Preventing Back Injuries in Healthcare Settings
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
Direct and indirect costs associated with back injuries in the healthcare industry are estimated to be $20 billion annually.4 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 = 39–79%), lost work days by 86% (range = 50–99%), restricted workdays by 64% (96% decrease to 17% increase), and workers' compensation costs by 84% (range = 53–99%). 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, Ph.D.; Jim Collins, Ph.D., MSME; Traci L. Galinsky, Ph.D.; Thomas R. Waters, Ph.D., CPE
Dr. Bell is a research epidemiologist in the Analysis and Field Evaluations Branch in the NIOSH Division of Safety Research.
Dr. Collins is (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.
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Comments
I borke my back ,over 30 years ago. Over the years I have learned many things about people like me. In general, we are not told we will NEVER BE THE SAME ! We are NOT told much of anything. Until M.D._s are REQUIRED to tell people like me the complete 9 yards,Training is a waist of time & money. All that is done is try to prevent lawers from getting involved. The commen head cold is the #1 reason for E.R. visits---#2 is related to BACK PAIN. People like me have no-one to talk to. We don't know who the BAD DOC_s are, etc. I'd love to hear your reasons for that.
Posted 9/22/08 at 3:05 pm
Work-related back injuries are a serious problem and account for nearly 20 percent of all injuries and illnesses in the workplace. All healthcare professionals need to be informed of the risks and prevention of workplace-related back injuries. NIOSH recently worked with its partners to ensure that nursing school training materials contain the latest evidence-based research on safe patient lifting and back injury information. Research studies have shown that a large fraction of work-related back pain can be prevented by ergonomic design of the workplace and use of assistive equipment.
NIOSH was created by the Occupational Safety and Health Act to examine ways to prevent injuries in the first place recognizing that once an injury has occurred there can be permanent damage. As such, NIOSH research in this area focuses on the use of ergonomic workplace design to prevent injury and/or re-injury. The Agency for Healthcare Research and Quality (AHRQ) funds studies on the effectiveness of injury treatment methods.
Posted 9/23/08 at 3:15 pm
I work in Employee Health and handle our Worker's Comp claims, consequently I have seen a few musculoskeletal injuries over the years. I have been instructing our staff on how to use the battery operated patient lifts and lateral transfer air mattress devices the hospital purchased.
The staff is extremely enthused about the equipment during the demonstrations and then never use it on the units. The equipment is kept buried in a closet with commodes, scales, electronic blood pressure cuffs ect. Unfortunately our facility has a policy that hallways must be kept clear.They feel that the time they take to get the equipment they could have had the patient manually moved. Equipment must be easily accessible and visable or staff will not use it! We need to start worrying less about how a hallway looks. Use of patient moving devices is a safety issue,not only will their use reduce employee injuries but can prevent potential patient injuries.
Posted 9/24/08 at 4:47 pm
Despite the fact that mechanical lifts and lateral transfer devices can make a huge impact on improving the safety of both health care staff and patients, a broader program is required to overcome the barriers and cultural resistance to using mechanical patient lifts.
Many healthcare organizations have dedicated resources on back injury prevention with little resulting improvement. Research has shown that in order for safe patient/resident lifting programs to be successful they must not only incorporate mechanical lifting equipment and repositioning devices and training in the use of these devices, but it requires a change in the workplace culture that can be facilitated with a written safe patient lifting policy, top management support, nursing management support on each unit, and patient lifting algorithms that identify how patients with different conditions and weight bearing ability should be lifted.
Details on establishing a comprehensive safe patient handling and movement program can be found at:
(94 pages, 2.78 MB)
(95 pages, 3.49 MB)
Posted 9/25/08 at 11:09 am
I understand the reasoning for implementing safe lifting practices in healthcare; however, due to the increase in obesity and the older adults who need assistance, it is hard to perform these tasks with minimal assistance and poorly maintained or out of date equipment. How can we get healthcare institutions to open their eyes to the fact that employees are getting injured and they could probably purchase new and improved equipment with the Workman's comp funds they have paid out?
Posted 9/25/08 at 8:37 am
NIOSH conducted an intervention trial in six nursing homes that included a business case and cost-benefit analyses (cost to implement the program was balanced with the workers' comp savings) that are described in the DHHS (NIOSH) Publication Number 2006-117, Safe Lifting and Movement of Nursing Home Residents, and the peer-reviewed publication, An evaluation of a "best practices" musculoskeletal prevention program in nursing homes, in Injury Prevention, August 2004.
The NIOSH numbered publication (on page 6) also cites Tiesman et al., 2003, Nelson et al., 2003, and Garg 1999 as other intervention trials on safe patient lifting that have included cost-benefit analyses.
Posted 9/25/08 at 11:04 am
Thank you for pushing this important issue forward. I am an Occupational Health Nurse in Maryland. At my last place of employment I was unable to convince my hospital management to commit any financial resources to safe patient lifting, even though I could show direct costs for back injuries related to moving patients. I brought in quality equipment for demonstrations, I gave presentations to senior management, I circulated articles regarding best practices, all to no avail.Our State Legislature passed a safe patient lifting bill last year that required all hospitals to form a safe patient lifting committee, and develope policies, but the bill fell short of requiring actual mechanical devices (in the case of this hospital, they passed out gait belts). There is also no oversight to see that it will be implemented, and no penalty for not complying. Because OSHA has not promulgated a standard, there is no fear of federal regulation. Joint Commission does not look at employee injuries as part of it's environment of care inspection process. Even "Magnet" status will only start to look at some types of employee injuries as part of it's application process in the coming year (but not back injuries). If we are to improve the working environment for healthcare workers, it seems NIOSH may need to lead the way by pushing OSHA to promulgate standards to protect us. Best practice recommendations will not be enough.
Posted 9/25/08 at 10:39 am
NIOSH is considering research that will evaluate the impact of the nine safe patient handling state laws to evaluate the effectiveness of each of the state laws to better inform pending Federal legislation. Links to each state law are provided below.
Three states have passed legislation supportive of, but not requiring, safe patient and/or resident handling:
Six states have passed legislation requiring safe patient and/or resident handling policies, and/or programs, and/or patient lifting equipment:
Language in three areas: 1. Grant funding Art 1, Sec 6, Sub 3, pp 25-26; 2. main body of wording Art 2, Sec 23. 182.6551 to Sec 25. 182.6553, pp 48-51; and 3. study ways for workers' comp insurers to recognize compliance in premiums and for on-going funding Art 2, Sec 36, and work groups on safe patient handling and equipment Sec 37, pp 58-59.
Additionally, the national bill HR 378 "Nurse and Patient Safety and Protection Act of 2007" was introduced into the House of Representatives in January 2007. The bill remains in committee. For links to the status, complete history, and text of HR 378, go to http://thomas.loc.gov.
Posted 9/29/08 at 5:46 pm
This was a very interesting article and great information, but is it in the actual job description for nurses or health care providers to physically try to lift or move patients? I know that it is something that we learn in nursing school (body mechanics) but if a nurse were to say to administration "I can not physically move this patient", do you think that she/he would be terminated?
Posted 9/27/08 at 8:28 pm
One thing I would like to add about back injury and nurses: As caretakers, we need to learn to take care of ourselves. If we are in poor physical condition because we have not taken "care" of ourselves, the likelihood of back injury increases.
Posted 9/29/08 at 12:30 pm
Injuries to the back are one of the most prevalent and costly work-related musculoskeletal disorders in the United States. Low-back pain adversely affects 1,000,000 workers in the United States every year and is responsible for more lost work days than any other musculoskeletal disorder.
Posted 10/1/08 at 5:25 am