Strains, Sprains, and Pains in Home Healthcare: Working in an Uncontrolled Environment
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You hope the discharge planner was a good one. You hope the doors aren’t too narrow for the wheelchair and the bed is higher than knee-level. Even then, as likely as not, your work area will be the size of a crawlspace and strewn with clutter and medical equipment.
Welcome to life as a home healthcare provider. In 2007, America’s 896,800 home healthcare workers reported a staggering 27,400 injuries.1 Some of these resulted from unintentional needlesticks, latex allergies, and violence against providers. However, the most common injuries were sprains, strains, and other musculoskeletal injuries related to lifting and moving patients.
The rate of patient lifting injuries in 2007 was 20.5 per 10,000 healthcare workers.2 In homes, the lifting equipment and adjustable beds that are often available in hospitals are conspicuously absent. Also, nurses, aides, hospice care workers, and other in-home care providers tend to work alone. Moving a patient without help, in cramped quarters, and without assistive equipment is a recipe for injury. In fact, research indicates that if any caregiver is required to lift more than 35 pounds of a patient’s weight, assistive devices should be used for the transfer.3
- A hoist should be used for lifting patients who don’t have enough strength to stand and walk on their own.
- A rolling toileting and showering chair can reduce six transfers (from bed to wheelchair to toilet to wheelchair to bathtub to wheelchair to bed) to two (from bed to chair and back to bed).
- Grab bars, adjustable beds, and raised toilet seats can improve leverage and prevent the need for awkward and unsafe postures.
- Slip sheets and other friction-reducing devices cut back on the effort needed to move a patient.
Recommendations
The work environment shifts drastically from home to home and conditions fall outside the control of both employer and worker. However, there are methods for reducing musculoskeletal injuries. The best of these is prevention through ergonomics designing work tasks so that they aren’t beyond workers’ strength and abilities. In healthcare, ergonomics involves using equipment and methods to decrease strain and increase safety when lifting and moving patients.
Employers
- Consult with a professional in patient-care ergonomics to determine when assistive devices are necessary and to provide training on proper use of the equipment.
- Provide ergonomics training for workers.
- Evaluate each patient-care plan to determine whether ergonomic assistive devices or more than one care provider are needed.
- Reassess the training, the care plan, and the assistive devices once installed and in use by the caregiver.
Workers
- Use ergonomic assistive devices if they are available.
- When it’s not possible to avoid manual patient handling:
- Stand as close to the patient as possible to avoid reaching, bending and twisting. To avoid rotating the spine, make sure one foot is in the direction of the move.
- Keep your knees bent and feet apart.
- Use gentle rocking motions to move a patient.
- When pulling a patient up from an adjustable bed, lower the head of the bed until it is flat or down. Raise the patient’s knees and encourage the patient to push.
- Don’t stand in one place. Move around the patient’s bed so you can position yourself in a safe posture rather than stretching, bending, and reaching.
In applying these recommendations, keep in mind that workers can be injured from lifting too much weight, regardless of whether they use proper body mechanics.
Nurses and other home healthcare providers should not have to fear becoming patients themselves; however, many safeguards may appear prohibitive because of cost, organizational inertia, lack of training, the difficulty of using devices, resistance from families, and so forth. It is important for employers, workers, patients and families to work together to try to overcome these problems.
- NIOSH Hazard Review: Occupational Hazards in Home Healthcare
- Preventing Back Injuries in Healthcare Settings
- Safe Lifting and Movement of Nursing Home Residents
- Parsons, KS, Galinsky, TL, Waters, TR. Suggestions for preventing musculoskeletal disorders in home healthcare workers part 1: lift and transfer assistance for partially weight-bearing home care patients, Home Healthcare Nurse 2006 Mar; 24(3):158-164.
- Parsons, KS, Galinsky, TL, Waters, TR. Suggestions for preventing musculoskeletal disorders in home healthcare workers part 2: lift and transfer assistance for non-weight-bearing home care patients, Home Healthcare Nurse 2006 Apr; 24(4):227-233.
Please share the information in this blog with any home healthcare providers you know, including friends and family members who provide care for their loved ones. As always, leave your comments, safety tips, and thoughts on safety roadblocks.
Look for future home healthcare blog entries on latex allergies, bloodborne pathogens and needlestick injuries, stress, and violence.
Dr. Galinsky (Captain, U.S. Public Health Service) is a research psychologist in the NIOSH Division of Applied Research and Technology.
Mr. Burnett is a health communications specialist in NIOSH’s Education and Information Dissemination Division.
References
- 1, 2. NIOSH Hazard Review: Occupational Hazards in Home Healthcare, NIOSH Publication No. 2010-125. January 2010.
- 3. Waters TR, When is it safe to manually lift a patient, American Journal of Nursing, 2007.
55 comments on “Strains, Sprains, and Pains in Home Healthcare: Working in an Uncontrolled Environment”
Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».
Some concerns about the practice of rocking a patient and standing them as unexpected movements can happen and the patient may become off balance.
This can be dangerous
Suggest the following instructions (usually taught by physiotherapists)
◦have the patient move to the edge of the bed or chair and if they have diffulty doing this position yourself in front of the client, bend your knees & hips, keep back straight, position hands on either side of the pelvis and instruct the patient to wiggle to the edge of the bed (assist the movement)
◦while caregiver then stands to the side of the patient ask the patient to place their hands on the arm of the chair or bed ready to push up off the bed – care giver may assist the patient to stand from the side (use a gait or transfer belt if the client is unsteady)
◦instruct the patient to lean forward and bring their head over their knees – their buttock will automatically lift off the bed (this is safer than rocking and mimics the normal mechanics of sitting to standing)
◦if the patient has weak quadricepts – stand in front of the patient and block their knees to perform a pivot transfer
Frances Ziesmann RPT, BSc BScPT DOHS
Oakville, Ontario
Canada
Thank you for your comment. I would like to clarify that the statement you referenced — “Use gentle rocking motions to move a patient” — was not intended to refer to helping a patient stand but to assist with lateral movements such as helping a patient move toward the edge of the bed.
When an agency take 4 cna/hha worker to vista a client in a nursing home. and the physical therapist a strong man was showing us how to transfer her. It took him one hour and the he called in a second p/t to help him.
This client has polio for 40 yrs. and can’t stand on her own, She had one hip and shoulder removed and a pinch nerve in her neck. My boss said that the nursing home would release her only if she has CNAS to help her. Tell me why my agency did not get her a hospital bed, a bed rail, portal-potty or a side board to help her and the CNAS to mover her in a safety way and the CNA. In her bathroom her spouse made 2 poles from top to bottom on the side of the toilet. The bathroom was same and the wheel chair barely fit..
Why done the agency help these people more. I fall back words and trip over the lip of the shower that was filled with all kind of stuff. I truly fill if these agency would put more safety equipment in homes, their would be lest accent.
Whether the patient is in the home or in a long-term care nursing facility, it is important to ensure that she can be assisted in a manner that is safe for both herself and her caretakers. Safety concerns should be discussed among all concerned parties, including the patient, the caretakers (family members and health-care professionals), and management personnel from the nursing home or home health care agency, in order to make any changes in the patient’s care plan that are necessary to ensure safety during patient handling.
home care is really difficult especially if you’re a woman and your patient is a man bigger than you..thanks for all the recommendations, ergonomics devices can really help a lot.
As a physical therapist I have done home health care. The most dangerous part of home health is transferring the patients from sitting and/or lying to standing. this can cause severe damage to one’s low back if they are not experienced in using safe body mechanics when transferring patients.
The other crucial factor is maintaining good core and low back strength.
Without good strength and sound lifting mechanics a home health care worker is likely to hurt his or her back while treating patients.
Research has demonstrated that training on body mechanics has not been an effective approach for preventing overexertion injuries from most patient handling tasks. Biomechanical analyses using the NIOSH Lifting Equation indicate that even under ideal circumstances in which a patient is cooperative and unlikely to make sudden movements, the maximum recommended weight limit for manual lifting of a patient or a part of a patient’s body (e.g., a leg or an arm) is 35 pounds (Waters, 2007). Strength training and body mechanics can benefit health and fitness and may help prevent injuries from loads of 35 lbs or less during manual patient handling. However, research evidence shows that safe patient handling programs using ergonomic equipment and methods are necessary for preventing overexertion injuries from heavier patient handling tasks.
Waters, T. (2007). When is it safe to manually lift a patient? American Journal of Nursing, 107, 53-58.
I think home care is very much helpful for senors who are independent.I think the home care can Preserve their physical and mental health.
Maintain a balanced nutrition regime
Have moral support and are involved in exciting conversations to remain sharp and interested Are actively monitored for their own safety and well-being.
As a physical therapy marketing and physical therapist. I have numerous patients incurring injuries that are under home healthcare. I agree to Gavin that transferring the patients from sitting and/or lying to standing. This should be done really carefully and the home healthcare service provider should be well trained
Thanks so much for taking time to show compassion to all of us bloggers.
Another assistant device is a transfer belt also known as a gait belt. This device allows for better grip when transferring your patients.
Thank you for your comment. Here is a description to elaborate on gait/transfer belts:
Gait belts are wide, fabric belts worn around the patient’s waist, with sewn-in fabric handles that are grasped by the caretaker. They are helpful assistive devices for some patient handling tasks, but they are not designed for lifting patients. Gait belts, as their name suggests, were designed to help stabilize weight-bearing patients during ambulation. In addition, patient handling algorithms developed by the Veterans’ Administration Patient Safety Center include the use of gait belts to assist with transfers in some circumstances. For example, they can be used to assist partially weight-bearing patients to stand and pivot or to assist a non weight-bearing patient who has upper extremity strength while s/he is initially learning to do a seated transfer with a seated transfer aid, such as a transfer board. The algorithms can be found in the document “Assessment Form and Algorithms” under “Algorithms for Safe Patient Handling and Movement” at the following website:
http://www.visn8.va.gov/patientsafetycenter/safepthandling/
I work with an in-home health care agency and the information you provided for helping a bed-bound person get is is invaluable. Thank you for offering that to people who don’t receive proper training.
I would like to request permission to copy and share this blog information for home health professionals at a public professional education seminar and printed as part of the manual vs. referencing the information as a source they can access via website.
Please let me know if that will be OK and if you need further information of the seminar specifics.
Thank you.
Thank you for your interest in the NIOSH Science blog. You may reprint the information for use at your seminar, we just ask that you please include the NIOSH Science Blog title and include a notation that NIOSH was not a seminar sponsor. You may also want to order free copies of the NIOSH Hazard Review: Occupational Hazards in Home Healthcare (publication number 2010-125) and Safe Lifting and Movement of Nursing Home Residents (publication number 2006-117) for dissemination at your seminar. You can do so online at http://wwwn.cdc.gov/pubs/niosh.aspx, by calling 1-800-CDC-INFO, or from the National Technical Information Service at http://www.ntis.gov/.
We are interested to learn more about your seminar such as the title, location, and date. If possible, any additional information such as number of attendees or seminar materials would also be greatly appreciated. Please send to Traci Galinsky at:tgalinsky@cdc.gov.
This is very informative post i am new in health care services and right now getting trained in a health care agency but i don’t think so person who is trying to train me do even know any of these words because he never told me any of this before. I will show his this post. Very nice work keep it up.
Regards,
Rina Walsh
First Care of New York, Inc
Great to see some info on the website. It is very hard to come by specific Home Health information.I work in Employee Health and Safety for a large healthcare organization that includes Home Care Services. We do not see a large number of injuries but the ones that do occur are often severe. One component of our patient assessment includes determining if moving the patient is necessary. For example, if a patient does not have equipment and it is not safe to bathe the patient in the shower or tub, a bed bath can be given instead. I thought I had seen somewhere that NIOSH was requesting volunteers from the Home Health realm to look at Safe Patient Handling. Will there be any updated resources and tools available as a result of this work or am I mistaken?
Hi friends, its great piece of writing CDC – NIOSH Science Blog – Strains, Sprains, and Pains in Home Healthcare: Working in an Uncontrolled Environment on the topic of cultureand completely explained, keep it up all the time.
Great article! I used to be a volunteer firefighter and an EMT and have lifted and transferred many patients. Many of those times I used bad mechanics and should have had more people around to help or should have used different equipment. As a result of this I now have a bad back. This is a great article for raising awareness for both the worker and the patients safety.
Hoping to add safety information to my home health aide site very soon. I’ll definitely be linking back to this page when I do.
Thanks for your sharing this blog post.I really like this article.
Thums up!
The blog is written very clearly. And after reading this blog, I also got to know much more about it. Thanks a lot for sharing.
Thanks for these wonderful home health care tips. I’m going to have to link to this page and show a few of my family members this. My mom works in the home care industry in Las Vegas and is always having pains and cramps from moving the ladies around constantly. Maybe this will help her, atleast I hope it does. Thanks again.
These are great tips and some that we can pass on to our staff to use when the visit home help for out elderly clients & sports physiotherapy
Everything is very open with a really clear description of the issues. It was truly informative. Your site is very useful.
Thanks for these wonderful home health care tips. I work in the home care industry in Las Vegas and is always having pains and cramps from moving the ladies around constantly. Maybe this will help me. Thanks for giving health tips.
This is so important and useful content…
I had no idea the rate of injury was this high for home care employees. I think this is a good question to ask a potential home care company. If they treat their employees well and train them on how to move patients safely, then they probably treat their patients even better.
It sounds like home health care can be pretty tough work. Especially considering that a lot of workers are probably middle-aged women or other people who shouldn’t be lifting so much weight. I agree that some of these devices would be a good idea to help out. I guess I’ll do my best to stay skinny as I age in order to make the provider’s job easier! This is a very interesting article, thanks for sharing!
Thanks for publishing this. I think everyone should be aware of the potential dangers in home care. It’s a much harder task than people realize, and everyone should adjust accordingly. Even if you just move to a first level bedroom or clear furniture from around the bed, you’re helping the aides a lot.
I never thought about using a hoist to lift patients that have a hard time getting out of bed. This is a great idea! I think that using this tip could help to avoid unnecessary falls and drops. Thanks for sharing your tips with us!
Hi Marc – Comment #23 I agree people should be aware of the potential dangers in home care. Many people also need help an can’t afford home health care. There are many ways to find out how to reduce healthcare costs but employers should be helping. A lot of the times families can’t afford professional help and it is the untrained family member that hurts the patient.
Really good tips for us. It will helpful for the people. Thanks for sharing.
Great Post
Cartainly I think everyone should be aware of the home accidentes. My brother works in the home care services and I can say that it’s hard for him!
What a nice information.. I never thought before that any kind of things such as hoist, A rolling toileting and showering chair, grab bars, adjustable beds, and raised toilet seats,
slip sheets and other friction-reducing devices could become the useful tools in home healthcare.
Home healthcare is something hard to do, but by this information provided, it looks like it is very easy to do.
Thank you so much.
Amazing.. Your Article was simply Good.. Great Research for sure and you have a awesome resource Page
we are proud that you are making difference by your articles, loved it a lot, may god bless you.
These tips will surely help the people, this is what i was looking for, great article i am working in home safety
I was assigned a 300 lb patient who was unable to participate in moving herself. I was given no equipment such as a slide board, never mind a lift, and have now been out of work for 6 weeks with a severe low back injury with no return in sight. As a per diem employee, I have no benefits, disability, and they just denied my workmen’s compensation claim. This is how they make millions and can offer Tiffany gifts to high volume employees, usually the office staff. Go into home care and it’s not if you get hurt, it’s when.
We are very sorry to hear of your injury. Lifting and moving a patient cannot be performed safely without equipment and assistance. As a research institute, NIOSH does not take part in workplace safety enforcement. You can visit the website of the Occupational Safety Administration (OSHA) at http://www.osha.gov to obtain further information in that regard. You can file a complaint (anonomously if you wish) on their website or by phone through your local OSHA office. Their general phone number is 1-800-321-OSHA (6742)
I am a home care provider.I have a home filled with Bio Hazerdous Waste Fecal everywhere.Employer kicked it under the rug.Its so bad the worst I ever saw.Who CanHelp I told the family OH Well they will not even walk into the house.Case Manager says if this does not work Adult protective Services Coming In.Its SO SO Bad
We agree that the situation described is unacceptable and requires intervention. Contacting Adult Protective Services is standard practice for home care agencies to resort to when this type of problem cannot be otherwise resolved.
This an extraordinary article about home healthcare services. We are additionally into Home Healthcare Services, data gave in this article will definitely help the people. Thank you so much.
Very informative and helpful post, great research. I’m glad where I found extremely helpful health care guide. Thank you so much.!
Thanks for these wonderful home health care tips. I work in the home care industry in Las Vegas and is always having pains and cramps from moving the ladies around constantly. Maybe this will help me. Thanks for giving health tips.
I am working as a home attendant. I have a client whom requires lifting but there is no lifting equipement and the agency that employs me will not allow more than two attendants on a shift. I have to lift the client on my own. The client is 300 pounds or more i am 145ft male whos 5’7″ tall. Well the night before last night i injured myself. I was lifting the client out of a recliner onto a medical toilet. In tbe process my clients legs gave out and she dropped to the floor. I had ahold of her and she took me with her. I believe I slipped a disc. I made an appointment with my doctor and reported it promptly. Even injured i went back to work yesterday because i am the only one who can do nights. Is there any regulations on lifting weight limits and number of attendants that can be on an in home shift.
We are very sorry to hear of your injury. There are no laws that specify weight limits or staff requirements for lifting people in health care or home care settings, although employers may establish policies about these issues. Several states have passed laws related to safe patient handling and mobility, but efforts to pass a federal law have not succeeded to date. Research has indicated that even under ideal conditions, if a caretaker lifts more than 35 lbs of a person’s weight, the risk of injury increases to an unacceptable level. The general consensus among safe patient handling professionals is that lifting a person cannot be done safely by a single caretaker without equipment, and assistance from one or more other caretakers is also needed in many situations. We encourage you to visit the NIOSH Topic Page on Safe Patient Handling and Mobility to get further information on these issues. You can visit the website of the Occupational Safety Administration (OSHA) or call 1-800-321-OSHA (6742) to get information about employers’ responsibilities to prevent hazardous work conditions, including overexertion while lifting.
I am really astonished that how you lifted Your client a heavy weight women out of a recliner onto a medical toilet , You are a so strong man. it could be accident, Also this type institution should have lifting equipment. But if this recliner chair to be a Power Recliner chair with wheel then you lifted easily. Medical should use power recliner.
What a nice information.. I never thought before that any kind of things such as hoist, A rolling toileting and showering chair, grab bars, adjustable beds, and raised toilet seats,
slip sheets and other friction-reducing devices could become the useful tools in home healthcare.?????
I am trying to find a regulation on the use of Hoyer’s for Waiver home clients.. Do you have to have two people to use a Hoyer in the homes??
There are no federal laws that specify staff or equipment requirements for lifting people in home care settings, but some home care agencies have safety policies in place about these types of issues. There is general consensus among safety professionals that each individual client should be assessed by healthcare professionals to determine the equipment and number of people needed. Many factors must be considered, such as the client’s medical condition, mental status, weight, size, and weight-bearing ability. It is also very important that anyone who assists the client, including home care workers and family members, are fully trained by a qualified person to use the (Hoyer™) lift and any other assistive devices.” You can find more information about these topics at the NIOSH Safe Patient Handling and Mobility Topic Page.
This is a really helpful, informative article. A friend of mine is under the training of in-home care, I hope this may be helpful for him. I know home health is different from home care, but many of these tips can be helpful in one way or another. Thanks for sharing.
I would like to see a study and guidelines done on the safe transporting of bariatric patients in wheelchairs. My employer has made me transport 400-600 lb. patients numerous times, sometimes up hill. This has resulted in numerous back, neck and knee injuries. With the increasing bariatric population this is a study that is way over due. I am 65 working as a “driver” transporting patients from there home, loading them in a vehicle to the facility ( large hospital group operating 5 hospitals) were I work and to doctor appointments. As a former durable medical equipment dealer I am aware that there is equipment that can assist in the movement of bariatric patients. When I told my employer about the need for this equipment or the need for two people I was told that there was no guidelines. End results was nothing was done. People can be replace. After numerous injuries and many workers compensation claims they finally started to look for a reason terminate me and did so. It should be noted that younger fellow workers, some in their twenty are having injuries. They are afraid to say anything due to possible loss of their job.
We are very sorry to hear of your injuries and those of your co-workers. Research has shown that workers whose jobs require manual pushing and pulling are at increased risk of back and shoulder injuries (Hoozemans et al., 2004; Hoozemans et al., 2014). Studies evaluating powered devices for moving hospital beds have shown that compared to when manually pushing and pulling beds, muscle activity and exertion forces were significantly reduced in workers using powered assistance (Daniell et al., 2014; Wiggermann, 2017). While NIOSH is not aware of any federal laws mandating the use of motorized transport devices for bariatric patients, employers can establish policies about these issues.
The Veterans Health Administration (VHA) provides toolkits containing comprehensive guidelines related to developing safe patient handling programs. You can download their bariatric toolkit at http://www.tampavaref.org/safe-patient-handling.htm. After double-clicking on the BSPH folder, you will find the guidelines document in pdf format, and a folder containing the enclosures for the document. If you double-click on the Enclosures folder you will see that Enclosure 4-2 contains safe patient handling and movement “algorithms,” or step-by-step diagrams for different tasks. Algorithm 5 is “Transport in Bed/Stretcher/Wheelchair.” As shown there, motorized devices are encouraged for transporting patients of any weight or size. For patients weighing over 300 lbs, the options specify the use of powered transport devices with one or more caregivers, or a minimum of 3 caregivers if no motorized transport device is available.
On June 25, 2015, DOL Assistant Secretary for Occupational Safety and Health issued memorandum, “Inspection Guidance for Inpatient Healthcare Settings” to OSHA regional managers naming musculoskeletal disorders (MSDs) as a “focus hazard” and including guidance on conducting inspections “as they relate to risk factors for musculoskeletal disorders (MSDs) associated with patient/resident handling.”. You can visit the website of the Occupational Safety and Health Administration (OSHA) or call 1-800-321-OSHA (6742) to get further information about employers’ responsibilities to prevent hazardous work conditions, including overexertion.
The General Duty clause, Section 5(a)(1) of the Occupational Safety and Health Act (“OSH Act”) (29 U.S.C. 654(a)(1)), requires employers to provide “. . . a workplace that is free from recognized hazards . . .” Additionally, Section 11(c) of the OSH Act (29 U.S.C. 660(c)) states, “No person shall discharge or in any manner discriminate against any employee because such employee has filed any complaint … or because of the exercise by such employee “…” of any right afforded by this chapter” and provides that “Any employee who believes that he has been discharged or otherwise discriminated against by any person in violation of this subsection may, within thirty days after such violation occurs, file a complaint with the Secretary alleging such discrimination.”*
References:
N. Daniell, S. Merrett, G. Paul (2014). Effectiveness of powered hospital bed movers for reducing physiological strain and back muscle activation. Appl. Ergon., 45 (4) pp. 849-856
Hoozemans, M., Kuijer, P. Kingma, I., van Dieën, J, De Vries, W., van der Woude, L, Frings-Dresen, M (2004). Mechanical loading of the low back and shoulders during pushing and pulling activities. Ergonomics, 47 (1) pp. 1-18
Hoozemans, M. Knelange, E., Frings-Dresen, M, Veeger, H, Kuijer, P. (2014).
Are pushing and pulling work-related risk factors for upper extremity symptoms? A systematic review of observational studies. Occup. Environ. Med., 71 (11), pp. 788-795
OSHA (2015). Inspection Guidance for Inpatient Healthcare Settings. Memorandum dated June 25, 2015 from the Deputy Assistance Secretary for Occupational Safety and Health, U.S. Department of Labor to Regional Administrators and State Designees. Accessed June 4, 2018 at https://www.osha.gov/dep/enforcement/inpatient_insp_06252015.html”
Wiggermann, N. (2017). Effect of a powered drive on pushing and pulling forces when transporting bariatric hospital beds. Applied Ergonomics, 58, 59-65.
*These references are provided for informational purposes only and not intended, nor should they be construed, as legal advice on any particular set of facts.
Great info I’ve been a CNA for 16 years and a caregiver for 15 years before becoming a CNA and you can always learn something new from others