76%

Hospital                95%

Ambulatory/             96%

Independent             89%

Assisted Living         83%

Home Health             83%

Other/Unknown           86%

+ Kruskal-Wallis non-parametric analysis of variance (ANOVA) on
five-point rating scale

Table 4: Factors associated with PN intention to leave
current position in the next 12 months

                   Coefficient          Est. OR        Chi-square
Factor              (Std Err)          (95% CI)+        p-value

Age               -0.026 (0.010)   0.77 (0.63, 0.94)     0.009

Gender            -1.230 (0.438)   0.29 (0.12, 0.69)     0.005

"Excellent"       0.448 (0.344)    1.63 (0.83, 3.20)     0.156
general health

"Excellent"       -0.275 (0.450)   0.76 (0.31, 1.84)     0.541
health rating

"Excellent"       -1.118 (0.301)   0.33 (0.18, 0.59)     <0.001
employer safety

"Excellent"       -0.516 (0.379)   0.60 (0.28, 1.25)     0.173
employer health

+ Covariate adjusted odds ratio estimates the effect on intention to
leave of: a 10 year increase in age; being female; providing an
"excellent" rating versus all other ratings for the given
health/safety question.

Table 5: PNs in Nursing Homes versus PNs in other settings

                                Nursing        Other      Significant
                                 Homes       settings     difference
                                 n=269         n=523        p-value

Sex (% female)                    92%           96%        0.06 (b)

Age - mean (std)              47.8 (12.4)   49.2 (10.8)    0.35 (a)

% over 60 years                   16%           15%        0.69 (b)

% over 65 years                   4%            3%         0.39 (b)

Years as PN - mean (std)       4.5 (2.6)     5.7 (2.5)    <0.001 (a)

Years in current position -    2.7 (1.6)     3.5 (2.2)    <0.001 (a)
mean (std)

% enrolled in nursing ed.         15%           8%         0.006 (b)

Hours worked per week -mean   34.7 (10.7)   34.0 (10.0)    0.75 (a)

% working over 32 hrs/week        60%           64%        0.09 (b)

% working over 40 hrs/week        8%            6%           0.22

% Per Diem                        16%           14%        0.42 (b)

(a) Kruskal-Wallis non-parametric comparison
(b) Chi-Square comparison

Table 6: Factors associated with intention to leave principal
position - PNs in nursing homes

                        Coefficient          Est. OR         Chi-Square
Variable                 (Std Err)          (95% CI)+         p-value

Age                    -0.009 (0.020)   1.10 (0.75, 1.62)      0.633

Sex                    -2.159 (0.839)   0.11 (0.02, 0.60)      0.010

Years in current       1.278 (0.533)    3.59 (1.26, 10.21)     0.017
position (1 year
versus >1 year)

Part-time employment   0.969 (0.550)    2.64 (0.90, 7.74)      0.078
(fewer than 32

Major activity         1.648 (0.640)    5.20 (1.48, 18.21)     0.010
(direct patient care
versus other)

Enrolled in nursing    2.196 (0.610)    8.99 (2.72, 29.69)     <0.001
education program

+ Covariate adjusted odds ratio estimates the effect on intention to
leave on a 10 year increase in age; being female; working in current
position for one year or less; working fewer than 32 hours/week;
working in direct patient care; being enrolled in a nursing education
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