Occupational Hazards of the

Health Care Industry

PROTECTING HEALTH CARE WORKERS

by Deborah \I. DiBenedetto, BSN, MBA, COHN

I n 1994, experts expected the health care industry to

contribute 15% of the nation's gross domestic
product (GNP, the total output of goods and serv-
ices) or $1.06 trillion versus $943 billion in 1993 ("$1
trillion in health care is predicted," New York Times,
(Smith, 1993). The Bureau of Labor Statistics accident
incidence for 1991 for nursing and personal care facilities
was 15.5 per 100 full time workers compared with lower
rates for perceived highly dangerous employment set-
tings or industries such as mining (7.5) or construction
December 29, 1993). The health care industry is the (13.8) (National Safety Council, 1993).
nation's largest employer; hospital workers constitute the Injuries frequently reported by health care workers
single largest group of employees in the United States. include musculoskeletal injuries, cuts, lacerations, and
Approximately 77% of these health care workers are contusions, along with needlesticks (unique to the health
women and nearly 17% are registered nurses (Wilkinson, care field). Most health care professionals believe they
1992). The primary business of the health care industry is are knowledgeable in areas of concern relating to occupa-
the provision of health care goods and services to tion, but, in fact, are not (Poitrast, 1994). While many
consumers, yet it is one of the industries that provides the health care workers may be aware of the overt occupa-
least attention to its own employees (Felton, 1990). tional hazards, others may be hidden or covert. Health
Despite the Occupational Safety & Health Act of care workers are exposed to myriad occupational hazards
1970 requiring all employers to provide safe and health- which can be classified under four broad categories:
ful employment and places of employment (general duty biological, chemical, physical, and psychosocial!
clause), and the standards under the act (DiBenedetto, psychological.
1992a), hospitals have had very poor health and safety
records. Only recently have they begun to come under BIOLOGICAL HAZARDS
scrutiny and develop procedures for control of dangerous Biological hazards include occupational exposure to
substances (Poitrast, 1994) and workplace hazards. bloodborne pathogens and infectious agents or diseases
Hospitals and medical centers have occupational (see Table). Exposure to bloodborne pathogens, particu-
hazards similar to those of other complex employment larly hepatitis B virus (HBV) and human immunodefi-
settings or industries, as well as risks unique to the health ciency virus (HIV), is of greatest concern today.
care environment (Lowenthal, 1994). Furthermore, as
health care extends into community and home environ- HBVandHIV
ments, hazards or risks to the health care worker increase The Occupational Safety and Health Administration
(OSHA) estimates that more than 5.6 million health care
and related occupations are at risk of exposure to
bloodborne pathogens such as HIV and HBV and other
ABOUT THE AUTHOR: potentially infectious materials. Of these health care
workers, approximately 3 million work in hospitals,
Ms. DiBenedetto is Director, Corporate physicians' offices, and government clinics. In 1991,
Occupational Health Services, The Rockefeller OSHA estimated that 18,000 health care workers with
occupational exposure to bloodborne pathogens will
Group, New York, NY. become infected annually with HBV, and 250 will die of
related complications (DiBenedetto, 1992a).
Needlestick injuries pose the greatest threat to health

MARCH 1995, VOL. 43, NO.3 131

 Reported cases of drug resistant TB generally have
been the result of contact with other persons with drug
While many health care workers may be aware resistant TB or inadequate treatment of initial TB infec-
tion. The magnitude of occupational risk of transmission
ofthe overt occupational hazards, others may varies considerably by type of health care setting, client
population, job category, and the work site area in which
be hidden or covert. an employee works.
Higher risk is anticipated for employees in contact
with persons with TB who are provided care before
diagnosis (for example, in clinics or emergency rooms )
care workers for exposure to bloodborne pathogens, or when diagnostic or treatment procedures that stimulate
including HB V and HIY. Exposure to these pathogens coughing are performed at the health care facility (Hell-
occurs when contaminated blood or body fluid from an man, 1993). However, all health care workers in all
infected individual comes in direct contact with the employment settings share the risk of TB transmission
health care worker through accidental injection (needle- once the hazard of an infectious patient is present. The
stick), an open lesion on the health care worker's skin, or CDC has developed detailed recommendations and pre-
through exposure to mucous membranes (e.g., eyes, cautions for exposure to TB in health care settings which
mouth). OSHA has adopted in evaluating an employer's TB
OSHA promulgated a standard on occupational expo- exposure control plan. CDC final guidelines issued
sure to bloodborne pathogens (29 CPR 1910 .1030), October 28, 1994 (Guidelines, 1994) list the characteris-
which took effect in March 1992. The standard protects tics of an effective TB infection control program:
employees who have occupational exposure to blood- • Assignment of responsibility for the TB infection-
borne pathogens, including, but not limited to: physi- control program to qualified person(s).
cians, nurses, phlebotomists, dentists, emergency medi- • Risk assessment (and periodic reas sessment) for TB
cal personnel, therapists, orderlies, nurses' aides , laundry exposure in the facility.
workers, and other health care workers. OSHA requires • A protocol for the early identification and manage-
employers covered by the standard to establish an ment of persons with acti ve TB.
expo sure control plan that comprises: • Written TB Infection Control Plan.
• Identifying jobs/titles with occupational exposure to • Engineering controls.
blood or other potentially infectious materials. • Written procedures to reduce TB exposure of person-
• Developing and training workers in exposure control nel during cough inducing or aerosol generating proce-
methods/procedures. dures.
• Establishing post-exposure and follow up procedures. • Respiratory isolation rooms for suspected or con-
• Providing appropriate personal protective equipment. firmed infectious TB patients. These rooms must be
• Offering HBV vaccine at no charge to the employee. maintained under negative pressure with inside air ex-
• Establishing housekeeping and safety procedures. hausted to the outside.
• Maintaining appropriate records related to the expo- • Training and information on signs and symptoms of
sure control program, training, and exposures. TB, medical surveillance, therapy, and site specific
• Establishing procedures for evaluating the circum- protocols, including the use of controls (administrative,
stances of an exposure incident. engineering, and use of personal protective equipment,
The exposure control plan must be in writing and made i.e., respirators).
available to workers and OSHA representatives, and • Provision of respiratory protection (i.e., respirators)
must be updated annually or whenever changes in where administrative and engineering controls may not
procedures create new occupational exposures to blood- provide adequate protection: in TB isolation rooms or in
borne pathogens. rooms/enclosures for cough inducing or aerosol generat-
ing procedures (such as bronchoscopy, suctioning); when
Tuberculosis transporting patients with infectious TB ; and during
A resurgence of tuberculosis (TB) in the mid 1980s urgent surgical/dental treatment prior to rendering the
was largely attributable to the HIV epidemic, influx of patient "non-infectious."
persons from Asia, physicians' non-adherence in pre- It should be noted that the use of high efficiency
scribing recommended drug regimens, the emergence of particulate air (HEPA) respirators is emphasized as a last
antibiotic resistant strains of TB, and a decrease in resort in controlling exposure to TB. When these respira-
resources for prevention and elimination of TB (Hellman, tors are used by employees, employers must provide
1993). Because of recent outbreaks of TB in health care appropriate health assessment, training, fit testing, and
settings, including outbreaks of multi-drug resistant maintenance according to OSHA's Respiratory Protec-
strains of Mycobacterium TB, the Centers for Disease tion Standard (29 CFR 1910.134).
Control and Prevention (CDC) has expressed heightened • Free medical screening including pre-placement eval-
concern about nosocomial transmission (Hellman, 1993). uation, administration, and interpretation of Mantoux

132 AAOHN JOURNAL

 TABLE
Infectious Agents and Their Sources
Infectious Agent Source of Transmission
Hepatitis A Feces
Hepatitis B Blood and body fluids
Hepatitis C Blood and body fluids
(non-A, non-B hepatitis)
Hepatitis D (found only in patients with HBV) Blood and blood products
Hepatitis E Feces
Rubella (German measles) Respiratory secretions; virus shed in urine and stool
Rubeola (measles) Respiratory secretions
Mumps Respiratory secretions, saliva
Influenza Respiratory secretions
Scabies Contact with infected skin lesions
Varicella zoster virus (VZV) Airborne droplet nuclei (chickenpox only)
Chickenpox Secretions of lesions, saliva (both chickenpox and
Shingles shingles)
Herpes simplex virus (HSV) Secretions of lesions, saliva
Type I
Type II
Herpetic whitlow
Acquired immunodeficiency syndrome (AIDS) Blood and body fluids
Pulmonary tuberculosis Airborne droplet nuclei
Sa/manella, Shigella, Campy/obaeter Feces
Cytomegalovirus (CMV) Blood and body fluids
Respiratory syncytial virus (RSV) Respiratory secretions

Adapted from: NYSNA (1992) and Professional Guide to Diseases (1992).

skin tests every 3 months for employees with high risk of Just as employees in other employment settings are
TB and annually for other employees. covered by the OSHA Hazard Communication Standard
• Evaluation and management of workers with a posi- (HazCom), so are health care workers. OSHA requires
tive skin test or a history of positive skin tests who are that employees in all employment settings be informed,
exhibiting symptoms of TB, and appropriate work re- by their employer, of the hazards associated with the
strictions for affected employees. chemicals used in the workplace. By law, manufacturers
and distributors must provide information in the form of
CHEMICAL HAZARDS a material safety data sheet (MSDS) for each chemical
Health care workers are occupationally exposed to a substance or mixture of chemicals.
multitude of chemical hazards including disinfectants The MSDS provides information about the chemi-
(e.g., isopropyl alcohol, iodine, betadine, chlorine), ster- cal trade and generic names, ingredients, safe handling
ilizing agents (formaldehyde, glutaraldehyde, ethylene and exposure information, emergency contact informa-
oxide [ETO]), solvents (alcohol, acetone, benzoin), anes- tion, reactivity data, health effects, storage, spill han-
thetic agents (e.g., gases such as nitrous oxide, enflurane, dling, and personal protective equipment require-
halothane, isoflurane), chemotherapeutic agents (e.g., ments. While the MSDS may vary from manufacturer
antineoplastic and cytotoxic drugs, pentamidine [an to manufacturer, categories of information are man-
anti-protezoan agent], and ribavirin [an antiviral drug]). dated by OSHA. MSDS must be readily available and
Latex (as in latex gloves) (Shama, 1993), detergents, accessible to the workers who use the chemical(s)
tissue fixatives, and reagents are among other chemical (DiBenedetto, 1992a).
hazards to which health care workers are exposed (Beh- Chemicals enter the body through various routes
ling, 1993; New York State Nurses Association, 1992). and are ranked according to order of occurrence:

MARCH 1995, VOL. 43, NO. 3 133

inhalation (of gases, vapors, fumes, dust, mists), enforced (through a memorandum of understanding) by
percutaneous skin absorption, ingestion, and acciden- OSHA.
tal needlestick.
Non-Ionizing Radiation
PHYSICAL HAZARDS Non-ionizing radiation includes lasers, ultraviolet
Occupational physical hazards for health care workers lighting, microwaves, and magnetic fields. Lasers, used
include exposure to needles and other sharp instruments, primarily in the operating room, pose a danger to the skin
ionizing and non-ionizing radiation, electrical hazards, and eyes because of light and heat. Health care facilities
compressed gases, noise, extremes of temperature, and should establish laser safety programs specific to the use
various forms of aggression and violence. Physical of lasers in their facility and educate exposed health care
hazards also include ergonomic hazards associated with workers about the establishment's laser precautions,
repetitive strain or motion and musculoskeletal injuries. which should address the following:
• Assigning a knowledgeable person as a Laser Safety
Back Injuries Officer (LSO) with the authority and responsibility for
Musculoskeletal injuries are the most common physi- laser program oversight who will monitor and enforce
cal hazard to health care workers. According to a study of the control of laser hazards.
more than 600,000 workers' compensation claims, more • Establishing laser policies and use procedures.
than one third of all claims are due to back injuries. Over • Training employees in the proper use of lasers.
50% of these back injuries occurred within the health Employees requiring laser training include, but are not
care field, a direct result of lifting; nurses and nurse's limited to the LSO, laser physicians, nurses, medical
aides incur the highest number of musculoskeletal or support staff; laser technical support staff; and laser
back injuries (National Safety Council, 1993). Approxi- system service support personnel.
mately 25% of all workers' compensation claims indem- • Ensuring that laser impact points are free of flammable
nity expenditures in eight states were for back injuries and combustible substances.
(Fieldstein, 1993). • Ensuring that warning signs are posted at entrances to
Back injuries are caused, in part, by job design, laser use areas.
improper body mechanics, equipment and patient han- • Establishing use precautions, including: provision and
dling, and transfers. Tasks such as transferring dependent use of appropriate goggles/glasses for affected patients
patients often exceed the maximal permissible lift as and health care workers; skin and tissue protection
defined by the National Institute of Safety and Health while laser is in use; and surgical high filtration masks
(NIOSH) (Fieldstein, 1993). Each year 40,000 nurses (respirators) if procedure produces a "plume"; ba-
report illness due to back pain, and over 764,000 lost seline and periodic medical surveillance (i.e., eye and
work days are incurred. At least one in 15 nurses will skin examinations) for exposed personnel.
experience back injury serious enough to interfere with
their professional career (Garrett, 1992). Violence
A University of California at Los Angeles study of Health care workers are at risk from both verbal and
179 nurses found that training the workers in proper lift physical aggression. Incidents of both are considered to
techniques did little to keep them from being injured. The be under reported due to peer pressure, the desire to avoid
18 month study also revealed that factors such as physical lengthy paperwork, fear of reprisal, and concern about
load and past back injury put the workers at considerable accusations of patient abuse (New York State Nurses
risk for on the job back injury. The researchers concluded Association, 1992). Violence toward health care workers
that formal training in proper lift technique did not appear is an emerging issue (Lipscomb, 1992). A special report
to be of significant protective value, and suggested that on occupational violence appeared in the December 1993
when training is overemphasized, it can cause the nurses issue of the OEM Report, and an entire issue of the
to fail to recognize other physical factors that can MORN Journal was devoted to the subject in May 1992.
increase potential risk of back injury (News roundup, The professional literature acknowledges that the health
1994). care industry is at greater risk for violent incidents than
other businesses (Felton, 1993).
Radiation
Ionizing radiation is used for a variety of diagnostic PSYCHOSOCIAUPSYCHOLOGICAL HAZARDS
and treatment procedures including radiographs, fluo- Psychosocial or psychological hazards in the health
roscopy, angiography, computerized axial tomography care setting include exposure to stress or stressors in the
(CAT) and nuclear medicine scans, teletherapy, and workplace, burnout, substance abuse, mental illness, the
cobalt treatments. Ionizing radiation has cumulative and effects of shiftwork, and sexual harassment. Emotional
long term effects, and, while all of the above procedures stress is considered one of the most significant health
have significant medical benefits, all radiation is harmful hazards for health care workers. Constant demands on
to living tissue. Occupational exposure limits are estab- their time, energy, and professional skills, along with the
lished by the Nuclear Regulatory Commission and stress of direct responsibility for patient care, exposure to

134 AAOHNJOURNAL
death and dying, and anxious and suicidal patients (all of
which may be exacerbated by hectic work patterns that
do not allow for restful breaks), put them at high risk. The occupational health nurse can provide a
Health care workers, especially physicians, have a high
incidence of depression (Behling, 1993). wide variety of quality services, which can
Shiftwork increase in scope and complexity with
Research has documented the negative health effects appropriate education, certification, and work
of shiftwork and the negative impact on the shift
worker's social life (strained relationships, fewer experience.
friends). Health care workers who work on a rotating or
night shift schedule report a higher incidence of sleep
disturbances, chronic fatigue, stress, and eating and
elimination disorders. Studies also indicate that female and healthful workplace, free of known hazards, it is
rotating shift workers have a higher incidence of miscar- impossible to eradicate all of the occupational hazards
riages and low birth weight babies (Behling, 1993). associated with the health care industry and resultant
exposures incurred by health care workers. Arduous tasks
REPRODUCTIVE HAZARDS are inherent in health care jobs; lifting and transferring
Occupational hazards studied in relation to adverse unconscious patients, facing terminally ill adults and
reproductive outcomes include radiation, chemother- children, responding to cardiac arrests and other emer-
apeutic agents, solvents, video display terminals (VDTs) gency services, and dealing with the victims of unex-
(McAbee, 1993), and shiftwork (Behling, 1993). Expo- pected community disasters (earthquakes, fires, train!
sure to occupational hazards has been associated with airplane crashes, multiple highway accidents) all require
altered fertility, gene size defects, chromosomal abnor- considerable psychic and/or physical energy (Felton,
malities, spontaneous abortions, late fetal deaths, con- 1993).
genital malformations, altered gestational length, intra- OSHA remains a major force in encouraging hospi-
uterine growth retardation, neonatal deaths, infant deaths, tals to address health and safety needs of their work force.
developmental disorders, chronic disease, and malignan- The development of an in house occupational health
cies (New York State Nurses Association, 1992). service can provide a wide range of health services to
When workers or their spouses are considering employees of a health care organization, provide a
pregnancy, special attention should be paid to the framework for a diverse occupational health and safety
workplace hazards that may impact on fertility, the program specific to the institution, and create a value
developing fetus, and/or the mother's health. McAbee added component as it provides specific services to
(1993) noted synergy between the adverse reproductive employer, employees, and the community (through con-
effects among nurses from multiple workplace factors, tract occupational health services for other employers/
including radiation, VDTs, and chemotherapeutic agents; establishments).
this finding warrants further investigation. Part of prena- The occupational health nurse, because of education,
tal care should include clinical evaluation of the woman's training, and experience, is the key individual on whom
medical and obstetrical status, work requirements and day to day services will depend (Lowenthal, 1994). In
activities, physical demands of the job, and potential for addition to the occupational health nurse (or nurses) the
exposure to reproductive hazards (McAbee, 1993). occupational health team may include the occupational
medicine physician(s) and representatives from infec-
DISCUSSION tious diseases/control, safety and radiation safety com-
Institutional health care workers face many of the mittees, and risk management. The amount of physician
hazards common to industry, but also hazards unique to time required for most programs does not require a full
a health care facility's operations. Occupational hazards time commitment; however, there are significant differ-
associated with home health care may mimic that of ences between community and metropolitan hospitals on
institutional health care as complex medical technologies this issue (Lowenthal, 1994). The basic components
are delivered in the patient's home (e.g., dialysis, chemo- (Felton, 1990) of a hospital occupational health service
therapy, respiratory therapy). Additional risks unique to may include:
the home health care environment may include fire, • Preplacement and periodic health assessments.
problems with the building's structural integrity, per- • Infection control.
sonal safety, and poor lighting. Changes in the nature of • Diagnosis and treatment of occupational injuries and
home health care may be equivalent to those of institu- illnesses.
tional health care, but home health care may carry • Knowledge and implementation of safe work practices
additional risks due to variable home environments concerning identified hazards.
(Smith, 1993). • Environmental hazard control and surveillance.
While OSHA requires employers to provide a safe • Health evaluation and counseling.

MARCH 1995, VOL. 43, NO.3 135

 The occupational health nurse can provide a wide
variety of quality services, which can increase in scope
and complexity with appropriate education, certification,
Occupational Hazards of the and work experience. Examples of the occupational
health nurse's responsibilities can include (DiBenedetto,
Health Care Industry 1992a,b):
• Working collaboratively with other disciplines (e.g.,
Protecting Health Care risk management, infection control, radiology, occupa-
Workers. tional medicine) to establish and implement occupational
health and safety policies and procedures.
DiBenedetto, D. V.
• Developing and maintaining the hospital's hazard
AAORN Journal 1995; 43(3):131-137 abatement program and occupational safety and health
program/services.
The health care industry contributes 15% of
• Participating on various workplace committees to
1. the nation's gross domestic product, and is
the nation's largest employer, with hospital
provide occupational health expertise and ensure that
operating procedures afford the greatest employee and
workers making up the majority of the health patient protection during implementation (e.g., the use of
care industry work force. However, it is one lead aprons by patients during radiography, hand wash-
of the industries that provides the least ing by staff between patient contacts).
attention to its employees. • Directing and administering OSHA compliance pro-
grams, including, but not limited to: exposure to blood-
Hospitals have had very poor health and borne pathogens, TB, and documentation of occupational
2. safety records. Only recently have they
come under scrutiny and begun to develop
injuries and illnesses.
• Identifying health problems and appropriate nursing
procedures for control of dangerous sub- intervention; applying case management and health care
stances and workplace hazards. cost containment measures to preserve the health and
well being of the work force.
Health care workers are exposed to myriad • Preventing injury and illness through health promotion
3. occupational hazards which can be classi-
fied under four broad categories of hazards:
and health education programs geared to the hospital or
health care worker.
biological, chemical, physical, and psycho- • Identifying real and potential hazards in the health care
social/psychological. worker's environment by directing or conducting facility
assessments and referring abatement to the appropriate
Teamwork between the occupational health discipline or members of management.
4. professional and health care management
is key to establishing and maintaining a
• Acting as a liaison between the worker, hospita1lhealth
care employer, outside community, and professional
health care environment with controls to resources to facilitate the lines of communication and
protect health care workers. professional cooperation.
• Providing crisis intervention and appropriate referral
to the employee assistance program or outside agency.

CONCLUSION
• Stress management. Occupational health nurses are uniquely qualified to
• Recordkeeping and confidentiality of medical records. provide specialized knowledge, skills, and leadership and
• Periodic evaluation of the occupational health service. to work collectively with peer professionals in their work
environments, especially in the health care arena. Team-
ROLE OF THE OCCUPATIONAL HEALTH NURSE work between the occupational health professional and
The occupational health nurse has a primary role in health care management is key to a working partnership
helping the health care work force attain and maintain a that promotes and maintains a health care environment
maximum level of health by performing a variety of with controls in place to protect health care workers.
health and management functions. The specific functions Through this working partnership, occupational health
are based on the hospital or health care facility environ- nurses not only promote the safety and health of health
ment, employer's need and expectations, corporate phi- care workers, but contribute to the quality of health care
losophy, and the occupational health nurse's professional delivered to consumers through increased work force
expertise in occupational safety and health. As in other productivity and employee health.
industries, the occupational health nurse should be a This article was modified from an article published by
member of management to establish and direct a quality the author in the February 1994 issue of The OEM
occupational safety and health program for the employer. Report with permission from the publisher.

136 AAOHNJOURNAL
REFERENCES McAbee, R.R. (1993). Adverse reproductive outcomes and occupa-
Behling, 0, & Guy, J. (1993). Industry profile: Healthcare: Hazards of tional exposures among nurses. AAOHN Journal, 41(3), 110-119.
the health care professional. Occupational Health and Safety, 2, National Safety Council. (1993). Accident facts (p. 42). Itasca, IL:
54-57. author.
DiBenedetto D.V., Harris J.S., & McCunney R.1. (I 992a). OEM New York State Nurses Association. (1992). Protect yourself from
occupational health safety manual. Boston: OEM Press. workplace hazards. Guilderland, NY: author. (Available for a
DiBenedetto, D.V. (I 992b). Say "goodbye" to the bandage brigade! nominal charge from NYSNA, 2113 Western Ave, Guilderland,
OEM Report, 6(7),51-52. NY, 12084, (518) 456-5371).
Felton, J.S. (1990). Occupational medical management (pp. 491-550). News roundup: About backs: Effects of lift training. (1994). OSHA
Boston: Little Brown. Compliance Advisor, 251,1.
Felton, J.S. (1993). Occupational violence-An intensified work con- Poitrast, B.1., & Zenz, e. (1994). Women in the workplace, industry
comitant. OEM Report, 7(12), 101-103. considerations. In e. Zeriz (ed.), Occupational medicine (3rd ed., p.
Fieldstein, A, Valanis, B., Vollmer, W, Stevens, N. & Overton, e. 833). St. Louis: Mosby.
(1993). The back injury prevention project pilot study. Journal of Professional guide to diseases (4th ed., p. 697-700). (1992). Spring-
Occupational Medicine, 35(2), 114-120. house, PA: Springhouse Corporation.
Garrett, B, Singiser, D. & Banks, S.M. (1992). Back injury among Shama, S.K. (1993). Life threatening reactions to rubber devices &
nursing personnel. AAOHN Journal, 40(11),510-516. gloves. OEM Report, 7(12), 101-103.
Guidelines for preventing the Transmission of Mycobacterium tubercu- Smith, WA, & White, M.e. (1993). Home health care: Occupational
losis in Health Care Facilities. (1994). Federal Register, 59,(208), health issues. AAOHN Journal, 41(4), 180-185.
54242-54303. Wilkinson, WE, Salazar, M.K., Uhl, J.E., Koepsell, T.D., DeRoos,
Hellman, S.L., & Gram, M.e. (1993). The resurgence of tuberculosis: R.L., & Long, R.1. (1992). Occupational injuries: A study of health
Risk in health care settings. AAOHN Journal, 41(2),66-71. care workers at a northwestern health service center and teaching
Lipscomb, J.A. (1992). Violence toward health care workers: An hospital. AAOHN Journal, 40(6),287-293.
emerging occupational hazard. AAOHN Journal 40(5), 219-228. Winburn, D.e. (1990). Practical laser safety (2nd ed., pp. 169-180).
Lowenthal G. (1994). Occupational health programs in clinics and New York: Dekker.
hospitals. In e. Zenz (ed.), Occupational medicine (3rd ed., pp.
875-882). St. Louis: Mosby.

MARCH 1995, VOL. 43, NO.3 137