1. Exploring First Line Nurse Managers’ Experiences with Work Related Musculoskeletal Disorders in Staff Nurses Susan Katz Sliski RN, MSN, CCM Doctoral Thesis Proposal Professor P. Glynn Professor K. Donaher Professor Eileen McNeely

2. Statement of the Problem Nurse work related musculoskeletal disorders (WMSDs) within hospital organizations should be considered equal to canaries in a coal mine; they are early indicators of work place hazards.

3. Statement of the Problem The factors related to high level of WMSD among nurses are documented as the underreporting of nurse injuries in hospitals, the management of human capital, and the role of nurse staffing patterns, among others.

4. Statement of the Problem Given that nurses continue to experience WMSDs it maybe that the research has been inadequately synthesized to affect change, perhaps due to a lack of consensus in the field, or there may be other factors related to nurse injuries about which little is known.

5. Statement of the Problem The first line nurse manager represents the intersection of the organization and the individual worker. The report of a potentially chronic injury, such as a WMSD, to a first line nurse manager should generate various strategies for addressing the injury at the individual, the group level, and organizational level. Little is known about the factors that influence the underreporting of WMSD to first line nurse managers, thus few strategies exist to address them.

6. Background and Significance of the Problem (1)Nurses are injured while at work in a number of ways (2)Work related musculoskeletal injuries receive the least amount of attention because of their cumulative nature. (3) Work related musculoskeletal disorders (WMSDs) include soft tissue disorders such as sprains, strains, inflammation, carpel tunnel syndrome, hand, shoulder, back, and other cumulative trauma (4) hospital organizations have been reluctant to accept full responsibility for these types of injuries as solely work related

7. Background and Significance  This study will focus on the reporting of work related musculoskeletal disorders by first line nurse managers in acute care hospital settings.  The first line nurse manager plays a pivotal role in establishing an organizational culture that encourages the reporting of nurse work related injuries.

8. Background and significance Organizational culture is typically called the informal organization  Work group rules are seldom if ever written.  Organizational culture informs staff nurses practice of reporting injuries to their first line nurse manager as well as the managers’ subsequent reporting of the injury

9. Background and Significance  The original intent of the OSHA Logs was to provide a surveillance tool to document worker injuries  Over time, institutions viewed the OSHA Logs as potential evidence of negligence that could result in government fines and resulting in underreporting. If the nurse manager lacks the necessary information to implement organizational culture change in regard to work place safety and address prevention of the injury, it is unlikely to occur.

10. Statement of the Purpose  The purpose of this study is to report what first line nurse managers of acute care hospitals describe as their experience in responding to and managing staff nurse work related musculoskeletal (WMSD) injuries.

11. Research Question  What do first line nurse managers of acute care hospitals describe as their experience in responding to and managing staff nurse work related musculoskeletal (WMSD) injuries?

12. Philosophical Assumptions  Study motivated by researchers exposure to a national database of OSHA hospital injuries which revealed repeated incidences  of the same injuries  in the same hospitals,  in the same environment

13. Review of the Literature The literature was reviewed and organized to reflect the themes that emerged from the search. They are:  Federal Perspectives on Work Related Musculoskeletal Disorders in Nursing  Public Health Perspectives and WMSDs in Nursing  Individual factors, Work Group, and Organizational factors that affect WMSDs in Nursing 

14. Federal Perspectives on Work Related Musculoskeletal Disorders in Nursing .. Strains and sprains of the back and shoulders accounted for one half of all healthcare workers injuries that were reported in 2007 by the Bureau of Labor Statistics (BLS). Nurses suffer from work related musculoskeletal injuries (WMSDs) every day. Manual patient handling is recognized as a high-hazard task contributing to the incidence of musculoskeletal disorders in nurses and other personnel (ANA, 2010). The ANA reported in 2010 that healthcare workers remain overrepresented for upper extremity WMSDs among worker's compensation claims and that injured nurses contribute to one- fourth of all worker’s compensation claims

15. Public Health Perspectives and WMSDs in Nursing  Healthcare workers rank second in work related injuries (15.9%) according to the BLS 2003 statistics,  only behind workers in the manufacturing industry, who sustain the highest injury rate at 21%.  Nurses are injured more often than construction workers (9.7%), miners (0.4%) and workers involved in retail trade (14.7%).  Results from 3 national surveys revealed one third of hospital based nurses experienced work place back and musculoskeletal injury (Buerhaus, Staiger, & Auerbach, 2009).

16. Public Health Perspectives Continued . It is estimated that by:  2012, the average age of a working nurse will be 44.5 years old and  2025, 12% of the RN workforce will be comprised of RN’s over the age of 60.  60 year old hands and backs are not as strong as those of younger workers which puts them at risk for WMSD

17. Individual, Work Group and Organizational factors that effect WMSD in Nursing .. Factors that affect nurses’ inclination to report WMSDs include individual factors, work group factors and organizational culture factors as reported by Brown et al.,( 2005). Inclination to report work place injuries as a whole is a complex concept. In fact upon review of the literature, this is the only study which attempts to directly define and measure factors at multiple organizational levels.

18. Individual, Work Group and Organizational factors that effect WMSD in Nursing  Underreporting of Work place injury is common  Nurses as individuals are reluctant to report work place injuries  Factors that contribute to underreporting by individual nurses are multifaceted and wide ranging

19. Individual, Work Group and Organizational factors that effect WMSD in Nursing  Factors that effect reporting:  Organizations require mandatory drug testing when an individual is injured  Immigrant status may be compromised  Fear deportation  PCP may not link complaint to work place injury  Long latency periods before symptoms arise  Nurse herself may not recognize source of injury

20.  Today nurses are more exposed to physical violence in the work place than ever before.  At first glance one might not directly relate nurse work place violence data with nurse work place musculoskeletal injury (WMSDs).  However, closer scrutiny identifies that nurses are struck, thrown, arm twisted, etc. and these injuries often result in nurse WMSDs  Nurses who are most at risk are: young, inexperienced, and those who work in high patient contact areas Individual, Work Group and Organizational factors that effect WMSD in Nursing

21.  The first line nurse managers (FLNMs) define work group authority.  They represent the intersection of the individual nurse, the first level of authority of a work group, and the organizational values.  The role of the FLNM has become work group and managerial in focus  FLNM competencies are just emerging Individual, Work Group and Organizational factors that effect WMSD in Nursing

22.  It is the FLNM to whom the injured staff nurse must report, creating a moment fraught with complex dilemmas.  Values, patterns of behavior, and survival strategies emerge when individuals work in groups.  Depending on the discipline, management versus anthropology, the result can be called the organizational culture or organizational climate.

23. Individual, Work Group and Organizational factors that effect WMSD in Nursing  Organizational factors that contribute to underreporting are complex  Organizational strategies to address WMSDs include creating safety committees and employee health clinics.  The original goals of the safety committees were to identify organizational risks  However they failed and, injury reporting was simply suppressed. 

24. 3 Research Studies of Significant Relevance  (1) de Castro, A. B., Cabrera, S., Gee,G., Fujishiro, K. & Tagalog,E.A. (2009). Occupational health and safety issues among nurses in the Philippines. AAOHN Journal, 57(4), 149-57.  (2) Brown, J.G., Trinkoff, A., Rempher, K., McPhaul, K., Brady, B., Lipscomb, J., Muntaner, C. (2005). Nurses’ inclination to report work-related injuries: Organizational, work-group, and individual factors associated with reporting. AAOHN Journal, 53(5), 213–17.  (3) Welch, C. (2010, August). Long term risk of repeat occupational injury or illness incidents among Veterans Health Administration nursing employees. AAOHN Journal, 58(8), 323- 9. 

25. De Castro et al 2009  Studied occupational health and safety issues among nurses in the Philippines  Needle stick injuries, work place violence, and musculoskeletal injuries Reporting behaviors indicated they did not report work related injuries to their employers. The rates of under reporting of workplace injuries was similar to U.S. nurses, however the reasons for under reporting were different. Low injury reporting by this group was attributed to factors including: nurses feeling that injuries were not significant, they were too busy to report, or that they felt that injury was “just part of the job”

26. Brown et al. in 2005  This study examined organizational, work-group, and individual factors and nurses’ inclination to report work injuries.  These data revealed that inclination to report was higher in organizations with onsite occupational and employee health services programs . Under reporting was experienced when a work group climate of blame was perceived from nurse managers  that all injuries are important as they reveal a pattern of potential hazards in the work place and thus need to be reported

27. Welch August 2010  a retrospective population based study that assessed the long term risk of repeat reported occupational injury or illness among Veterans Health Administration nursing employees  N=25,697  After adjusting for attrition, disability and retirements, approximately ½ of the surviving cases reported repeated occurrences during the 3 years

28. Welch 2010  This study, with an impressive N of 25,000 employees  and the use of the ASISTS data system.  The researcher recognizes that even though the VA has an existing administrative database, incidences are often underreported

29. Issues of Underreporting remain unknown  These three studies shed light on certain aspects of individual nurse injury experiences, very little is known about experiences of first line nurse managers understanding and management the cumulative injury management  Organizational management of primary and secondary strategies for prevention of injuries is clearly minimized if factors for under reporting are unknown.

30. Qualitative design  This study will explore the moment when the injured nurse reports his or her injury to her first line nurse manager in order to potentially shed additional light into the factors related to underreporting and cumulative work related musculoskeletal injuries.

31. Implications for Practice  Understanding of first line nurse manager’s experience with response and management of nurse muscular skeletal injuries could provide an essential foundation for future studies. These studies could in turn provide research direction for musculoskeletal injury prevention and management.  Understanding to provide nurse injury reporting in general.  Provide direction to nurse manager education.

32. Methodology  Study Design  This study will use a qualitative, descriptive design to describe first line nurse manager’s experience in responding to and managing staff nurse work related musculoskeletal (WMSD) injuries.  The sample will be comprised of six to ten first line nurse managers from acute care hospitals.  The subjects will be selected through purposive sampling

33. Inclusion Criteria  These first line nurse mangers to be included in the sample must have:  (1) been in their role/job for more than 6 months, must have  (2) had experience with more than one reported work related staff nurse musculoskeletal injury, must be  (3) a first line nurse manager and must  (4)work in an acute care hospital facility.

34. Consent and Privacy protection  Participants who agree to participate will sign a consent form  Consent forms will be destroyed 1 year after research has been concluded along with all other research materials.  Consent forms along with all research material audio taped, and printed will be stored in a locked file cabinet.

35. Interviews  Interviews will be face-to-face  The tape recording will be the primary method of documenting the interview  Subjects will be informed that in order to provide privacy their actual name will be blinded

36. Demographic Questions   Nurse Manager Demographic/Survey Questions  Nurse Managers assigned name:­­­­­­­­­­­­­­­­________________  The purpose of these questions is to describe the sample only.  How many years of nursing experience do you have as an RN?________  How many years of nursing experience at this institution?___________  What is your highest level of education?___________  What is your highest level of education in Nursing?__________  How many units do you manage?_______________  How many nurses do you manage?_______________

37. Asking the Research question  After the demographic questions have been completed, the researcher will turn on the tape recorder and begin the interview process.  All subjects will be asked the following research question:“Describe your experience in responding to and managing staff nurse work related musculoskeletal injuries?”.  The subject will be encouraged to speak in their own language for as long and he/ she is comfortable.

38. Frame Work for Analysis  Lincoln and Guba’s framework will be used for analysis.  Credibility, dependability, confirmability, and transferability are the four categories that are required in order to demonstrate trustworthyness  Category schemes will be extracted  Search for trends that ring throughout the data

39. Content Analysis  Category schemes will be extracted  Search for trends that ring throughout the data  Demographic Data will be analyzed for then purpose of describing the sample as a whole and not to determine any relationships

40. Limitations of the Study  This study excludes first line nurse managers from alternate organizational settings.  Therefore the findings may not be generalized to first line nurse managers in alternative settings.  Further research will be needed to determine how practice setting affects the findings.

41. Summary  For the above stated reasons, this Doctoral Thesis proposal presented here within, should be granted to:  Susan Katz Sliski RN MSN CCM  Discussion  Feed back and review