Takeaways:

• Home care is unique, placing nurses and other healthcare professionals in patients’ homes and personal space, and doesn’t include typical healthcare organization requirements.
• Home care safety can be divided into three responsibilities: workers’ responsibility to protect their own safety, agency and organization responsibility to train workers and provide workplace safety practices, and patient and family responsibility to promote home care team member safety.

Healthcare organizations with the mission of caring for people in their homes provide a valuable service. Keeping these workers—nurses, therapists, hospice team members, aides, and others—who provide this care requires policies and procedures that focus on safety assessment, risk identification, and situation management.

What makes home care unique?

For purposes of clarity in this article, “home care” will be inclusive of any care models that comprise home visits, regardless of the program or type/kind of home visit. And “home”   will mean wherever the patient calls home. For many, home is a sacred and personal space, and most people wouldn’t enter someone’s home without knowing him or her first. However, home care, including hospice at home and other community-based home visiting models, requires providers to enter the homes of people they don’t know personally. Essentially, they’re guests in this personal space.

When care is delivered in the home, no health­care organization dictates visiting hours, sets visitor age requirements, establishes a dress code, or creates other standards. And because home care personnel may be the only providers seeing the patient, they must be comfortable working independently but also recognize that they’re part of a larger team of care providers, which includes the patient, other clinicians, and informal caregivers, such as family and friends.

This combination of factors can create safety issues for those who provide care. (See Safety risks.)

Workplace violence

Wherever providers practice, they must recognize the possibility of violence, so those who work in the home also should be aware of the patient’s community, know how to avoid violent situations, and be familiar with their organization’s policies and procedures related to violence avoidance and de-escalation.

Recent U.S. Bureau of Labor statistics show that home care workers experience more than double the national rate of workplace injuries for all industries. In addition, studies have shown that 5% to 61% of home care workers have experienced some form of workplace violence. In the United States, home care workers are most susceptible to verbal abuse and aggression, threats, and sexual harassment. Over a 3-year period in the United Kingdom, 1,544 assaults (including sexual assault, hostage situations, headbutting, biting, strangulation, and weapons use) against lone healthcare workers occurred. In Australia, a survey of 300 physicians who make home visits was conducted using an electronic form that evaluated their experiences over a year. Findings showed that nearly one in two physicians encountered aggression; verbal aggression was most common.

Nurses, providers, and others can take measures to prevent or mitigate violent situations. Some strategies may be learned in new employee orientation, while others may be shared by colleagues or in violence-prevention training. However, safety and violence-avoidance training should not be a one-time event; it requires practice, ongoing education, and awareness.

Home care safety

Home care safety can be divided into three responsibilities: workers’ responsibility to protect their own safety, agency and organization responsibility to train workers and provide safety practices in the workplace, and patient and family responsibility to promote home care team member safety.

Worker responsibilities

Because most home care workers practice alone, they have a responsibility for their own safety and to avoid violence, when possible. You should receive orientation about your specific agency’s policies and procedures (including personal safety, blood-borne patho­gens, and conducting home visits), and also must participate in ongoing safety training. If training isn’t provided by your organization, request it.

Previsit strategies. Know and follow your organization’s policies and procedures for home visits, including what to do if you have concerns about your safety or experience violence. Create a professional presence, which should be reflected in your clothing, and demonstrate a caring and concerned attitude toward your work.

Be respectful and watch for clues about household norms; this begins when you call to make plans for the initial visit. Ask for directions, where to park, where to enter the home, who will greet you, and if any pets are in the home. In addition, establish care priorities for each home visit, try to schedule the visits during daylight hours, and let your agency know when you plan to return from each visit. Keep all healthcare equipment, supplies, and personal belongings locked in the trunk of your vehicle and remove only what’s needed at each visit.

Visit strategies. During the home visit, explain everything you’re doing and ask before touching anyone. In a tense situation or one that’s getting more tense, know that asking too many questions can be overwhelming and patients and families can get irritated. In this instance, ask questions that are specific only to the reason the person was admitted to the service and save other questions that concern the patient’s general condition for another visit. If a patient or family member’s behavior begins to escalate, remain calm and caring to diffuse anger; don’t match threats or give orders. Throughout the visit, use basic safety precautions, including being alert to your surroundings and watching for signals of potential violence. These include shouting, verbal abuse, threatening gestures, weapons, or signs of drug or alcohol misuse. Kindly but firmly establish and maintain professional boundaries and recognize your own limits and abilities. The National Council of State Boards of Nursing has additional information on establishing professional boundaries. (See Be prepared.)

Just as you would in other healthcare settings, stay up-to-date with patient care standards, policies, and processes related to infectious diseases, blood-borne pathogens, and sharps injuries. Refer to your organization, professional association, and the Occupational Health and Safety Administration (OSHA) for the most recent recommendations and guidelines.

Employer responsibilities

OSHA recommends that employers regularly (at least once a year) assess and control risks of workplace violence to ensure worker protection. Policy revisions may be needed when a change occurs in the nature of the workplace (for example, if an employee’s vehicle is stolen from the agency parking lot or an employee was verbally abused during a home visit), type of work provided, or work conditions (such as increased or decreased staffing levels, increased patient acuity, or increased number of patients on service). Management should allocate sufficient resources—including mandatory compensated training for managers, supervisors, and direct care employees and providing an escort for staff working in high crime areas. Employers also should uphold program expectations (for example, maintain compensated safety training and staff assistance in high crime areas even when budgets are tight and resources hard to find).

Policies and procedures. Employee safety policies and procedures should encompass personal safety measures when making home visits, zero-tolerance for all incidents of violence, and specific steps staff should take if they’re concerned about their safety or experience violence during a home visit. (See Ensuring employee safety.)

Mendes recommends that healthcare organizations implement measures that support staff preparation for violent situations. In addition to training, organizations should provide access to appropriate tools (such as a household safety checklist) to manage difficult situations and offer appropriate debriefing support (for example, with a trauma counselor) after a violent event. And organizations should have pro­cedures for investigating reports of dangerous environments or encounters.

Organizations might consider inviting an officer from the local police department to train staff annually, provide updated crime statistics for the geographic area served by the organization, and offer examples of precautions staff can take. Some municipalities have a dedicated community officer who can do this. Agencies also could make local police aware of the presence of home care employees so they can increase patrols in the area.

Pets can pose safety and health risks, including allergies, infections, and bite injuries. Organizations should assess whether pets have created a risk in the past, clarify how the risk was addressed, and consider a policy for asking that pets be secured before home visits. More research is needed on this topic.

Emergency preparedness. Does your organization have a plan for home care workers in the event of a natural disaster, large-scale violence, riot, pandemic, or other emergency? In 2017, the Centers for Medicare and Medicaid Services (CMS) established national emergency requirements for all participating organizations, including hospitals, home health agencies, and hospices. Organizations must have a functional emergency preparedness program that describes their comprehensive approach to meeting the health, safety, and security needs of the facility, its staff, and its patient population and community before, during, and after an emergency or disaster. The book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital by Dr. Sheri Fink details lessons learned about disaster and emergency preparedness as well as implications for leadership.

Please be aware that the CDC has released interim guidance for home care related to the coronavirus (COVID-19). This guidance can be found here.

Patient and family responsibilities

Patients and their families also have a role in creating safe environments for home care personnel. Patients and families should be provided with a document from the organization that explains their rights and responsibilities, which may include:

• adhering to the worker safety information and organization’s policies
• informing home care workers of potential hazards (for example, a guard dog) during the call to schedule the initial visit
• restraining pets during visits
• removing tripping hazards in the home or be willing to remove the hazard during the visit
• providing an escort (patient, family member, or friend) to walk home care personnel to their car in high crime neighborhoods
• limiting a potentially violent family member’s access during the visit
• refraining from shouting or swearing at home care personnel
• refraining from inappropriately touching home care personnel.

Safety is a team effort

Adhering to best practices can help minimize risks and keep home care personnel safe. Organizations with a thoughtful and organized safety orientation and onboarding process can provide a structure that supports employees in their journey to becoming effective home visiting team members. Safety as a quality improvement project could benefit all team members who make home visits and the managers and organizations seeking to provide the framework and processes to promote safety. More research is needed to better determine the scope of home care worker risk and safety and to identify improvement recommendations. We challenge you to help in this important effort.

Tina M. Marrelli is president at Marrelli and Associates, Inc., and chief clinical officer at e-Caregiving.com in Venice, Florida. Nathalie Rennell is an instructor at Arizona State University Edson College of Nursing and Health Innovation in Phoenix.

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