Nurse, Protect Thyself

Nurses work under conditions that threaten their safety and well-being.
By: | August 1, 2013 • 7 min read

Charged with providing a safe environment for their patients, nurses themselves work under conditions that threaten their safety and well-being. One key factor is that the field’s ongoing labor shortage may exacerbate the stress of working nurses, as more medical responsibilities are shifted from doctors to nurses.

Other factors are that the majority of nurses are in their 40s and 50s and are more vulnerable to back and other injuries from pushing heavy medical equipment and assisting overweight patients. Nurses are also prone to drug and alcohol dependency, as some self-medicate for stress.

A 2012 Aon study found that these workplace hazards contribute to nearly $2 billion in nurse-related workers’ compensation claims annually.

Creating a safer workplace for nurses depends on a combination of education, technology, and behavior change, according to experts. It must be driven at the executive level and influenced by incentives from insurance companies.

The health care industry has had mixed success in controlling workplace injuries.

On the positive side, Mark Noonan, a broker at Integro, said fewer claims are filed these days for bloodborne pathogen infections and slips and falls, thanks to disciplined health care sanitation and training policies.

The numbers bear out his observation: The frequency of health care workers’ compensation claims has decreased slowly but consistently.

But nursing claim severity, including medical, indemnity and defense costs, has increased at a rate of 2 percent per year, according to Aon.

The home heath market, which will grow even larger as the 2010 Affordable Care Act takes force, raises safety questions for off-facility nurses, said Lori Severson, loss control consultant at Lockton.


“The safety issues raise the hairs on my neck,” she said. Homes are an uncontrolled environment not subject to OSHA inspections.

“At this point, we can hope families will comply with a safety checklist about dogs, sidewalks and mold,” she said.

Patient management injuries — including those from turning and moving patients, and from slips, trips and falls — each account for about 30 percent of claims payouts, said Tim Portale, chief safety and security officer at Nashville-based Hospital Corp. of America. Materials handling accounts for another 8 percent, and workplace violence for 7 percent.

Nursing injuries resulting in lost work time account for only 10 percent to 20 percent of claims, but they account for 85 percent of workers’ comp payouts in that field, according to Portale.

“Typically, health care safety programs concentrate on those high-value claims,” he said. HCA owns 162 hospitals and 113 freestanding surgery centers in 20 states and England, and it extrapolates the above statistics from its own experience.

Back Injuries, Scourge of Nurses

Back injuries, the second-leading occupational injury in the United States across professions, are the single most costly injury for nurses, according to the National Institute for Occupational Safety and Health.

America’s obesity epidemic, said Kevin Gabhart, managing director at Beecher Carlson in Brentwood, Tenn., affects more than patients, especially on bariatric floors. “Imagine a 150-pound nurse lifting a 300-pound patient,” he said. “The cumulative effect of patient handling takes a toll on their skeletons and soft tissue.”

Since most nurses are in their 40s and 50s, many suffer injuries related to lifting, pushing and carrying heavy weights, Gabhart said.

“Treatment for a 50-year-old nurse costs more than treatment for a 20-year-old with the same injury.”

According to the American Nursing Association, 38 percent of nurses report job-related back pain severe enough to require leave from work, 12 percent leave nursing because of it, and 20 percent change to a different role within the profession.

That doesn’t include the majority of nurses, said Noonan, who simply accept pain as an occupational hazard and use over-the-counter analgesics until the pain becomes unbearable.

“Nurses are a pretty stoic cohort,” he said.

A 2011 American Nurse Today article, however, suggested 10 percent to 15 percent of nurses may be impaired or in recovery from alcohol or drug addiction, mostly the result of self-medication for pain relief.

The ANA agreed that manual patient handling is responsible for nurses’ musculoskeletal disorders and recommended assistive equipment and devices, such as lifting machines, to prevent them.

“The benefits of safe patient handling are well documented,” said Jaime Murphy Dawson, senior policy analyst at the ANA.

“Proper use of technology and manual techniques produces great savings in suffering and workers’ comp claims,” she said.

A 2004 Centers for Disease Control and Prevention study of a self-insured hospital found the cost of lifting equipment and worker training paid for itself in reduced workers’ compensation expenses in slightly less than three years. The return on investment is quicker, the study found, if savings in indirect costs (lost wages, cost of hiring and retraining workers, etc.) are included.

However, many hospitals don’t have the budget to buy enough lifts, which can cost thousands of dollars apiece.

Even lifts aren’t the perfect solution, said the ANA’s Dawson. Back injuries have declined as more lifts have come on line, but shoulder injuries are on the rise from nurses pushing the heavy machinery from room to room.

Some new hospitals are designed with ceiling and floor tracks, ANA’s “gold standard” of hospital design, but the cost of retrofitting existing facilities is often prohibitive.

Nursing schools are responding to the risk of injuries with beefed-up clinical curricula. Temple University’s baccalaureate nursing program, for example, tests students in safe patient handling every semester rather than the semester in which the procedures are first taught. The program increased its required clinical hours by 30 percent five years ago.

In June the ANA released professional standards for safe patient handling and mobility that includes contributions from architects, ergonomists, administrators, and health care providers.

Stress and Burnout

Although back injuries account for more workers’ compensation dollars than any other single category of claim, nurses themselves are more concerned about stress. The ANA survey found a majority of nurses are concerned about health effects from stress and overwork.

Long hours, sensory overload from medical device alarms, too many patients, and high accountability for an excess of life-or-death decisions contribute to the stress load. “Nurses juggle two, three, four chainsaws at a time,” said Integro’s Noonan.


“Pressure to do more with less is a reality in the present health care system, and it leads to accidents,” he said.

Workplace violence, including harassment, is another factor.

Although their appearance makes for good television drama, violent patients with weapons in the emergency room are few and far between, said Pamela Popp, executive vice president and chief risk officer at Western Litigation, a law firm representing health care providers.

Abuse of nurses by an unexpected slice of the population — seniors — is rising, however.

“Self-control weakens with age and dementia,” said Noonan, “and nurses are on the front lines, often delivering bad news to patients and their frightened families.”

Nurse-on-nurse bullying and physician bullying of nurses are also workplace realities.

“Nurses’ historical roles as handmaidens to doctors created a culture where harassment and intimidation became normal,” Popp said. She said such abuse compromises patient care and contributes to a hostile workplace for some nurses.

Remediation starts at the beginning, with training for both nurses and doctors, and continues through on-the-job training and licensing standards, according to a 2002 American Journal of Medical Quality study. Both medical and nursing schools include behavioral performance in their curricula.

“We teach conflict resolution skills,” said Karen Desjardins, assistant professor of clinical nursing and assistant dean at the Columbia University School of Nursing. “In times of conflict, our students know how to respond without escalating the hostility.”

Creating an internal culture that prevents a hostile environment — and its attendant stress-related workers’ compensation claims — is a challenge, Popp said.

“Only real training can reverse the culture of blame that prevails in health care now,” she said.

Currently, said David Marx, CEO of Outcome Ingenuity, a not-for-profit that supports health care system safety, most U.S. hospitals have an overly punitive environment that penalizes people for making mistakes rather than seizing an opportunity for educating workers.

The culture of blame applies equally to needle disposal and safe patient handling, for example, as to behavioral choices.

“The ‘no harm, no foul’ culture encourages risky behavior,” he said. “We turn a blind eye to risk until harm occurs, and then we whack the offender.”

Instead of focusing on events, errors and outcomes, Marx said, health care organizations should focus on risk, system design and behavioral choices.

“When they don’t fear reprisal, nurses are more likely to speak up if they, or their colleagues, slip into risky behavior,” he said. “Then the hospital can change the practice.”

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.


Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.

R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.


We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?


Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.


Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now and where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.


More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

The R&I Editorial Team can be reached at [email protected]