The Needlestick Safety and Prevention Act at the 10-year mark
Key advocate reflects on why it was and continues to be essential to healthcare workplace safety
Last month, on the eve of the 10th anniversary of the signing of the Needlestick Safety and Prevention Act (NSPA)—that was November 6, 2000—Medical Environment Update (MEU) had the opportunity to conduct a telephone interview with Karen Daley, PhD, MPH, RN, FAAN, president of the American Nurses Association (ANA), who played an instrumental role in making needlestick prevention measures the law in U.S. healthcare.
Daley reflected on the significance of the NSPA then and its continuing importance today in protecting healthcare workers from exposures to such life-threatening diseases as hepatitis B, hepatitis C, and HIV. She also offered her opinion on what current healthcare workplace safety concerns might benefit from the same energy and advocacy that resulted in the passage of the NSPA 10 years ago.
Here’s what she had to say:
MEU: What are the elements of the NSPA that make it unique among occupational safety and health legislation and of particular importance to nurses?
KD: Requiring employers or healthcare facilities to involve those directly in the delivery of care—in most cases, the nursing staff—for the evaluation and selection of safety devices is the first unique aspect of the law. Data shows—especially the numbers coming from the Massachusetts Department of Health, which requires the recording of all needlestick and sharps injuries—that nurses represent a significant percentage of needlesticks recorded by occupation. It is appropriate that those who use safety devices the most, and those who are most at risk to incur injuries, should have the greatest input in evaluating and selecting safety devices for their workplace.
That way, devices that take excessive training can be eliminated in favor of devices which are easier to adapt to. A needle with a safety feature that takes two days to master probably shouldn’t pass evaluation. Likewise, safety needles which take two hands to engage are significantly behind with regard to design innovation.
Obviously, it’s better to put the purchase decision in the hands of users than the person who fills out the inventory order.
The other unique element of the act was to require evaluations on a continuing basis and make it part of the exposure control plan required by OSHA. It is not that you can evaluate safety devices once and be done with it. The rate of innovation from the first generation of safety devices to the third and even fourth generation is amazing.
MEU: I understand a needlestick exposure significantly changed your personal and professional life. Would the NSPA have prevented your exposure?
KD: I know there is much more awareness now about preventing injuries than when my injury occurred.
I visit patient care areas where sharps containers are easily accessible and at eye level, which is the correct height for wall-mounted units.
I know there are some settings that lag behind in acceptance—for example, ambulatory settings and home healthcare, in comparison to hospital settings, which have more resources to devote to preventing needlesticks and sharps injuries. Nurses should not have to settle for a lower degree of protection because of the setting in which they choose to practice. That is one area where we can continue to look for improvement.
MEU: What was it like to practice in the pre-NSPA days? Did you know then that there were measures and technology to prevent such injuries?
KD: I didn’t know how much information and technology was available and how little of it was being used. It was a learning process for me. Back then, too many hospitals were using no prevention technology.
At a recent press briefing hosted by the ANA, Jordan Barab, deputy assistant secretary of labor for OSHA, made the point that we have had 10 years of technological innovation in safety devices, and we should not accept first-generation measures when better third-and fourth-generation solutions are available. Those devices shouldn’t even be on the market, he said.
In 10 years, devices have become obsolete and less safe relative to newly introduced products, which is why continuous evaluation so important.
MEU: Do you remember where you were and what you were doing when the act became law?
KD: Actually, I was in the Oval Office with President Clinton for the signing. I have one of the pens he used to sign the act into law. I never use it, but I take good care of it.
MEU: What were your feelings at that time?
KD: It’s still emotional when I think about it. It was gratifying to know that we—and I’m not just talking about the ANA here, but others such as the healthcare unions, the hospital associations, leadership in the Department of Health and Human Services, and, of course, our congressional supporters—this collection of stakeholders had come together to make it an incredible day.
There were not very many in attendance in the Oval Office, maybe 15–20 people, and I remember President Clinton taking time to speak with each one of us. I knew then that his level of commitment was sincere, equal to ours. It wasn’t just a routine piece of legislation he was signing, but rather that he was celebrating with us because that legislation was the right thing to do. It was a special day.
MEU: During the advocacy efforts for the NSPA, was there opposition? What were the main points of contention? How valid was it, knowing what you know now?
KD: I can actually sum that up with one word: cost. That was no more unusual then than it would be now. And I appreciated congressional concern about the cost to their constituents.
We spent time explaining how in healthcare especially, concentrating the prevention effort on the front end, no matter how costly it appears, would pay dividends on the back end, and the country would recoup its investment.
The reality was that this legislation was the right thing to do, and it would eventually pay for itself in improved safety and fewer consequences from contaminated needlesticks. Furthermore, we stressed that efforts to improve safety in the healthcare work environment will be appreciated. Nurses notice things like that.
MEU: What issues today concerning occupational health and safety for nurses could use the same advocacy energy, legislation even, as the NSPA?
KD: No question about it, there are two issues right now.
The first is safe patient handling—the whole issue of eliminating manual patient lifting. We have outstanding data and the technology available to show, similar to the needlestick act, that the investment will pay off—in some cases as quickly as three to four years.
We have the medical evidence and the business model to move on this issue. Nurses know that, and again, nurses will notice and appreciate when employers make efforts to protect them.
The other issue out there—and it has not consistently attracted attention outside of the healthcare profession—is workplace violence prevention.
I’ve personally known nurses who have been assaulted, and the escalation of incidents is probably the result of a combination of societal pressures and economic causes that will bring it to a critical stage. It’s a concern for all types of healthcare settings, especially emergency departments and psychiatric settings, but also ambulatory settings such as clinics and medical practices.
I hope that soon Congress will be able to listen to both issues and take action.
There is also the idea of an infectious disease standard on which OSHA is gathering information and stakeholder input. Clearly the whole issue of infectious diseases and its impact on workers in healthcare is one that I welcome, and we should pay attention to it.
MEU: What could nurses do in the advocacy arena or in daily practice to make sure the goals of the NSPA continue to protect members of the profession today?
KD: Stay involved with the issues so as to take care of your own health so you can provide the best care to your patients.
That means using the safety devices that are available, and if they are ineffective, get involved in the evaluation process so you can advocate for newer and more effective replacements. That also means always activating the devices you have on the unit.
This isn’t always done, and we will someday have to insist on passive safety features over user-activated devices. There is evidence showing the move from active safety devices to passive devices makes a difference in reducing needlesticks.
Also, when it comes to a lack of management support for needlestick prevention, nurses need to advocate up the line. Usually that means going beyond the unit, beyond the department, and if nothing happens, finally going outside the organization to OSHA. That’s a nurse’s right, and if engagement is not welcome and improvement does not happen, I encourage nurses to pick up the phone and call OSHA.
We can’t afford to lose experienced healthcare workers over substandard safety measures. The societal and economic stakes for that are too high.
MEU: Do you have any insight or advice for the challenges that nurses face, particularly those in nonhospital settings?
KD: Nurses in nonhospital settings might have to be more aware of, and probably have to advocate more actively for safety devices and prevention systems that they need. Be active in establishing and communicating what steps are in place to prevent needlesticks, and also what to do and what kind of support is needed in the event of a needlestick to you or your colleagues.
It truly is a top-down, bottom-up process where everyone—nurses, managers, administrators, and owners—need to be on the same page.
MEU: What is the significance that needlesticks and blood exposure are no longer considered just part of the job for anyone going into the nursing profession?
KD: We’ve come a long way from that statement as a valid prevailing attitude in healthcare. Maybe there was a time when a needlestick was like getting blood on your scrubs. Obviously HIV and hepatitis C, especially since there is no vaccine for it, have changed all that. The stakes, one’s health, are too high to accept that attitude. Today, it is a ludicrous idea.
It’s about creating the mind-set to take care of the caregiver so that nurses can be the best caregiver to their patients. To explain it, I often use the example that we have all experienced during the airline safety demonstration prior to takeoff. They explain that if the cabin depressurizes, the oxygen masks will drop down. The key in this situation is to create the mind-set that you put your own oxygen mask on first, seeing to your essential safety, before turning to help the person next to you.
Nurses need the same important reference point: Make sure that you are safeguarding your own health as you provide care to your patient.