Preventing Back Injuries in Health Care Settings
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Healthcare workers often experience musculoskeletal disorders (MSDs) at a rate exceeding that of workers in construction, mining, and manufacturing.1 These injuries are due in large part to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures. The problem of lifting patients is compounded by the increasing weight of patients to be lifted due to the obesity epidemic in the United States and the rapidly increasing number of older people who require assistance with the activities of daily living.2,3
Costs associated with overexertion injuries in the healthcare industry were estimated to be $1.7 billion in 2015.* 4a, 4b Additionally, nursing aides and orderlies suffer the highest prevalence (18.8%) and report the most annual cases (269,000) of work-related back pain among female workers in the United States.5 In 2000, 10,983 registered nurses (RNs) suffered lost-time work injuries due to lifting patients. Twelve percent of nurses report that they left the nursing profession because of back pain.6
As our nursing workforce ages (average age 46.8 years) and we face a critical nursing shortage in this country (an expected 20% shortage by 2015 and 30% by 2020), preserving the health of our nursing staff and reducing back injuries in healthcare personnel is critical. The National Institute for Occupational Safety and Health (NIOSH) has a comprehensive research program aimed at preventing work-related MSDs with major efforts to reduce lifting injuries in healthcare settings. NIOSH’s research with diverse partners has already made great strides in developing and implementing practical intervention strategies, with further progress expected.
The first research effort was a comprehensive lab and field study to identify safer ways to lift and move nursing home residents by removing the excessive forces and extreme postures that can occur when manually lifting residents. Historically, the caregiver has used his or her own strength to provide manual assistance to the resident. NIOSH conducted a large field study to determine if an intervention consisting of mechanical equipment to lift physically dependent residents, training on the proper use of the lifts, a safe lifting policy, and a preexisting medical management program would reduce the rate and the associated costs of the resident handling injuries for the nursing personnel in a real world setting.7
During the 6-year period, from January 1995 through December 2000, 1,728 nursing personnel were followed before and after implementation of the intervention. After the intervention, there was a significant reduction in injuries involving resident handling, workers’ compensation costs, and lost work day injuries. When injury rates associated with patient handling were examined, workers’ compensation claims rates per 100 nursing staff were reduced by 61%; Occupational Safety and Health Administration (OSHA) recordable injury rates decreased by 46%; and first reports of employee injury rates were reduced by 35%. The initial investment of $158,556 for lifting equipment and worker training was recovered in less than 3 years on the basis of post-intervention savings of $55,000 annually in workers’ compensation costs and potentially more quickly if indirect costs (lost wages, cost of hiring and retraining workers, etc.) are considered. This is significant given that cost is an often cited barrier to purchasing lifting equipment. Another advantage of lifting equipment is the reduction in the rate of assaults on caregivers during resident transfers—down 72%, 50%, and 30% on the basis of workers’ compensation, OSHA recordable incidents, and the first reports of injury data, respectively.
More information on this study can be found in the NIOSH publication Safe Lifting and Movement of Nursing Home Residents. Based on the successes achieved in the long-term care industry, NIOSH is undertaking a six-year longitudinal research study to evaluate the effectiveness of a “best practices” safe patient handling program at two large acute-care hospitals in the United States.
Another major study demonstrating success in reducing back injuries to health care workers was funded by NIOSH through a cooperative agreement. The study examined the long-term effectiveness of a safe lifting program with the primary objective to reduce injuries to healthcare workers resulting from manual lifting and transferring of patients.8 The safe lifting programs, which used employee management advisory teams (participatory-team approach), were implemented in seven nursing homes and one hospital. The eight facilities varied in the available number of beds and number of nursing personnel. In this study, manual lifting and transferring of patients was replaced with modern, battery operated, portable hoists, and other patient-transfer assistive devices. Ergonomics committees with nearly equal representation from management and employees selected the equipment and implemented the safe lifting programs.
Injury statistics were collected post-intervention for 51 months and were compared with 37 months of pre-intervention data. The results were compelling. The number of injuries from patient transfers decreased by 62% (range = 3979%), lost work days by 86% (range = 5099%), restricted workdays by 64% (96% decrease to 17% increase), and workers’ compensation costs by 84% (range = 5399%). Overall, the eight facilities experienced decreases of 32% in all injuries, 62% in all lost work days, 6% in all restricted work days, and 55% in total workers’ compensation costs. The program produced many intangible benefits including improvements in patient comfort and safety during transfers and patient care. The nursing personnel perceived that their backs were less sore and that they were less tired at the end of their shifts. More pregnant and older workers were able to perform their regular duties and stay on the job for a longer period.
Despite the obvious advantages to using lifting equipment, schools of nursing continue to teach, and nurses’ licensure exams9 continue to include, outdated and unsafe manual patient handling techniques. This is due in large part to outdated books and curricula which promote unsafe patient handling practices. To address this, a team of experts from NIOSH, the American Nurses Association, and the Veterans Health Administration developed and evaluated an evidence-based training program on safe patient handling for educators at schools of nursing. The study found that when using the curriculum, nurse educator and student knowledge improved significantly as did the intention to use mechanical lifting devices in the near future.10,11 The curriculum module, which won the 2008 National Occupational Research Agenda (NORA) Partnership Award, is ready for broad-scale dissemination across nursing schools to reduce the risk of MSDs among nurses.
Looking ahead: Beginning in 2009, NIOSH will conduct a project aimed at improving safety while lifting and moving bariatric patients. In healthcare settings, the term “bariatric” is used to refer to patients whose weights exceed the safety capacity of standard patient lifting equipment (300 lbs), or who otherwise have limitations in health, mobility, or environmental access due to their weight/size.12 Compared to the non-obese population, obese individuals require more frequent and extensive healthcare due to obesity-related health problems, and healthcare personnel are encountering hospitalized and critical-care bariatric patients on an increasingly frequent basis.13,14,15 In the extreme, such patients can weigh over 1,200 pounds. The upcoming NIOSH project will evaluate bariatric patient handling practices at multiple hospitals, including intervention programs and health/safety outcomes, in order to identify and promote evidence-based best practices.
We all have a vested interest in taking care of those who help take care of us and our families when we need medical attention. It is likely that the implementation of the research presented here will significantly reduce injuries and illnesses for healthcare workers and increase the quality of patient care. In turn, reducing MSDs among nurses may help address the critical issues of nurse recruitment and retention.
As we contemplate further research, we would like to hear about your experiences with lifting equipment and practices in medical settings. Additionally, your thoughts about retooling student nursing curriculum as well as your opinions on state laws regulating safe patient handling and movement would be appreciated.
—Jennifer Bell, PhD; Jim Collins, PhD, MSME; Traci L. Galinsky, PhD; Thomas R. Waters, PhD, CPE
Dr. Bell is a research epidemiologist in the Analysis and Field Evaluations Branch in the NIOSH Division of Safety Research.
Dr. Collins (Captain, U.S. Public Health Service) is the Associate Director for Science for the NIOSH Division of Safety Research.
Dr. Galinsky (Captain, U.S. Public Health Service) is a research psychologist in the NIOSH Division of Applied Research and Technology.
Dr. Waters is a research safety engineer in the Division of Applied Research and Technology.
* The cost figure was revised 9/22/2017 to reflect most current data available.
References
1. Bureau of Labor Statistics, 2007, Incidence rates for nonfatal occupational injuries and illnesses involving days away from work per 10,000 full-time workers by industry and selected events or exposures leading to injury or illness, 2006. U.S. Department of Labor. Washington, DC.
2. State of Washington [2006]. An act relating to reducing injuries among patients and healthcare workers. Accessible on Web at: http://www.leg.wa.gov/pub/billinfo/2005-06/Pdf/Bill Reports/House/1672.HBR.pdf
3. Ogden, C., Carroll, M., and Curtin, L. (2006). Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association, 295, 1549-1555.
4a. BLS Table R12 https://www.bls.gov/iif/oshwc/osh/case/ostb4764.pdf
5. Guo, HR, Tanaka, S, Cameron LL et al. (1995) Back pain among workers in the United States: national estimates and workers at high risk. Am J Ind Med, 28:591-602.
6.Stubbs DA, Buckle PW, Hudson MP, Rivers PM, and Baty D [1986]. Backing out: nurse wastage associated with back pain. International Journal of Nursing Studies 23(4): 325-336.
7. Collins, J.W., Wolf, L., Bell, J., and Evanoff, B. (2004). An evaluation of a “best practices” musculoskeletal injury prevention program in nursing homes. Injury Prevention, 10, 206-211.
8. Garg, A. (1999). Long-term effectiveness of “Zero-Lift Programs” in seven nursing homes and one hospital. U.S. Department of Health and Human Services, National Institute for Occupational Safety and Health, Contract Report No. U60/CCU512089-02.
9. National Council of State Boards of Nursing [2006]. National Council Licensure Examination (NCLEX)® Website. Accessible on Web at: https://www.ncsbn.org/245.htm. Last accessed on November 25, 2006.
10. Nelson et al. (2007): Evidence-Based Nursing School Curriculum in Safe Patient Handling. International Journal of Nursing Education Scholarship, Vol. 4, Iss. 1, Art. 26.
11. Menzel, N. (2007). Preventing Musculoskeletal Disorders in Nurses: A Safe Patient Handling Curriculum Module for Nursing Schools. Nurse Educator. 32 (3):130-135.
12. Bushard, S. (2002). Trauma in patients who are morbidly obese. Association of periOperative Registered Nurses (AORN) Journal, 76, 585-589.
13. Pieracci, F., Barie, P., and Pomp, A. (2006). Critical care of the bariatric patient. Critical Care Medicine, 34, 1796-1804.
14. Reto, C. (2003). Psychological aspects of delivering nursing care to the bariatric patient. Critical Care Nursing Quarterly, 26, 139-149.
15. Tizer, K. (2007). Extremely obese patients in the healthcare setting: Patient and staff safety. Journal of Ambulatory Care Management, 30, 134-141.
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