H&S in the Home Care Enviornment- Lap_301

7/29/2019 H&S in the Home Care Enviornment- Lap_301

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Health & Safetyin the Home Care Environment

Second Edition January 2003


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Health and Safety in the

Home Care EnvironmentPublished by the Ontario Safety Association

for Community & Healthcare


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Health and Safety in the Home Care Environment

Copyright 2003 Ontario Safety Association forCommunity & Healthcare (OSACH)

4950 Young Street, Suite 1505Toronto, Ontario M2N 6K1

Canada

Telephone: (416) 250-7444Fax: (416) 250-9190

Toll Free:1-877-250-7444Web site: www.OSACH.on.ca

This booklet was produced in partnership with theWorkplace Safety & Insurance Board (WSIB) of Ontario

and the Ontario Ministry of Labour.

Parts of this document may be reproduced for thepurpose of education and training without permission

provided that appropriate credit is given to the OntarioSafety Association for Community & Healthcare.

ISBN 1-895793-71-8Product Number LAP-301

Second edition: January 2003


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Table of Contents i

Table of ContentsTable of Contents .................................................... i

Introduction .......................................................... 1Chapter Set-up 2

Module 1 Legislative Requirements ............................. 5

Module 2 Personal Safety......................................... 112.1 Employer Strategies............................................... 11

2.2 Worker Strategies ................................................. 14

Pre-Visit..................................................... 14

En Route to Client's Home ............................... 15

Leaving a Client's Home .................................. 16

Client Visits ................................................ 17

When Someone is Venting................................ 20

Module 3 Home Hazard Assessment............................ 233.1 Employer Strategies............................................... 24


Module 4 Communicable Disease Prevention................. 294.1 Employer Strategies............................................... 30

4.2 Worker Precautions ............................................... 31Module 5 Musculoskeletal Injury Prevention ................. 37

5.1 Employer Strategies............................................... 39


5.3 On-The-Job Exercises............................................. 43

Standing Extension (Back Bends)........................ 44

Flexion in Sitting .......................................... 45

Retraction in Sitting ...................................... 46

5.4 At Home Exercises ................................................ 47Lumbar Extension (Sloppy Push-Up).................... 47

Hamstring Stretch......................................... 50

Upper Abdominal .......................................... 51

Lower Abdominal .......................................... 52

Upper Back Extensors (Chest Raise).................... 53


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ii Table of Contents

Lower Back Extensors..................................... 54

Module 6 Motor Vehicle Safety.................................. 556.1 Employer Strategies ............................................... 55

6.2 Worker Strategies.................................................. 56

Module 7 Wellness Promotion ................................... 617.1 Employer Strategies ............................................... 62


Module 8 Emergency Preparedness Procedures ............. 658.1 Employer Strategies ............................................... 65


Appendix A Assessment of Unsafe Conditions in the Home En-

vironment 69Examples of Hazards 71

Entrance to Building/ Home............................ 71Chemical/Biological/Environmental Hazards ....... 71Personal Safety Hazards ................................ 72Fall Hazards ............................................... 73Fire Hazards............................................... 74Physical/Psychological/Ergonomic Hazards ......... 75

Hazards Impeding Emergency Response............. 75

References .......................................................... 77

Resources............................................................ 81Video Resources 82

Notes.................................................................. 83

Index.................................................................. 85


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Introduction 1

IntroductionA number of workersare involved in the deliv-

ery of home care: casemanagers, nurses,health care aides, ther-apy specialists, socialworkers, home supportworkers, physicians,laboratory technicians,dieticians, transporta-tion providers, and soon. This handbook isdesigned for theseworkers and the organi-zations that employthem or coordinate theirservices. It providesinformation on ways toreduce risk, prevent injury and promote worker safetyin the home care environment and emphasize theimportance of Internal Responsibility Systems (IRS). It

is consistent with the standards for home care organi-zations developed by the Canadian Council on HealthServices Accreditation.

According to the Canadian Home Care Association(1998), over 300,000 clients receive home care serv-ices in Ontario every year and the number of clientscontinues to grow. Demand for home care serviceshas increased as a result of earlier discharges from

hospital, increased outpatient surgeries, reduced hos-pitalization, as well as technological advances andpharmaceutical developments that have lengthenedthe survival of severely and chronically ill clients. Cli-ents receiving home care services include clients withAIDS, those on dialysis, chemotherapy and ventila-tors, as well as clients with mental illness and physical

"In the homeenvironment, safety is amore complex issuethan it is in a controlledsetting. There's morefor you to think aboutand watch out for, andthere may be moredangers facing youpersonally. Even in safehomes, you'll need tomaintain a level of

watchfulness that'stypically unnecessaryin dedicated health caresettings" (Cray et al.,1998:71).


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2 Introduction

disabilities. Medical technology in the home isincreasingly complex. Home health care workers arenow managing intravenous therapy, tracheostomycare, wound irrigations, etc., in addition to managingthe risks inherent in home environments, where pre-dictability and controls may be lacking.

Chapter Set-upThis handbook consolidates information availablefrom a variety of sources. It is organized under eightsections:

1. Legislative Requirements2. Personal Safety

3. Home Hazard Assessment

4. Communicable Disease Prevention

5. Musculoskeletal Injury Prevention

6. Motor Vehicle Safety

7. Wellness Promotion

8. Emergency Preparedness Procedures

Information for both employers and workers is pro-vided under each topic. The term "responsibilities" isused to denote legislative requirements. The terms"strategies" and "precautions" are used to denote sug-gested ways that employers and workers canenhance health and safety.

Each of these topics is interrelated. It is recom-mended that all the information be reviewed beforedeveloping policies and procedures regarding occu-pational health and safety.

Assessment of Unsafe Conditions in the Home Envi-ronment on page 69 contains information on helpingemployers and workers identify hazards in a homeenvironment. Home care agencies are encouraged touse or tailor this form so that it fits within their healthand safety programs as well as their client demo-

graphics.


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The creation of this document was made possible

by a partnership of the Ontario Safety Association

for Community & healthcare (OSACH), the WorkplaceSafety & Insur-ance Board (WSIB) and the Ontario

Ministry of Labour. These partners would like to

acknowledge the contributions of the following groups

to the contents of the document: the former Community

Workplace Safety Program (a collaborative project of 23

Toronto-area agencies), the Community Care Access

Centres throughout Ontario and the OSACH Community

Care Workplace Specific Hazard Certification AdvisoryCommittee.


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4 Introduction


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Legislative Requirements 5

Module 1 LegislativeRequirements

What is the Occupational Health and Safety Act(OHSA)? The OHSA is legislation enforced by theOntario Ministry of Labour to make sure that work-places are healthy and safe for workers. There arealso regulations made under the Act that apply to spe-cific types of workplaces and workplace hazards. TheOHSA applies to owners, employers, supervisors andworkers. Each person in the workplace is responsiblefor health and safety and must comply with therequirements of the Act.

Does the OHSA apply to a home health care agency?

Yes. An agency that employs workers to provide careto clients in the clients' homes is an "employer" underthe Act, with specific obligations to protect workers'health and safety.

Does the OHSA apply in a client's home? It may. While

the agency's worker is in a client's home providingservices to the client, the client's home is a workplaceunder the Act. However, the OHSA does not apply towork performed by the client in his or her home. Whilein the client's home, a worker must comply with theAct and work in a safe manner, according to theemployer's established work practices.


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6 Legislative Requirements

What are some of the potential hazards to a home careworker that could exist in clients' homes? Hazards inthe home might include the following:

potential violence from clients or others

exposure to communicable diseases

ergonomic issues (e.g., lifting of clients, etc.)

physical conditions (e.g., poor lighting, coldtemperatures, broken stairs, snow/ice onwalkways, etc.)

hazardous chemicals

environmental tobacco smoke

pets

oxygen equipment/tanks

What kind of responsibilities does a home care agency

have under the OHSA?A home care agency is anemployer. As an employer, the agency must takeevery reasonable precaution to protect the health andsafety of all its workers, including office staff and

those providing services in clients' homes. Theemployer must develop a health and safety policy andprograms that address the requirements of the Actincluding:

establishing joint health and safetycommittees or designating workerrepresentatives

conducting assessments of workplace

hazards establishing safe operating procedures for

the workplace

training workers

obtaining and providing workers with healthand safety information

providing appropriate personal protectiveequipment

ensuring equipment is inspected andmaintained

reporting accidents and fatalities


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Does a health care agency need to set up a Joint Healthand Safety Committee (JHSC)?An agency that has 20or more workers (full-time or part-time) must set up aJHSC. The committee must have at least two mem-bers for workplaces with 20 to 49 workers, and four ormore members for workplaces with 50 or more work-ers. At least half of the JHSC members must be non-management and selected by the workers or theunions they represent. At least one of the manage-ment and one of the worker representatives must becertified by training administered by the WorkplaceSafety & Insurance Board (WSIB).

The primary purpose of a JHSC is to provide a forumfor all workers to participate in the health and safety oftheir workplace, including those who work outside theagency office (e.g., in clients' homes). The JHSC hasthe power to identify hazards found in the workplace,including hazards that workers are likely to encounterin clients' homes.

A JHSC also investigates accidents and makes rec-

ommendations to the employer to improve workers'health and safety. The JHSC has the authority toinspect the workplace, but does not have the authorityto inspect a client's home. The employer is required torespond to the recommendations made by the JHSC.

If an agency has six to 19 staff, no JHSC is needed,but the workers or union must select a worker repre-sentative with rights similar to those of the workermembers on a committee. No committee or worker

representative is needed if there are fewer than sixstaff.

If an agency has many branches and those branches allhave more than 20 workers, is a JHSC needed at each

branch or is a central committee with representativesfrom each branch acceptable? Note that each sepa-rately located branch of a head office is a separateworkplace. A JHSC is required if a branch office has

20 or more workers regularly employed.

Employers may seek permission from the RegionalDirector of the Ministry of Labour to establish a multi-workplace JHSC. A multi-workplace JHSC is a JHSCestablished and maintained for more than one work-place or parts thereof. For further information, consult


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the Ontario Ministry of Labour document, Multi-Work-place Joint Health and Safety Committees (July2001). This document can be obtained by phoning thelocal Ministry of Labour office.

Can a home care worker refuse to do unsafe work underthe OHSA in a client's home? Yes. All workers have theright to refuse to do unsafe work, including home careworkers. Section 43 of the Act sets out restrictions onthe right to refuse unsafe work for workers who areemployed in specific types of health care facilities(e.g., hospitals and nursing homes), but these restric-tions do not extend to workers providing health care

services in a client's own home.

The OHSA sets out a general procedure to follow dur-ing a work refusal. Home health care agencies shouldbuild on this procedure and develop a detailed plan onhow the employer/supervisor and worker would pro-ceed with a work refusal while in a client's home.

As the Smoking in the Workplace Actdoes not apply

to private residences, employers should addressworkers' concern about residents smoking in theirhomes as part of their health and safety policy, whichis required under the OHSA.

Are home care service providers required to performinspections in the homes where their clients live?

Employers are required under the OHSA [Sec.25(2)(h)] to take every reasonable precaution in thecircumstances for the protection of the worker.Employers should try to obtain as much informationas possible about the client and his or her homethrough pre-placement inspection of the residence,questionnaires and/or interviews with the client orreferral agency.

Inspections of a private residence can only occur withthe permission of the occupier of a private residence.The authority of a JHSC or health and safety repre-

sentative is to conduct inspections at the employer'sworkplace, but this does not include a private resi-dence. The employer is required to address healthand safety concerns associated with the client's resi-dence, which are brought to his or her attention by thehome care worker, JHSC or health and safety repre-sentative.


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In order to conduct an investigation in the event of anaccident involving a home care worker, the employermust have permission from the occupier to enter theprivate residence. It would be a good idea to informthe client and obtain permission at the beginning ofthe service provision and then again if there is an inci-dent.

What is the role of the Ministry of Labour inspectors andwhat powers do they have? Health and safety inspec-tors respond to work refusals, complaints and acci-dents. They conduct investigations and, when theyfind a contravention of the Act or any health and

safety regulations made under the Act, they can issueorders to remove or reduce the hazard.

Although an inspector has the power to enter mostworkplaces without prior notification, she or he mayenter a dwelling that is being used as a workplaceonly with the consent of the occupier. This extends tosituations where there is a critical injury.

Which requirements apply to the handling of hazardouschemicals in the home? Ontario Regulation 833 asamended, applies to the control of exposure to biolog-ical or chemical agents in a workplace. Employersmust train workers in the safe use and handling ofhazardous substances in the workplace.

The OHSA includes the Workplace Hazardous Materi-als Information System (WHMIS), which is "right-to-know" legislation for workers. Under WHMIS, employ-ers must ensure that hazardous products in the work-place are properly labelled and that workers haveaccess to material safety data sheets and training forthe handling and use of these products.

Ontario Regulation 860 (WHMIS Regulation) asamended sets out the details regarding labels, mate-rial safety data sheets and worker training.

If agencies purchase industrial supply controlled prod-ucts for use in clients' homes, WHMIS applies. How-ever, it does not apply to consumer products that havebeen purchased by the agency or the client for use inthe client's home. Employers are required to providetraining in the use of consumer products and to


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ensure that all decanted products are properly identi-fied.

When workers are working alone in a private residence,what first aid requirements apply?All employers cov-ered under the Workplace Safety and Insurance Actmust meet the first aid requirements of Regulation1101. However, it is recognized that workers workingalone cannot treat themselves, even though therequirement for first aid training is enforced. In prac-tice, it is suggested that workers who drive vehicles toand from a client's home have small first aid kits avail-able in their vehicles.


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Personal Safety 11

Module 2 Personal SafetyThere is growing recognition of the problem of work-place violence. For home care workers, the potentialthreats to personal safety are amplified. Compared toworkers in institutional settings, they often work alonein environments where there are limited controls andgreater unpredictability. Travelling to and from clients'homes also poses security risks. For workers operat-ing in rural areas, there are obvious obstacles toaccessing prompt help in crisis situations.

While the Mental Health Actexists to regulate how

much information an employer is allowed to giveworkers about a client's history, protection of clientconfidentiality does not exempt employers from warn-ing workers of anticipated dangers related to a client'sbehaviour. The duty to warn a worker of a dangeroussituation relating to a client's behaviour supersedesclient confidentiality.

2.1 Employer StrategiesTo reduce threats to workers' personal safety, employ-ers should:

Have a written policy that commits theorganization to promoting worker safety. Thepurpose is to protect workers in situationsthat could result in injury or health problems,or expose them to possible criminal violenceor other adverse conditions. This policy

should prevent visits to homes where there isa likelihood of violent or dangerousbehaviour, as assessed by the worker, andpromote zero tolerance for violence(physical, sexual or verbal abuse) againstworkers.


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Employer Strategies

12 Personal Safety

Consult with the JHSC or worker health andsafety representative, as well as the workersdirectly involved, to develop work processesthat will ensure, as far as possible, workers'safety.

Ensure there is an adequate assessment ofthe home environment prior to undertakinghome visits. Use a letter of agreement orservice contract with the client so that allparties understand their roles andresponsibilities, as well as the zero tolerancepolicy for violence, the requirements for noalcohol or illegal drug use during the visit, etc.

Gather appropriate information that includesidentification of the possible risks in the homeenvironment, control measures that willminimize each risk and details of howworkers can get help in the event that theyare injured or encounter situations that couldendanger their safety.

Choose appropriate control measures. Thesecould include: a "buddy system;" directionson when to involve police; generic businesscards/name tags that provide only the firstname, professional title and organizationname; permission for taxi use where entryand exit of a neighbourhood could be a safetyissue; notification of police about nighttimeservices; a computerized client database thatflags higher risk environments; scheduling,which takes into consideration the

neighbourhood and other risk indicators; etc. Ensure workers are familiar with the

organization's control measures. Be alert tothe unique dangers that exist for workersservicing remote, high-risk areas. Specialcontrols may be needed in thesecircumstances.

Ensure that there is good communicationflow between the organization and the

workers. Workers should know about policychanges or administrative problems likecancelled appointments, which may upsetclients and elicit aggravated responses.


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Personal Safety 13

Ensure workers are aware of culturalinterpretation and translation services thatcan be accessed. The aim is to facilitate anunderstanding of the client's needs andappropriate violence prevention strategies.

Provide workers with training that includes:the employers' and workers' responsibilitiesfor the prevention of violence; how todetermine the risk of specific situations; howto leave a risky situation safely; and how toidentify, prevent and manage aggressivebehaviours. It needs to be emphasized to allworkers that their safety comes first. Where

workers will be involved in transporting apotentially violent person, ensure they aretrained on appropriate procedures.

Ensure that all incidents are reportedpromptly and that accurate record keepingexists. Continual analysis of incidents andinjury trends will assist to evaluate and revisethe organization's safety program - animportant component of a continuous quality

improvement approach to identified risks. Institute policies and procedures whereby

supervisors must approve all work completedafter routine business hours and must beinformed of the location, time, contact orclient name and phone number. A goodstrategy is to have workers leave a voice mailmessage for supervisors at a prearrangedtime when their after-hours work assignments

are completed. If a worker does not call, thesupervisor initiates the following to locate theworker: (1) calls the worker's home; (2) callsthe client; (3) calls the identified emergencycontact person; (4) calls the police.

Develop appropriate policies and procedureson how to re-establish worker-clientrelationships after a client has acted outverbally or physically.

When problems have occurred, provide thenecessary counselling or other help that theworkers need. Investigate the incidentthoroughly to identify ways to prevent futureproblems.


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Worker Strategies

14 Personal Safety

Provide a comprehensive program ofcounselling, debriefing, etc. for workers whohave experienced or witnessed violentincidents.

Provide workers with cellular phones/pagers,personal safety alarms, car spotlights, CALLPOLICE signs, etc. In rural areas, satellitephones may be required. Note: In Canada,pepper sprays and mace are illegal.

Ensure any mechanical safety devices areroutinely tested for effectiveness andmaintained on a schedule based on the

manufacturers' recommendations.

2.2 Worker StrategiesWorkers can use the following strategies to minimizerisks to their personal safety.

Pre-Visit Get to know the area, particularly the safe

areas in the district. Sources of danger can

only be anticipated if workers are constantlyin tune with the community and its changes.Tenant associations, local clubs, the police,etc. may have knowledge that could behelpful.

Plan the safest route to and from the client'shome, even if it isn't the most direct. Make anote of the locations of nearby policestations, public telephones and other public

buildings like hospitals as well as restaurantsor stores that are open late.

Know the numbers of police, emergencyservices and well-known, reliable taxiservices.

Know the bus, streetcar or subway route andschedule.

Do not give clients personal phone numbers.When placing calls to clients from home, beaware of the potential "call display" feature.To block call display, press "*67" prior tomaking the call.


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Personal Safety 15

Schedule and set up visits based on theknowledge of the area and the client (e.g.,visiting early in the day, with another person,meeting the family outside the dwelling).

Ensure head office is apprised of the locationof all visits, estimated arrival times andduration of visits.

En Route to Client's Home Dress conservatively. Wear religious symbols

discreetly. Clothing should not restrict yourmovements. Wear comfortable shoes with

nonskid soles that allow you to move quicklyand safely. Avoid wearing earrings or otheraccessories that could be grasped or pulledby another person.

Wear light-coloured clothing during eveningvisits to ensure visibility.

Inform the client if you are going to be late foran appointment.

Sit near the bus driver or streetcar operator

or in the Designated Waiting Area section ofthe subway.

Stand away from the edge of the subwayplatform and use the alarms in the subway,bus, streetcar as necessary.

If taking a taxi, ensure the driver'sidentification and photo are clearly displayedand match the driver. Sit behind the frontpassenger seat. State the route you prefer,

sticking to main streets. If you becomeuneasy with the driver, request that he or shepull over and let you out.

Make sure your headlights have been turnedoff to avoid draining the battery during thevisit.

Avoid parking in underground parking lots, inisolated areas or in deserted alleyways.

Don't park beside a van or other large vehiclewhere there is the possibility of being wedgedin.

Don't park too far from the client's homeunless it is safer to do so.

Roll up windows and lock the car.


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Worker Strategies

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Don't leave personal or nursing items visiblein the car. Visible medications can be atarget. Purses should be left at home and notlocked in the car or trunk. Requiredidentification and money should be placed infront pockets. Some groups recommendposting a sign on the dashboard, whichstates that there are no drugs or equipment inthe car.

Be alert to any passengers sitting in parkedcars and, where possible, avoid these cars.

Try to keep arms free, where possible.

Do not wear headphones. Stick to well-travelled streets and avoid

shortcuts through parks or other woodedareas, lots or alleys. Stay alert and mindful ofthe surroundings.

Walk briskly and with purpose. Stand tall andmake quick eye contact with the peoplearound you. Walk against the flow of traffic soyou can see approaching vehicles.

Do not participate in lengthy conversationswith people in the street.

Where possible, do not walk through acrowd.

If someone harasses you, stay calm and sayloudly, "I don't know you. Leave me alone."

Leaving a Client's Home

Notify the office that the visit is completed. Have car keys in hand before leaving to avoid

delays in entering the car. Car keys should bekept on your person at all times. You maywant to carry a second set of keys as backup.

If the neighbourhood seems dangerous, askone of the client's family members to escortyou to your car.

Check the outside as well as the front andback seats before getting into your car.

Lock the doors as soon as you are in the car.

Obtain a CALL POLICE sign. Use this sign torequest help in the event of a car breakdown.

Do not use pay phones in potentiallydangerous areas unless it is an emergency.


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Personal Safety 17

Avoid using automated bank machines in theevenings.

If you think someone is following you, switch

direction or cross the street. Walk toward anopen store, restaurant, or lighted house. Ifyou're scared, yell for help.

If you think you are being followed in yourcar, drive to the nearest police, fire station orgas station or an open business. Do not headhome.

Never hitchhike or pick up hitchhikers.

If someone tries to rob you, don't resist. Give

up your property, not your life. Shout FIRE toattract attention from bystanders. Report thecrime to the police.

If someone attempts to assault you near yourcar and you fear serious injury, roll under thecar if possible and yell for help.

If someone tries to force you into a vehicle,fight back (yell, kick) even if they have aweapon. You are at significantly greater risk ifyou are forced into the vehicle.

Report broken street lights, etc. Lobby localgovernment for better lighting in publicplaces.

Client Visits Never enter a home that is not scheduled for

a visit.

Where appropriate, inform thesuperintendent or security personnel of yourwhereabouts in an apartment building.

Exercise care in hallways, elevators andstairwells. In elevators, stand close to thecontrol panel with your back to the wall. Beaware of the location of the alarm. If anyonebothers you, press the buttons on the floorclosest to the one you are on and press the

alarm - do not push stop. Get off as soon aselevator stops. Knock on the first availableapartment door. If avoiding an assault, yellFIRE and kick the walls. Do not get on anelevator where you feel uneasy about anyonewaiting with you to enter the elevator. Use theexcuse "Go ahead. I'm waiting for a friend."


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Worker Strategies

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Stick to the centre of the hallway, avoidingalcoves and hidden corners. In a hallwayemergency, knock on as many doors aspossible and yell FIRE. If you fear seriousinjury to yourself or others, pull the fire alarm.

If you must use stairwells, keep a count of thenumber of floors you are ascending ordescending as some buildings may not havethe floor doors numbered.

Do not enter a home if there is a visible threatto safety (e.g., drugs, alcohol, weapons,animals, pornographic posters, etc.) or where

your instinct tells you not to. According toCanada's Firearms Act, all firearms are to beunloaded, locked or in a secure containerand in a place where ammunition is notreadily accessible.

Pause for a few seconds when enteringsomeone's home to assess the situation andplan a response. Observe the environmentfor signs of used syringes, odours, clutter,other people, household items that could beused as weapons, etc. Make a sweep witheyes in the first 30 seconds to note thelocation of the phone and any obstacles to aquick exit.

Do not remain at a visit where a client, aclient's visitors or family members areintoxicated, abusive, inappropriately dressedor where sexual comments and innuendoesare made or pornography is viewed in your

presence. Leave if you are told to leave.

Let the client lead the way down corridors, upstaircases, etc.

Sit where you have a good view of thebedrooms or the hall to the bedrooms. Listenfor anyone coming in from an outside door.

Always leave an exit route or situate yourself

between the exit and the client. Do not allowyourself to be cornered. Use your judgementas to whether a door should be left open andunlocked.


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Personal Safety 19

Carry a lightweight briefcase for an interview.Place necessary valuables, equipment, etc.in your briefcase. If you need to carryvaluables outside your briefcase, wear ajogger's pouch. Try to turn it so it is notvisible.

For an interview, stay in the living room ordining room. You may want to avoid havingconversations in the kitchen, where potentialweapons (e.g., knives) may be readilyavailable.

Never promise what you cannot deliver.

Record any notes with discretion. If a client orfamily member seems protective and hostileabout having a stranger in the home orperceives that your assessment questionsare intrusive, avoid lengthy explanations orjustifications for your presence.

Adopt a defensive sitting position. Sit withyour strong leg back and your other legforward. This will allow you to get out of your

seat quickly without using your hands. Sit in a hard-backed chair. You can get up

faster from a firm chair than a soft sofa.

Leave your shoes on. If a confrontationarises, you need to be able to leave in ahurry. If you do have to leave your outdoorfootwear at the door, carry a pair of shoes forindoor use. If the client doesn't want youwearing shoes inside, mention that you have

to wear them because of your employer'shealth and safety policy.

Recognize the first signs of a change in yourclient's behaviour or the behaviour of othersin the home. Assess the client's appearance,routines of daily living, how he or she spendsthe day, and any other outstandingcharacteristics. Watch for subtle changes anddanger signals (e.g., explosive anger, pacing,

destruction of property) that might indicatethe need for immediate safety interventions.

Report any unusual incidents to yoursupervisor as soon as possible.


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Worker Strategies

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When Someone is Venting

Hunter (1997) suggests that a proactive preventionapproach to violence involves collecting informationprior to doing the first home visit. Information from thereferring agency as well as the client and his/her fam-ily can be gathered. Specifically, potentially violent

conditions need to be determined. From the referringagency, Hunter recommends asking questions abouthistory of physical or verbal abuse, known triggers,existence of restraining orders, recent divorce/separa-tion, frequent requests for changes in providers, thepresence of mental illness and impaired cognitivefunction. From clients and their families, the existenceof weapons or lethal items (e.g., bows and arrows,acids, etc.), vicious pets, volatile relationships withothers (e.g., neighbours) should be determined aswell as their plans for reducing these threats duringthe worker's visit.

If clients are delusionaland believe that theyarebeing threatened, workers should attempt toincrease their feelings of safety. For example,workers could reassure clients that they will besafe talking to them. It is important that workersallow about four times the personal space betweenthemselves and the client and refrain fromtouching the client. While firm and consistentdirection is needed, workers should not argue ortry to convince delusional clients that their thinkingis irrational. If clients have dementia, workersshould aim to anticipate their needs and avoidunfamiliar situations. A family member who knowstheir routine can help to determine the best time forhome visits (e.g., when the client isn't too tired orhungry). Every time workers visit, they shouldensure that the family member introduces themand explains the reason for the visit. If the client isgetting frustrated by requests, the assessmentprocess, etc., workers should stop makingdemands and try changing the conversation or

invite the client to sit quietly, take a walk, etc.Workers should not touch the client as it mightstartle him or her.


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Personal Safety 21

With potentially aggressive clients, "no harm" con-tracts can be used as a measure of protection1. Thatis, clients can be asked to agree to and sign a writtenstatement that they will not hurt themselves or others"no matter how bad things get" and will use an alter-native strategy such as talking to someone, usingrelaxation techniques, etc. Workers who are trained inanger management and relaxation techniques candiscuss these methods with clients.

If a client or a family member is angry and begins tovent, it is important that workers stand up so that thisperson does not dominated them. It is also advised

that workers:

Stay calm.

Stand facing the aggressive person with theirfeet slightly apart. They should keep theirarms at their sides with palms up (neverclench fists). This is less threatening and theindividual can see that the workers do nothave a weapon.

Keep their voices down. Don't argue with theaggressor. Speak slowly using simple,precise words. Be polite, calm and positive(e.g., "You seem upset. Can we sit down andtalk about your concerns?" "What can we doto increase your comfort with this situation?").

Identify the issues leading up to theescalating behaviour to reassure the clientthat the worker is concerned.

Use culturally-appropriate eye contact. Somepeople find eye contact a threat or challenge;for others, direct eye contact conveys asense of concern and support.

Let the person know they are being listenedto, by using appropriate communicationsignals (e.g., paraphrasing, head nodding,etc.). Reassure clients that their specificconcerns will be addressed as soon as it is

feasible and safe to do so.

1. Hunter, 1997


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Worker Strategies

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Advise clients of the organization's complaintprocedures when they disagree withsomething or believe that something is unfair.

Communicate to clients, in verbal andnonverbal ways, that they are expected tomaintain control over their behaviour. Issuebehaviour limits and inform clients of thepositive consequences that will result fromcompliance.

If possible, move away from the person,leaving a distance of about six feet. At thisdistance, it will be more difficult for the worker

to be hit. Watch the person's body language, includingshaking or clenching fists, or a change inposture. He/she may be ready to dosomething physical.

If the client is quietly looking off into spaceafter a period of venting, he/she may beconsidering taking action against the worker.The worker should say something out of the

ordinary to get the client's attention or try todivert him/her by giving him/her something todo in another room (e.g., ask for a glass ofwater).

If possible, phone the office to alert them to aproblem. A prearranged code can be used toalert them to a crisis (e.g., "I need to speak toDr. Black.").

Leave the house if it is suspected that the

person is going to lose control. If a workercannot leave, he/she should call the police.

Leave immediately if the client brandishesany kind of weapon. The worker should callpolice from a safe distance or from his/hercar. If a worker needs to get out fast, he orshe should not be concerned about gatheringpossessions.

In the event of family violence, workers

should leave the premises and call policewhen they are a safe distance from theresidence or in their car.


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Home Hazard Assessment 23

Module 3 Home HazardAssessment

There are four ways thathazards are controlled,reduced and elimi-nated. These are:

1. Engineering con-trols: modifica-tions to theenvironment to

reduce exposureto hazards (e.g.,substitution of lesshazardous prod-ucts, provision oflifting device).

2. Administrativecontrols: policiesand procedures

determined by employers (e.g., work assign-ment, training in specific work practices).

3. Work and hygiene practices: worker practices(e.g., hand washing, proper body mechanics,use of Standard Precautions).

4. Personal protective equipment (PPE): clothingor equipment designed to protect the worker(e.g., gloves, eye protection). Implementingengineering controls in the home environment

can be problematic. More reliance is typicallygiven to administrative controls, work andhygiene practices and PPE. It is particularlyimportant that workers hone their observationand analytical skills so they can assess homeenvironments for hazards.

"The first contact with aclient should be used tonegotiate the jointresponsibilities of homeservice delivery. Theworker's responsibility isto deliver the right serviceto the right person at theright time. One of the

client's responsibilities isto ensure a safe workenvironment. This meansa work area that is free ofpets, alcohol, illegal drugsand abusive behaviour"(Leiterman, 1999).


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Employer Strategies

24 Home Hazard Assessment

3.1 Employer StrategiesEmployers should:

Have in place control measures and policiesaimed at the prevention, recognition andcontrol of potential exposures. Thesedocuments should address areas such asrisk communication, notification of pregnancyor planning for pregnancy, job reassignment(when necessary) and medical surveillance.All workers should have the right to askclients and their family members to refrainfrom smoking and remove pets during thehome visit. A letter of agreement betweenthe CCAC and the client may be used toclearly identify the roles and responsibilitiesof the client, workers and members of theteam.

Adopt a hazard identification system andtrain workers to use it. For example, theGrey-Bruce CCAC uses a colour codingsystem to alert providers to potential risks(i.e., purple = violence/abuse; orange =weapons; red = fire; green = environment;blue = substance abuse; black = other). Thename of the colour is written on theassessment sheet beside "Current History"and underlined to alert providers uponreferral.

Have in place policies related to preparation,administration, transportation and disposal of

antineoplastic agents, other drugs andspecimens. Arrange working relationshipsand written agreements with pharmaciesregarding the type and amount of supplies,timing of delivery and pickup, emergencyresponse plan and pertinent client education.

Train workers on procedures and techniquesfor administering and disposing ofantineoplastic agents and equipment with an

aseptic technique. Include information onhow to protect family members, visitors andpets.


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Ensure a formal documented inventory isconducted, listing chemicals and otherhazards to which workers, clients and theirfamily members could be exposed.

Provide training to workers on how to readconsumer product labels, recognizeconsumer product symbols, properly use,handle, store and dispose of consumerproducts and respond in the event of anemergency. Where controlled products (asdefined in the Hazardous Products Act) arealso present, the requirements under WHMISwith respect to labels, MSDSs and training

must also be met. Ensure workers know how to use public

equipment like emergency exits, fire alarmsand fire extinguishers.

Provide workers with appropriate PPE(Personal Protective Equipment - gloves,gowns, eye wear, face protection, respirators,PPE disposal products) and ensure theyknow how to correctly use this equipment.

Ensure home health care workers assess,document and evaluate a client's techniquefor self-administering medication andperforming clean-up to ensure proper safetyprecautions are taken for the worker's ownprotection.

Develop methods for reporting accidentalexposures and hazardous effects.

Provide an appropriate monitoring, record-keeping and a hazard communicationprogram, which addresses methods for spillmanagement and disposal of bodily fluids.

Consult with the JHSC or worker health andsafety representative about work-relatedaccidents and problems and appropriatepreventative measures.

Use team conferencing as a means of

effectively communicating concerns aboutclients and transferring knowledge ofproblem-solving techniques.


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Worker Strategies


Have an intervention procedure in place fordealing with workers at risk of psychiatricemergencies (e.g., suicidal behaviour).

Establish an Employee Assistance Program(EAP) so that workers can receivecounselling for problems both on and off thejob.

3.2 Worker StrategiesIn addition to addressing the problems identified in anassessment of the home environment, workersshould:

Report any health and safety concerns thatthe client does not address. The employershould have a policy on this.

Take along a snake light for a makeshiftsource of light.

Carry as little as possible into the home untilinsect or rodent infestations are handled.Place any belongings in a clean area. Inspect

it discreetly before leaving so that insects oreggs are not carried out.

Ensure spills are promptly cleaned.

Conduct a formal documented inventory ofchemicals and other hazards to which theworker, the clients and their family memberscould be exposed. This should include anyhazardous material that the worker bringsinto the home to provide client services.

Conducting an inventory will help to identifyhazardous substances.

Where necessary, educate clients in the safeuse, handling and storage of consumerproducts and other hazardous materials andemphasize the importance of maintaining ahazardous material inventory.

Always read the label before using ahousehold cleaning product or otherconsumer product used in the home.

Ensure grab bars and bath stools are madeavailable. Educate the client on how to useaids and prevent falls. Falls prevention forclients means less opportunity formusculoskeletal injury in workers.


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Ensure client and family members neversmoke around oxygen delivery equipmentand that such equipment is never usedaround an open flame. Remind clients thatoxygen will saturate their clothing, towels andsheets, increasing the risk of a rapidlyspreading fire. Workers should leave if clientsrefuse to exercise caution around oxygendelivery equipment.

Never lubricate an oxygen gauge with apetroleum-based product. Never usepetroleum-based adhesive tape to label anoxygen cylinder.

Ask that pets be kept restrained or kept out ofthe room on initial visits. If it is determinedthat the pet has attacked any visitor in thepast or if the worker is uncomfortable arounda pet, have the pet restrained or put in aseparate room for every visit.

Do not assume that animals will react thesame way on every visit. It is important thatworkers proceed with caution - they are theintruders in the animal's home. Even anormally calm animal may grow protectiveduring unfamiliar nursing procedures.

Never offer an outstretched palm or look at adog or cat straight in the eye. Look down or tothe side. Do not approach a dog or cat thathas its hair raised, teeth bared, tail raised orbetween its legs - these are signals that theanimal feels threatened.

Maintain a distance of at least ten feet fromthe pet. If a pet approaches, slowly backtoward an exit or safe area.

Acknowledge the importance of pets in thehome environment and show interest in therelationship that clients have with theiranimals.

If required to handle or clean up after pets,

including reptiles, fish or birds, wash handsthoroughly with soap and water. Because ofthe risk of a fetal illness called toxoplasmosis,pregnant women must not clean up cat litteror cat feces.


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Worker Strategies


Keep a flea spray bottle in your car,especially during the fall season. Spray lowerlegs and feet when you suspect you havebeen in contact with fleas.

If bitten by a dog and there is a puncture/laceration, wash wound thoroughly with soapand water at the client's home and goimmediately to the nearest treatment facility.A worker may need to undergo rabiesprophylaxis if the animal has rabies.

If scratched or bitten by a cat, wash lesioncarefully with soap and water at the client's

home and seek medical attention after thevisit. (Cat bites and scratches may result inhemorrhagic septicemia or cat scratch fever.)Any animal bite that occurs must be reportedto the local public health unit for follow up todetermine if there is any risk of rabiestransmission. Clients can be advised that thebite will be reported and that such a report isroutine and not intended to get anyone "introuble."

Call animal control authorities as soon aspossible when sick animals are noticed in aclient's home or neighbourhood.


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Communicable Disease Prevention 29

Module 4 CommunicableDisease Prevention

Understanding how the specified communicable dis-eases are transmitted is important in terms of theirprevention and control. Workers should have knowl-edge of the following:

the agents (i.e., bacteria, fungi, viruses) thatcause communicable diseases

where the agents are commonly found (e.g.,blood)

objects or surfaces in the environment thatcan play a role in the spread of the specifieddisease

how the agents can be spread

how long it takes to develop signs orsymptoms of the disease (incubation period)

when people are most likely to be infectious(i.e., when the disease is communicable or

the stage in the disease when it is mosteasily spread)

whether the worker is susceptible (likely toget the disease) or has a natural or acquiredresistance to the disease

Immunization is a key strategy in preventing transmis-sion and spread of certain communicable diseases. Inaddition, precautions, safe work procedures, barriersand equipment should all be used to reduce the risk ofexposure.


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Employer Strategies

30 Communicable Disease Prevention

Health Canada's revised infection control guidelines,Routine Practices and Additional Precautions for Pre-venting the Transmission of Infection in Health Care(1999), should be consulted for further details.

4.1 Employer StrategiesEmployers should provide:

A comprehensive control program incollaboration with local public healthdepartments and infection controlpractitioners. OSACH offers a documenttitled "Developing Infection Control Policies"available on the OSACH web site and CD-ROM.

An ongoing risk assessment program thatincludes information about tuberculosis (TB)in the community, data interpretation andfollow-up for exposures in co-ordination withthe local health department.

Participate and encourage participation in TB

control programs for staff and clients. An annual influenza vaccination campaign forworkers providing direct care to susceptibleindividuals.

A written TB infection control program. TheEmployment Agencies Actrequires that newworkers have a skin test or x-ray within the12-month period prior to beginningemployment.

Engineering, administrative and workpractice recommendations and requirementsfor PPE (e.g., respiratory protection).

A blood borne pathogen exposure controlplan that is evaluated and reviewed annually.

A hepatitis B vaccine program includingpolicy, procedures, a consent/refusal formand an employee information sheet.

A policy and procedure for the safe disposalof used needles and other sharps, whichdefines whether it is the client's or agency'sresponsibility.

A process whereby workers are trained,observed and evaluated in the performanceof infection control measures in the home


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environment. This process should occur atthe time of orientation, and at least annuallywhen there are changes in client status.

Education and training that will give workersthe skills to apply Standard Practices andadditional precautions appropriately in allsituations. A training program called"Developing Infection Control Policies &Procedures: Infection Education Program in10 Modules" is available on the OSACH website or in CD-ROM.

Sharps containers for all clients who are

receiving infusion therapy or injections. Non-latex barrier protection for workers.(Although less than 1% of the general publichas allergic reactions to latex, more than10% of health care professionals do.)Workers who have a latex allergy should beencouraged to wear a medical alert bracelet.

Procedures relating to antibiotic resistantorganisms (AROs), which include direct

communication with workers regarding theARO status of clients to ensure properprecautions are followed.

4.2 Worker PrecautionsWorkers should:

Use proper food handling techniques toprotect workers and clients. This means

ensuring raw meats are separated fromcooked or ready-to-eat foods, cleaning andsanitizing all surfaces contaminated by rawmeat, thorough hand washing after handlingraw foods and before preparing any foods,thoroughly cooking hazardous foods such asmeats or eggs (i.e., ground meats andchicken must be cooked so that there is nopink in the middle), ensuring that all foods arefrom a reputable source and storing foods atrefrigeration temperatures below 5C.

Avoid handling dog treats as some may becontaminated with salmonella.

Teach sound infection control techniques toclients and their families.


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Worker Precautions


Keep immunizations up-to-date using thefollowing guidelines:

Tetanus/diphtheria should be

administered once every 10 years. If aperson sustains a puncture wound, otherthan a clean minor one, and it is 5 yearsor more since the last inoculation, then abooster dose of vaccine should be given.

Polio routine immunization is notconsidered necessary for adults living inCanada. Most adults are already immuneand have a very low risk of exposure towild polioviruses in North America.However, immunization is recommendedfor health care workers who are in closecontact with people who may beexcreting wild or vaccine strains ofpolioviruses, and some employingagencies may require polio vaccinations.

Rubella (German measles) vaccineshould be administered to femaleworkers who have no documentedhistory of vaccination or who testnegative for the rubella antibody. Femaleworkers should be advised to avoidpregnancy for three months aftervaccination.

Measles vaccine should be administeredto people born after 1956 and who haveno documented record of immunizationor who are known to be seronegative.

Hepatitis B vaccine should beadministered to workers who are at riskof potential exposures such as blood orsharps injuries. A series of threeinoculations should be administered overa six-month period.

Use Standard Precautions and additionalprecautions with all procedures where thereis risk of exposure. Standard Precautionsgive workers the knowledge and skills toassess personal risk in emergency situationsand to take precautions to protect

themselves.


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Wash their hands using the seven stepslisted below, after any contact with a client, aswell as before and after each home visit,even if gloves have been worn:

1. Remove all rings.2. Wet hands with fresh, running water.

3. Place a small amount (1-3 mL) of liquid soapfrom a single-use dispenser on the palm of onehand.

4. Rub hands together for 10 seconds so a latheris produced. Provide friction to all surfaces,getting in between fingers and under finger-

nails.5. Rinse hands thoroughly with clean, running

water. Try not to handle the faucets oncehands are clean. Use a paper towel, if avail-able.

6. Pat hands with paper towels.

7. Use hand lotion from a single-use dispenser, toput moisture back into the skin.

Encourage clients to purchase soap andpaper towels. Do not use the client's towelsfor drying hands.

Carry antimicrobial hand wipes or hand gelsin the event that access to water is limited.

Handle any clothing splattered with blood orother body fluids as little as possible. Thisclothing can be washed in a normal laundry

cycle. Treat the nursing bag as a piece of cleanequipment and handle it in such a way as toprevent contamination from hands or usedequipment. Hands should be washed beforehandling equipment inside the nursing bag.

Clean and disinfect any equipment asinstructed by the manufacturer prior toplacing it back in the nursing bag.


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Worker Precautions


Wear clean, non-sterile gloves when incontact with blood, body fluids, secretionsand excretions, mucous membranes,draining wounds or non-intact skin; whenhandling items visibly soiled with blood, bodyfluids, secretions and excretions; and whenthe worker has open skin lesions on his/herhands.

Wear disposable gloves when cleaning bloodor body fluid spills on floors or other surfacesand wipe up the fluid using disposabletowels. The area must then bedecontaminated with an appropriate

germicide or a fresh 1:10 solution of bleachand water. Let the area air dry. Removegloves before touching clean surfaces. Washhands after removing gloves.

Change gloves as soon as they become tornor soiled and also between handling differentpeople. If latex gloves are chosen, lowprotein and unpowdered gloves should beselected. Dispose of gloves in the proper

manner and wash hands as soon as possibleafter removing gloves.

Wear masks and protective eye wear whenthere is a risk that the worker may besplashed with blood or body fluids.

If artificial respiration needs to be given to aclient, use a resuscitation mask with a one-way valve to limit exposure to the client'ssaliva.

Handle soiled dressings and other medicalsupplies carefully, using protective gloves.Try to keep the materials away from clothing.Wash hands thoroughly with soap and waterafter removing gloves and immediately afterexposure to infectious waste. Placedisposable materials in plastic bags andclose them securely. Put the garbage bag outfor regular garbage pickup.

Avoid contact with any sharp object orinstrument, including needles. If workersaccidentally punctured or cut themselves witha used sharp, they should treat the woundusing first-aid measures and then seekmedical attention within two hours.


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Dispose of sharps in properly designedpuncture-resistant containers. Do not re-capneedles. A sharps disposal container shouldbe made of puncture-resistant material andshould not be stored near food supplies orwhere children can reach it. Sharpscontainers should be clearly labelled ashazardous materials.

At the end of the workday, remove clothesupon arriving home and store them in a safe,contained area until they can be washed.

TABLE 1. Worker Precautions by Transmission Route

a

Transmission Diseases Precautions

AIRBORNE

Carried in

airborne or

dust particles

and inhaled

Suspected and active

tuberculosis (TB),

measles, varicella,

herpes zoster and Lassa

fever, Ebola, Marburg,

other hemorrhagic feverswith pneumonia

All workers should be immune

to measles and varicella.

Workers' susceptibility should

be assessed prior to caring for

clients with varicella or herpes

zoster. Workers not immuneshould be restricted from visiting

infected clients.

Workers should wear an

appropriate mask (NIOSH

Certified N-95) at all times while

in the home of a client who has

infectious TB.


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Worker Precautions


DROPLET

Transmitted

via client

coughing or

sneezing and

procedures

like

bronchoscopy

Diphtheria, H. influenzae

type B invasive

infections, mumps, N.

meningitis, parovirus

B19, pertussis, plague,

rubella, streptococcus

Group A invasive

disease and

streptococcus Group A

pharyngitis, pneumonia,

scarlet fever, viral

respiratory tract

infections, influenza,

Lassa fever, Ebola,

Marburg, other

hemorrhagic fevers with

pneumonia.

Workers not immune to rubella

or mumps should not conduct

visits to infected clients unless

essential and equipped with a

mask.

Workers should wear a surgical

mask if within one metre of the

client who is coughing or is

likely to cough. (It is notnecessary to wear a mask if the

worker is immune.)

Workers should wear eye

protection as per Standard

Precautions.

CONTACTDirect (body

surface to

body surface)

or indirect via

hands not

being washed

between

clients,

contaminatedequipment,

other

inanimate

objects in the

client's

immediate

environment

Diarrhea due tocampylobacter,

pathogenic strains of E.

coli, giardia, rotavirus,

salmonella, shigella,

yersinia, C. difficile

infections with diarrhea,

enteroviral infections,

hepatitis A and B, herpes

simplex virus, scabies,

varicella, herpes zoster,

congenital rubella,

certain viral respiratory

tract infections,

hemorrhagic fever,

antimicrobial resistant

organisms

Workers should wear gownsand gloves if there will be

substantial contact with the

client or environmental

surfaces.

Equipment should be cleaned

and disinfected before it is

transported and used with

another client. The need for

dedicated equipment should beassessed.

Workers should take all

precautions to minimize the risk

of transmission.

a. Source: Health Canada. (1999). Routine Practices and Additional

Precautions for Preventing the Transmission of Infection inHealth Care: Revision of Isolation and Precaution Techniques.

CCDR Supplement, Volume 25S4.

TABLE 1. Worker Precautions by Transmission Routea

Transmission Diseases Precautions


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Musculoskeletal Injury Prevention 37

Module 5 MusculoskeletalInjury Prevention

The home environment poses many risks in terms ofmusculoskeletal injury. For example, traditional, non-adjustable beds in the home can be ergonomically ill-suited to allow the worker to perform a proper lift ortransfer and workers must often perform transfers andlifts without assistance. A study conducted in Swedenfound that the annual incidence of injury from overex-ertion accidents and musculoskeletal diseases wasfound to be higher in home care workers than all

employed women in the country2. Lifting other peoplewas the most frequently reported cause of overexer-tion accidents. A more recent study conducted in theU.S. found that injuries among home health careworkers, while less frequent than among workers fromnursing homes, resulted in greater lost time fromwork3. This indicates greater severity of injury. Muscu-loskeletal injuries are usually caused by awkward orstatic/prolonged postures, repetition and forceful exer-

tions.

Awkward postures result when the body is forcedinto a position that deviates from the neutral positionof a joint. When the body is forced into awkward pos-tures, the ligaments and muscles with their tendonscannot protect the underlying joints. There is a dangerof injury to all these structures. Client handling tasksmay involve awkward postures of the back, neck,shoulders, elbows, wrists and lower extremities. Inaddition, space limitations in the home environmentoften result in awkward postures being used.

2. Ono et al., 1995

3. Meyer and Muntaner, 1999


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38 Musculoskeletal Injury Prevention

With static/prolonged postures, the body is held inthe same position for a long period of time. The mus-cles are in a constant state of static contraction. Pro-longed standing puts stress on the legs and back.Tasks, such as making beds, transferring and lifting,bathing, feeding and dressing clients cause prolongedtrunk and neck flexion.

Repetitive lifting and bending, squatting and stoopingalso occur during the provision of home care services.When the musculoskeletal tissues are used tooquickly, too often and for too long, they become dam-aged.

Forceful exertions result from pushing, pulling, low-ering, grasping, carrying and lifting excessive loads orsudden/unexpected shifts in loads (e.g., when a clientmoves unexpectedly during a transfer).

A Swedish study undertaken to investigate physicalwork load, physical capacity, physical strain and per-ceived health among elderly aides in home care serv-ice found that home care work was characterized bylong periods of standing and walking. In addition, pos-tures potentially harmful for the low back and shoul-ders occurred frequently. It was concluded that elderlyaides in home care service are probably exposed tohigh risks of overexertion and impaired health as aresult of high postural loads in combination with thestress created by time pressures and lack of equip-ment.


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5.1 Employer StrategiesIn order to reduce musculoskeletal injuries, it is impor-tant that employers:

Screen workers for potential risk factorsregarding back injury (e.g., past history ofback injuries, knowledge of body mechanics,physical conditions) and delegateassignments accordingly.

Put in place policies and procedures tosupport a client handling program thatincludes:

Procedures for all service groups (i.e.,nurses, social workers, support workers,therapists).

Procedures for hazard assessment (i.e.,when, how and by whom it should bedone).

Procedures for obtaining information onsuppliers and their equipment.

Procedures for ensuring equipment is

maintained. Methods of reporting incidents and

injuries.

An occupational health componentregarding prompt and early treatment ofan injured worker.

Develop procedures so that the need forequipment in the home, such as liftingdevices, adjustable beds and commodes, isdetermined during the initial assessment andwhen the condition of the client changes.Ensure that workers know how to operatelifting devices and other aids correctly.Include information about hazards, defectsand recalls.

Establish an assessment process wherebythe home environment is modified to reducethe intensity of biomechanical stresses andphysical demands associated with transfersand lifts.

Include specifics about the type of lift/transfer/equipment required in the clientassessment and client contract.


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Worker Strategies


Train new workers in musculoskeletal injuryprevention. This training should includeinformation on the anatomy and physiology ofthe spine, body mechanics, specialconsiderations during pregnancy, practicaldemonstrations of transfers and lifts(including how to use transferring/liftingdevices) and "on the job" evaluationcomponents.

Provide refresher training to all workers on anannual basis.

Provide task reassignment for pregnant

workers where client transfers and lifts areconcerned (i.e., pregnant workers are atgreater risk due to softening of ligaments andan inability to lift close to the body).

Provide a wellness program to promotephysical fitness and proper body mechanics.

5.2 Worker StrategiesWorkers should:

Attend training, as required (initial andreview), for lift and transfer procedures andapply the knowledge acquired when workingwith clients.

Request client-specific demonstrations orinstruction on lift/transfer when unsure orwhen the type of lift/transfer has changed.

Report any unsafe lift/transfer or defective

equipment and refuse unsafe lift/transfer. Report changing client conditions (e.g.,

physical deterioration that would make aspecific lift/transfer no longer appropriate orsafe).

Employ safe work practices with respect toclient handling, material handling (e.g.,laundry baskets, garbage), back care andergonomics.

Ensure that equipment and aids are in goodworking order.

Educate the client and family members aboutthe safe use of equipment, supplies andmedical devices.


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Ensure that there is adequate lighting.

Where possible, aim to control thetemperature in the home environment.

(When exposed to hot or cold temperatures,the body is more susceptible to overexertion.)

Take into consideration the type of flooring inthe home prior to engaging in client handlingtasks. For example, pushing andmanoeuvring a wheelchair on a carpet ismore difficult than on hard surfaces likelinoleum.

Exercise caution in client bathrooms. The

limited space and poor layout of many homebathrooms increases the risk of injury to theworker and the client. Where possible,arrange bath and shower accessories (i.e.,towels, washing and cleaning supplies) foreasy access.

Exercise caution in the client bedrooms.There is often limited space. The workershould have access to the side of the bed

where the client will be transferred or lifted. Ifpossible, rearrange furniture to accomplishthis.


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Worker Strategies


FIGURE 1. Assessment card


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When using gloves, ensure that they fit welland are made of material that is appropriatefor the task. Gloves increase the amount offorce needed to perform tasks or grip objects.

In cases where children are present, ensurethat they do not interfere with the health careprocedures, the operation of potentiallydangerous medical equipment or the client'smobility or safety. (The same can be said forpets.)

Remove physical hazards, especially trippinghazards, from the environment. This will help

to prevent client falls and, thus, reducepotential injuries in workers who must thenget the clients back on their feet.

Use good posture when driving - sit close tothe pedals and use the seat belt and a firmbackrest. Backrest should be reclined to a10 angle. Make use of all the adjustmentsthe car seat has.

Immediately after driving, give yourself one or

two minutes to stretch and rest before tryingto lift anything heavy.

Practice good body mechanics whenretrieving items from the car and/or trunk. Donot retrieve items stored on the passengerseat from the driver's side. Place items in thetruck toward the front edge.

5.3 On-The-Job ExercisesBefore initiating any exercise program it is recom-mended that an individual consult their family physi-cian or another appropriate health care professional.

The purpose of the on-the-job exercises is to periodi-cally interrupt activities and restore normal spinalalignment by performing movements in the oppositedirection (counter movements). Work tends to stressthe same structures on a sustained or repetitive basis.

Performing counter movements on a regular basisrestores balance to the spinal structures and assistsin reducing pain and preventing injuries. A detailedexplanation regarding the importance of restoring nor-mal spinal curves on a regular basis can be obtainedby referring to the chapter on posture.


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On-The-Job Exercises


Standing Extension (Back Bends)Who: Recommended for caregivers who perform pro-longed sitting or forward bending activities.

Frequency: One set each hour or as required toreduce pain.

How:

Standing with the feet approximatelyshoulder width apart and knees slightly bent.

Place the hands on the hips or buttocks.

Arch backwards until a slight pressure is feltin the small of the low back.

Pause (do not hold) and return to a standingposition.

Repeat 10 times.

FIGURE 2. Standing extension


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Flexion in SittingWho: Recommended for caregivers who stand forlong periods of time or perform activities requiring

backward bending of the spine (i.e., painting a ceiling)Frequency: One set each hour or as required toreduce pain.

How:

Sit on a chair or stool with the knees apart.

Place arms at the sides.

Bend forward as if to touch the ground withyour forehead until a stretch is experienced inthe low back.

Pause (do not hold) and return to an uprightsitting position.

Repeat 10 times.

FIGURE 3. Flexion in sitting


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On-The-Job Exercises


Retraction in SittingWho: Recommended for caregivers who performactivities requiring sustained and repetitive forward

bending (flexion) of the neck.Frequency: One set each hour or as required toreduce pain.

How:

Sit upright in a chair.

Attempt to position the head so that the earsare in line with the shoulders.

Keep looking straight ahead and move thehead backwards until a stretch is felt at thebase of the neck.

Pause (do not hold) and return to the startingposition.

Repeat 10 times.

FIGURE 4. Retraction in Sitting


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5.4 At Home ExercisesBefore initiating any exercise program it is recom-mended that an individual consult their family physi-

cian or another appropriate health care professional.

The on-the-job exercises described in this manualfocus on movements designed to reduce the physicalstress that work activities tend to place on the spine.On-the-job exercises do not assist in maintaining orenhancing range of movement, muscular strength ormuscular endurance of the spine.

The at-home exercises described in this manual serveas a basic exercise routine to promote spinal health. Itis recommended that this program be completed on aregular basis (5-7 days/week) to promote a healthyspine. This home exercise routine is intended as abalance program and it should feel comfortable. Thecaregiver should discontinue any exercises and con-sult their health care practitioner if they experienceany difficulties with any of the exercises.

The muscles of the spine are primarily postural mus-cles. As a result the exercises comprising this pro-gram focus on spinal mobility and muscle endurance.

Lumbar Extension (Sloppy Push-Up)Purpose: Provides an effective counter movement ofthe lumbar spine and maintains/increases low backextension range of movement.

Frequency: 10-15 repetitions/session

Technique:

Lying on the stomach with the hands placedbesides the shoulder.

Keeping the hips on the floor extend the lowback by pushing the shoulders up using thearms.

Continue until the arms are either straight orthere is a stretching sensation in the lowback.

Pause (do not hold) and return to the startingposition.

Continue until repetitions are complete.


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At Home Exercises


Helpful Hint: If the hips elevate during the exercisetry placing the hands further forward in front of theshoulders. As the movement improves the hands cangradually be placed closer to the shoulders.

FIGURE 5. Lumbar extension

Lumbar Flexion (Knees to Chest)

Purpose: Provides an effective counter movement forcaregivers performing prolonged standing or over-head activities and stretches back extensor muscles.

Technique:

Lying on the back pull both knees toward thechest.

Use the hands to provide extra stretch.

Pause (do not hold).

Perform 10-15 repetitions.

FIGURE 6. Lumbar flexion


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Quadriceps Stretch (Thigh Stretch)Purpose: Stretch the muscles in the front of the thigh.These muscles are used during client handling proce-

dures and need to be stretched. One of the musclescomprising the quadriceps muscles group attachesonto the top of the hip. If this muscle becomes short-ened it can alter the position of the pelvis andincrease stress on the facet joints of the spine.

Technique:

Lying on the stomach and bend one foottowards the buttocks.

Grab the foot with the hand and gently pullthe foot closer to the buttocks until acomfortable stretch is felt in the front of thethigh.

Hold 15-30 seconds and release.

Perform 3-5 repetitions/leg.

Continue until the desired number ofrepetitions is completed.

Helpful Hint: Wrap a towel around the foot if unableto grasp the foot comfortably with the hand. The exer-cise can also be performed in standing.

FIGURE 7. Quadriceps stretch


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Hamstring StretchPurpose: To stretch the muscles on the back of theleg.

Bending the low back forward is a combination ofmovements from the low back and the hips. Short-ened hamstring muscles can reduce the amount offorward bending. Shortened hamstrings can alter theorientation of the pelvis and reduce the normal curveof the low back. This can lead to increased stress onthe discs and surrounding structures.

Technique:

Lying on the back bend both knees whilekeeping both feet in contact with the floor.

Keeping the knee straight lift one leg as highas possible (remember to keep the oppositeknee bent).

Hold 15-30 seconds.


Continue until the desired number ofrepetitions is completed.

FIGURE 8. Hamstring stretch


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Upper AbdominalPurpose: To improve the muscular endurance of theupper abdominal (stomach muscles).

Technique:

Lying on the back with the knees bent andfeet flat on the floor.

Place the arms along the side of the body.

Raise the head and shoulders off the flooruntil the shoulder blades are off the floor (youshould be able to touch the top of the knees

with the hands). Pause and return to the starting position.


Helpful Hint: The exercise can be made more difficultby changing the position of the hands. To progress theexercise place the arms across the chest and performthe exercise as described. A further progressionwould involve placing the hands behind the head.

FIGURE 9. Upper abdominal


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Lower AbdominalPurpose: To increase the muscular endurance of thelower abdominal muscles.

Technique:

Lie on the back with the legs extended.

Bend one knee and keep the foot flat on thefloor.

Perform a pelvic tilt by attempting to flattenthe low back against the floor.

While maintaining the pelvic tilt slowly raise

and lower the extended leg. Perform 10-20 repetitions

Repeat 3-5 sets/leg

Helpful Hint: The exercise is easier the higher the legis raised. The exercise can be progressed by perform-ing the leg-raising portion of the exercise progres-sively closer to the floor or by adding light ankleweights.

FIGURE 10. Lower abdominal


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Upper Back Extensors (Chest Raise)Purpose: To increase the muscular endurance of theupper back extensors.

Technique:

Lie on the stomach with the legs straight.

Place the arms straight along the sides of thetrunk.

Raise the upper chest off the floor.

Pause and return to the starting position.


Repeat 3-5 sets.

Helpful Hint: The exercise can be made more difficultby changing the position of the hands. To progress theexercise place the hands beside the temple while per-forming the exercise. A further progression wouldinvolve placing the arms in front of the head.

FIGURE 11. Upper back extensors


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At Home Exercises


Lower Back ExtensorsPurpose: To increase the muscular endurance of thelower back (buttock muscles) extensors.

Technique:

Lie on the stomach with the leg straight.

Place the hands underneath the forehead.

Raise one leg (keeping the knee straight)until the knee is slightly off the floor.

Pause and return to the starting position.

Complete 10-20 repetitions.


Helpful Hint:The exercise can be progressed by add-ing light ankle weights.

FIGURE 12. Lower back extensors


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Motor Vehicle Safety 55

Module 6 Motor VehicleSafety

For home care work-ers, driving risks canbe created by tight

time schedules,inclement weather,traffic congestion,aggressive drivers andpoor driving skills. Inrural areas, getting to aclient's home may bemore of a concern thanwhat happens after

they get there (Ram-age, 1999).

6.1 Employer StrategiesEmployers should:

Have in place specific policies andprocedures regarding driving andtransportation on the job that include the

reporting of motor vehicle accidents. Clearly identify a protocol for transporting

clients to and from appointments in theworkers' cars and by public transportation.

Hold orientation and periodic reinforcementtraining on the employers' and workers'responsibilities regarding the transportationpolicy.

Provide workers with defensive driving

courses and specialized training on driving inwinter conditions. Stress managementcourses that include information on copingwith traffic congestion and aggressive driversare also recommended.

The definition of"workplace" in the OHSA

includes a "thing." A"thing" could be avehicle. Therefore, theAct applies to a vehicle ifthe home care worker isdriving to and from aclient's home.


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Worker Strategies

56 Motor Vehicle Safety

6.2 Worker StrategiesWorkers should:

Keep the gas tank over half full at all times.

Use steel-belted radial tires to reduce thechance of a flat tire.

The Canadian Automobile Associationrecommends the following items as part of a wintercar survival kit:

In the trunk

Axe or hatchet Booster cables Cloth or roll of paper towels Compass Emergency food pack Extra clothing and footwear Fire extinguisher Ice scraper and brush Matches and a "survival" candle in a deep can Methyl hydrate (for fuel line and windshield de-icing) Sand, salt or kitty litter Shovel Tow chain Traction mats Warning light or road flares

In the cab

Road maps Flashlight First-aid kit Survival blanket

In addition, a CALL POLICE sign is alsorecommended. This is a national initiative of theOntario and Canadian Association of Chiefs of

Police. The sign is made

H&S in the Home Care Enviornment- Lap_301

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