Participants were identified through informational flyers and emails distributed by home health care agencies and professional organizations. A $50 department store gift card was provided to each participant. Sixty-eight workers, 59 (95%) females and 3 (5%) males, participated in the study (Table 1). Participants worked primarily in home health care and were able to converse, read, and write in English. A majority of participants were registered nurses (31%), aides or homemakers (21%), administrators or educators (19%), or physical or occupational therapists (19%).

Prior to attending the focus group or interview, participants completed the Modified–Home Health Care Worker (M-HHCW) questionnaire. The 38-item M-HHCW includes demographic information, checklists of home health care tasks performed, injuries or adverse outcomes experienced in home health care situations, household hazards encountered in clients’ homes, and health history items. An open-ended question asked participants to indicate the most serious hazards they have encountered in homecare work. Parallel versions of M-HHCW questionnaires were constructed for various participant categories (registered nurses and home health aides, physical and occupational therapists, owners, managers, and home health care educators). The M-HHCW is written at a sixth-grade reading level and has been validated for face and content validity (Gershon, Canton, et al., 2008).

Each focus group and interview began with a discussion of hazards encountered by study participants in the homes of their clients. Although recognized as a significant hazard, participants were instructed to avoid discussing situations involving interpersonal violence as these hazards were generally outside the scope of the study and particularly outside the scope of the training system that was being developed as the main goal of the study. Focus group participants were then provided with separate floor plans of a bedroom, bathroom, kitchen, living room, and hallway (each participant was given a separate room) as well as cutouts of furniture/objects (e.g., bed, couch, sink) that generally belong in a given room. Participants were asked to reflect on their own homecare experience and to use the furniture and other objects to “furnish” a room as a room in a client’s home might be furnished. Participants then drew in the environmental health and safety concerns that immediately came to mind for that room. Once they completed identifying the hazards for the room, they passed their floor plan to the person next to them who reviewed the drawing and added additional hazards based on their experiences. This process continued until each participant provided input on each room drawing. Once the drawings were completed, the session moderator asked each participant to identify their top three priority hazards, using red adhesive stickers. Five additional adhesive dots were used to denote other, lower priority hazards. Following this hazard prioritization process, a discussion about the identified priorities in each room was facilitated by the moderator. Interview participants who interacted with a facilitator via a web-based meeting program or phone described the room-based hazards in several ways. Some dictated instructions to the facilitator, who furnished rooms, labeled hazards, and added “stickers” using a shared computer desktop. Others completed the drawings by themselves during the interview or verbally discussed hazards they had encountered in specific rooms in client homes. Interviews and focus groups lasted 45 minutes and two hours, respectively.

All focus groups and interviews were digitally recorded, professionally transcribed, and independently verified. Focus group and interview transcripts were uploaded into Dedoose qualitative and mixed-methods analysis software (Dedoose Version 5.0.11, 2014) and content-analyzed. Transcripts were coded independently by two research team members (B.J.P., C.E.W.). Any discrepancies in coding were discussed and resolved to reach 100% agreement. Analysis of the transcripts was conceptualized in terms of density of response categories instead of frequency counts of content-coded categories. The analyzed responses could not be considered mutually exclusive responses as the focus groups and interviews were interactive discussions in which independent individual responses to questions were not gathered. The floor plan drawings were coded on a spreadsheet for hazards drawn by participants, and priority hazards were identified using adhesive dots. The M-HHCW questionnaire data were entered into an SPSS-PC database and analyzed descriptively. The open-ended M-HHCW item was content-analyzed.

Strategies to support validity and reliability focused on credibility and confirmability approaches. The researchers used multiple forms of triangulation, including triangulation of analysts, methods, and sources. As described above, two research team membeis coded the data separately and worked together to achieve 100% consensus. Data were collected from participants veibally and also by creating a visual depiction of in-home hazards. Data gathered from participants were corroborated through reviews of the literature. The research team used member checking to ensure hazards were correctly captured, and made adjustments when necessary. Seven participants representing all professional disciplines participated in member checking interviews. Participants reviewed the hazards and room analyses and provided feedback on and confirmation of the results.

This study explored environmental health and safety hazards encountered by HHPs in clients’ homes and in specific rooms within those homes. Study strengths included the use of triangulated quantitative and qualitative methods, representation of diverse types of HHPs, and a room-by-room analysis of specific hazards. Integrating data from multiple data sources and professions lends confidence to the overall conclusion that HHPs are exposed to a variety of environmental health and safety hazards that can lead to costly injuries and illnesses. To the authors’ knowledge, this is the only study to date that has included a room-by-room analysis of these types of environmental health and safety hazards.

Consistent with other studies (Czuba et al., 2012; Darragh et al., 2012; Wipfli et al., 2012), trip/slip/lift hazards were the most commonly identified hazards, and the specific sources for these types of hazards varied, a key finding with implications for enhanced HHP training. Sprains and strains, commonly attributable to lifts, slips, and trips, have previously been documented to be the most frequent lost work-time injuries to HHPs, resulting in almost 1 month of lost work time (Centers for Disease Control and Prevention, 2010; Wipfli et al., 2012). Recommendations to reduce exposure to trip/slip/lift hazards include making changes in the work environment, (e.g., removing throw rugs, securing cords, providing adequate lighting), using assistive devices such as transfer or gait belts, participating in ergonomics training, and wearing sturdy shoes with slip-resistant soles (Centers for Disease Control and Prevention, 2010; Marrelli, 2008; Satink, 2007). These and other recommendations can be incorporated into specific training for HHPs on how to assess and manage trip/slip/lift hazards, especially for home health aides who have the most exposure.

Exposures to potential biohazards, such as human or pet waste and blood-borne pathogens, were commonly expressed concerns in this study as well as by other researchers (Gershon, Canton, et al., 2008; Gershon, Pogorzelska, Qureshi, & Sherman, 2008; Leiss, Sitzman, & Kendra, 2011; Markkanen et al., 2007; Wipfli et al., 2012). Occupational Safety and Health Administration (OSHA; 2011) regulations require agencies to have an exposure control plan and annual blood-borne pathogen training, but neither a control plan nor training is required for other biohazards. Most participants in this study (73%) indicated they received training on standard precautions and were supplied with gloves, but not other forms of personal protective equipment (PPE) such as face shields, goggles, or protective clothing. These findings highlight the need for agency- and policy-level changes to assure that HHPs have the protective equipment necessary for personal safety.

Air quality and allergen exposures from tobacco smoke, mold, and inadequate ventilation were considered highly hazardous by participants with asthma and allergies. Several participants commented that their agency had a tobacco smoking policy in which clients agreed not to smoke (nor allow others to smoke in their home) while the HHP was there. Although helpful, not all agencies have this type of policy and not all HHPs insist their agencies’ policies be followed. Although the consequences of exposure to secondhand tobacco smoke are well known (Centers for Disease Control and Prevention, 2014), the National Institute for Occupational Safety and Health (NIOSH) does not include this hazard in its 2010 Occupational Hazards in Home Care publication (Centers for Disease Control and Prevention, 2010). The findings of this study highlight the need for policy- and individual-level interventions to reduce risk of exposure to secondhand tobacco smoke. The U.S. Surgeon General has stated that no risk-free level of exposure to tobacco smoke exists (U.S. Department of Health and Human Services, 2006), so it is imperative that NIOSH and OSHA develop a standardized smoke-free policy template that can be adapted and implemented by home health agencies to protect their workers.

Participants in this study identified the most hazards in the kitchen, followed by the bedroom and the bathroom. These locations were also the primary locations where Czuba et al. (2012) reported that injuries occurred to home health aides. Although trip/slip/lift hazards were the most common hazard type reported in each room in the present study, with the exception of throw rugs, which pose a hazard in every room, the specific types of risks differed. Water and grease spills were described frequently on kitchen floors; tight spaces and missing equipment in bathrooms; clutter, tight spaces, and lifting hazards in the bedroom; electrical cords and oxygen tubing in the living room; and clutter in the hallway. Similar differences in the types of biohazards encountered in each room were identified. Pet droppings were key biohazards in the kitchen and living room; human waste was commonly noted as bathroom and bedroom hazards. The rooms in clients’ homes in which HHPs work varied by type of HHP and clients’ needs. For example, nurses may not go into a client’s bedroom or kitchen if client care is provided in the living room. By contrast, home health aides are often in all rooms if they provide cleaning, meal preparation, and personal care services. A key implication of these findings is that health care agencies should provide tailored training that addresses the different hazards HHPs are likely to encounter by room, also taking into account HHP job descriptions and client needs.

Although home health care is not a traditional practice site for occupational health nurses, the recent significant growth in home health care, high incidence of injuries and illnesses among HHPs, and the breadth of hazards encountered by HHPs supports a need for home health care agencies to use or contract with occupational health nurses to improve occupational safety practices, thus preventing the adverse health events that can affect HHPs. This study provides critical information that occupational health nurses could use to effectively train home health care personnel to conduct thorough home hazard assessments to identify hazards that HHPs might encounter in their work. In addition, occupational health nurses can provide expert guidance to agencies and policy makers to develop and implement policies that assure a safe working environment for HHPs. Examples include a standardized smoke-free policy template previously discussed, as well as policies clearly outlining protocols with sequentially ordered management steps for HHPs to follow when potential hazards are encountered in client homes. These steps may range from securing assistance moving an obese homebound client, to informing a family member when a faulty electrical outlet is identified, to contacting the agency when evidence of pests such as cockroaches or mice are noted. Through training, education, and active involvement in policy development and implementation, occupational health nurses could make a significant safety and health impact on the working conditions of HHPs.

This study is unique in its focus on a room-by-room analysis of specific environmental hazards in clients’ homes. Trip/slip/lift hazards were the most common hazards throughout the home, but, with the exception of throw rugs, varied from room to room. Biohazards were most common in the kitchen and bathroom, and electrical and fire hazards were most common in the kitchen. Training for individual HHPs should include specific approaches to managing hazards that the HHPs can address at the point of care, as well as how to effectively engage assistance from their agencies. These findings can contribute to the development of evidence-based, efficacious, and engaging training programs using interactive virtual simulation approaches. This research also revealed opportunities for agency-level training to facilitate coordination and communication between HHPs and agency management.