Special Report Safe Patient Handling

Safe patient handling and mobility: The journey continues

Hazards associated with manual patient handling continue to compromise the health and safety of nurses. Among nurses who responded to the American Nurses Association’s (ANA’s) Health Risk Appraisal:

42% believe they are at risk at work from lifting or repositioning patients

13% have had a debilitating musculoskeletal injury

75% have access to safe patient handling and mobility (SPHM) technology, but only half use it consistently.

We must take a closer look at this problem and ask critical questions: Why do only half of the nurses who could use SPHM technology actually use it? Is the equipment relatively inaccessible? Is it heavy or difficult to use? Is enough SPHM technology available to meet patients’ needs? Have nursing staff received the education they need to use it properly? But even if every nurse had access to SPHM technology, equipment alone isn’t the answer. Comprehensive SPHM programs are necessary to eliminate manual patient handling. ANA’s Safe Patient Handling and Mobility: Interprofessional National Standards and the corresponding implementation guide provide a framework for developing effective and sustainable SPHM programs. Important program elements include:

maintaining a commitment to a culture of safety

choosing appropriate SPHM technology

ensuring SPHM technology is accessible

conducting ongoing training to maintain competency

conducting ongoing program evaluation and remediation.

This special report gives you the information you need to help you or your employer develop and implement an SPHM program or enhance an established one. The report details risk factors for patient handling injuries, describes a multifactorial approach to preventing these injuries, discusses the importance of a culture of safety and commitment to SPHM, and provides strategies that help prevent injuries. A graphic on the last page summarizes key points of the report. Additional information is available in the article “Five strategies to help prevent nurses’ patient-handling injuries.”

Debilitating musculoskeletal injuries have ended too many nurses’ careers. We can no longer allow the health and safety of the nursing workforce to be compromised. We’re all on this journey to a safer workplace together. We all need to do our part.

Ruth Francis is a senior policy advisor and Jaime M. Dawson is a program director in the Nursing Practice and Work Environment Department at ANA.

Selected References

Executive Summary: American Nurses Association Health Risk Appraisal (HRA). Preliminary Findings October 2013-October 2014. nursingworld.org/HRA-Executive-Summary.

American Nurses Association. Safe Patient Handling and Mobility: Interprofessional National Standards. Silver Spring, MD: American Nurses Association; 2013.

patient care handle safety

Strengthening your evidence base: Focus on safe patient handling

Over the last 3 years, important new evidence has emerged about safe patient handling. You can apply this evidence at the bedside to help protect yourself and your patients from injury. Below we describe the top 10 new findings and their potential impact. Continue reading »

The ANA Handle with Care Recognition Program

The American Nurses Association (ANA) historically has had a strong commitment to safe work environments for registered nurses (RNs), including prevention of musculoskeletal disorders (MSDs). During an 8-hour shift, the cumulative weight a nurse lifts equals an average of 1.8 tons.

Fear of a disabling MSD has led some nurses to leave the profession. In 2003, alarm over unacceptably high MSD rates resulted in the launch of ANA’s Handle with Care® campaign. The goal—to establish a national no-manual-handling policy—would be achieved through partnerships, outreach, education and training, legislation, and regulation.

ANA increasingly became aware that numerous healthcare organizations were making a commitment to their workers and investing in establishing safe patient-handling programs. Such programs consist of policies and processes that enable nurses and other healthcare workers to move patients using equipment and other devices in a way that doesn’t cause strain or injury to them, other healthcare providers, or the patient, while preserving the patient’s dignity. A safe patient-handling program is comprehensive and consists not only of equipment but also education, training, procedures, policies, and other components to keep caregivers safe while creating a safe environment for patients.

To acknowledge the organizations committed to safe patient handling and enable them to serve as role models to others, ANA developed a program to highlight these admirable organizations. In 2009, it launched the ANA Handle with Care Recognition Program™. The main goal is to assist healthcare organizations to establish, implement, and monitor a comprehensive program to reduce or eliminate MSDs in clinical healthcare workers and patients. The program consists of nine key elements:

  • program planning and leadership
  • initial assessment
  • program development
  • equipment
  • education and training
  • program implementation
  • program evaluation
  • program sustainability
  • regulation.

For recognition award eligibility, the safe patient-handling program must be operational at the applicant facility for a minimum of 3 years. The program start date is the date the equipment is put in use after completion of education and training of healthcare workers. The program must have a dedicated facility coordinator responsible for management and oversight. The chief nursing officer must have a leadership role in the program. The program must have a multidisciplinary committee consisting of frontline nursing staff. High-risk tasks on individual units must be determined from hazard and walk-through assessments. Department-specific safe patient-handling plans must be developed. Equipment selection must involve frontline staff and include evaluation of at least two different manufacturers. Education and hands-on training must be conducted for all staff on participating units. Policies and procedures specific to safe patient handling must be developed and readily available to the staff. The program must be evaluated periodically, with changes communicated and implemented within the organization. Compliance with state and federal regulations is required.

The electronic application must be submitted to ANA and cannot exceed 50 pages. After review and determination, the organization must meet eligibility criteria. Then a site visit will be conducted. Two nurse reviewers will visit the facility to review the program and assess whether program elements are reflected, thereby meeting the ANA’s comprehensive criteria.

After the visit, the reviewers’ report will be evaluated by the review panel of the ANA Handle with Care Recognition Program™, which will decide whether to grant the award to the organization. The award will be granted for a 3-year term. Recipients will be permitted to use the program logo during the recognition term. During those 3 years, the organization will be required to submit annual update reports to ANA. Significant changes to the program may trigger additional update reports.

More information about the ANA Handle with Care Recognition Program™ and a program application are available at www.ANAHandleWithCare.org.

Nancy L. Hughes is the director of ANA’s Center for Occupational and Environmental Health.

Patient handling: Fact vs. Fiction

Ideally, hospitals, nursing homes, and other healthcare facilities should evoke images of healing and comfort. But for many workers on the front lines of patient care, these settings can be hazard­ous—especially if they frequently lift and reposition patients manually. Hospital patients are older, heavier, and sicker than they used to be, making manual handling an even more serious hazard.

In fact, patient handling can be as risky as construction work. According to the Bureau of Labor and Statistics, nurses’ aides, orderlies, and attendants had 44,930 days away from work due to injury in 2007; their injury rate was 465 cases per 10,000 workers. Compare this to construction workers, who had 34,180 days away from work and an injury rate of 394 cases per 10,000 workers. The musculoskeletal disorder rate of the healthcare workers cited above (252 cases per 10,000 workers) was more than seven times the average national rate for all occupations.

The physical hazards of manual patient handling are well documented. Yet much misinformation persists about safe handling and the use of equipment, such as ceiling and floor lifts, to move patients. Disseminating accurate information is an important step in eliminating injuries.

Myth: If you use proper biomechanics and lifting techniques when moving patients manually, you can avoid injury.

Many studies show that training caregivers on how to use proper body mechanics during patient handling has no impact on work practices or injury rates—perhaps because the biomechanical stresses of manual lifting exceed what the body can handle. Healthcare professionals and researchers have begun to question whether existing biomechanics research (on which caregivers’ training is based) can be generalized to patient care. Early studies examined the physical load of lifting a box with handles in the vertical plane. But patients aren’t static objects, and lifting and handling them more often take place in the lateral plane. Also, a systematic review of lifting studies done between 1960 and 2001 found that many popular manual techniques (such as the shoulder lift, through-arm lift, pivot lift, bear hug, and rock lift) aren’t recommended by research and are unsafe.

The revised lifting equation from the National Institute for Occupational Safety and Health is a tool that calculates the recommended weight limit (RWL) of two-handed manual lifting tasks. When used to assess a manual patient lift, this equation found the RWL was 35 lb, given the following ideal—but uncommon—conditions:

  • The patient is cooperative and not combative.
  • The amount of weight the caregiver handles can be estimated.
  • Lifting is smooth and slow.
  • The caregiver’s position relative to the patient and the weight being lifted doesn’t change.

Yet except for pediatric patients, patients weigh more than 35 lb, and a growing percentage are obese. According to one estimate, the average nurse lifts 1.8 tons per shift. What’s more, the ideal conditions listed above rarely exist, adding to the difficulty and unpredictability of patient handling. But despite all the evidence, “proper” lifting techniques remain a part of the nursing school curriculum.

Myth: You can move patients faster when you do it manually than when you use equipment.

In some cases, it is faster to move a patient manually. Nonetheless, using lift equipment is much safer. Usually, the extra time it takes to use equipment results from looking for the equipment in the first place.

On the other hand, manual handling may take more time if you need to wait for additional staff to assist you. One researcher found that using mechanical lift equipment to transfer patients took fewer personnel and about 5 minutes less (even accounting for the time needed to find and set up the equipment) than manual transfers. Installing fixed ceiling lifts in patient rooms can eliminate the extra time it takes to look for, retrieve, and conveniently store equipment.

Myth: Using mechanical equipment to move or reposition patients jeopardizes their comfort and safety.

Numerous studies show that use of mechanical lift equipment increases patient comfort and feelings of security compared to manual handling. Patients may even feel that use of the equipment makes them less of a burden to nursing staff.

You may find some patients are leery of the equip­ment; they may worry about their dignity as well as safety. Patient education can eliminate these concerns. Nurse managers, physical and occupational therapists, and even family members can reinforce to patients that the lift is for their safety as well as the caregiver’s and reduces the injury risk for both. (For an educational resource for patients and families, visit the website of the Safe Patient Handling Steering Committee of Washington State: http://www.lni.wa.gov/Safety/Research/SafePatient/.)

Myth: Lift equipment is expensive and many facilities can’t afford it.

Long-term benefits of proper lift equipment far outweigh the costs of injuries from manual patient handling. The benefits of safe patient-handling programs in hospitals have been demonstrated repeatedly. Where safe handling programs exists, related injuries, workers’ compensation claims and costs, and lost or modified workdays have decreased and worker satisfaction and retention have improved.

The payback period for the initial capital investment in program implementation (including equipment) is relatively short. In one hospital, the payback period for direct costs associated with a ceiling lift program was approximately 4 years; when indirect costs were considered, it was less than 2 years. In another hospital, the payback period was less than 1 year when indirect costs were considered. In Washington State, acute-care hospitals can receive a business and operating tax rebate of $1,000 per acute care bed as part of the Hospital Safe Patient Handling Law.

Myth: You don’t need to worry about patient-handling injuries if you are healthy and strong and have never had a problem.

It may seem logical to assume younger or more physically fit caregivers are less likely to be injured, but the research doesn’t support this. Although the risk of back injury rises with increasing age or years worked in nursing, younger or “healthier” caregivers do sustain patient-handling injuries. In fact, good health and strength may put these nurses at greater risk: Coworkers are four times more likely to ask stronger, fitter peers rather than older ones to assist with patient handling. (See Risk factors for manual handling by clicking on the PDF icon above.)

Also, leisure, household, and exercise activities may predict lower back pain. In nursing students, higher levels of moderate and vigorous physical activity have been shown to be a significant predictor of back pain.

And when nurses suffer back injuries, physical conditioning may not get them back to work sooner. A review of research of physical-conditioning programs aimed at promoting employees’ return to work found these programs didn’t reduce sick leave for workers with acute back pain.

Help end the injuries

Patient-handling injuries continue to exact a toll on healthcare workers. The nurse’s average age is rising faster than that of the workforce as a whole, and fewer younger people are entering the profession. When older nurses leave the profession through injury or attrition, the situation only worsens. It becomes more difficult to recruit new nurses and retain experienced nurses; ultimately, this contributes to a nursing shortage.

Healthcare organizations and their staff need to recognize the importance and benefits of a safe patient-handling program. A comprehensive program with effective risk assessment and risk control policies, adequate amounts of “no-lift” equipment, ongoing training in equipment use, and cooperation at all levels will improve staff health and safety.

Selected references

Alamgir H, Li OW, Yu S, Gorman E, Fast C, Kidd C. Evaluation of ceiling lifts in health care settings: patient outcome and perceptions. AAOHN J. 2009;57(9):374-380.

Baptiste A, Boda SV, Nelson AL, Lloyd JD, Lee WE. Friction-reducing devices for lateral patient transfers. AAOHN J. 2006;54(4):173-180.

Chhokar R, Engst C, Miller A, Robinson D, Tate, RB, Yassi A. The three-year economic benefits of a ceiling lift intervention aimed to reduce healthcare worker injuries. Appl Ergon. 2005;36:223-229.

Collins JW, Nelson A, Sublet V. Safe lifting and movement of nursing home residents. DHHS (NIOSH) Publication #2006-117. Department of Health and Human Services; 2006.

Mitchell T, O’Sullivan PB, Burnett A, et al. Identification of modifiable personal factors that predict new-onset low back pain: a prospective study of female nursing students. Clin J Pain. 2010;26(4):275-283.

Occupational Health & Safety Agency for Healthcare in BC. Ceiling Lifts as an Intervention to Reduce the Risk of Patient Handling Injuries: A Literature Review. Vancouver, B.C.: Occupational Health & Safety Agency for Healthcare in BC; 2006.

Patient Safety Center of Inquiry. Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and Department of Defense; 2001.

Pellino TA, Owen B, Knapp L, Noack J. The evaluation of mechanical devices for lateral transfers on perceived exertion and patient comfort. Orthop Nurs. 2006;25(1): 4-10.

Schaafsma F, Schonstein E, Whelan KM, Ulvestad E, Kenny DT, Verbeek JH. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev. 2010(Jan 20);(1):CD001822.

Strøyer J, Jensen LD. The role of physical fitness as risk indicator of increased low back pain intensity among people working with physically and mentally disabled persons. Spine. 2008;33(5):546-554.

U.S. Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work, 2007. www.bls.gov/news.release/archives/osh2_11202008.pdf. Accessed May 23, 2010.

Waters TR. When is it safe to manually lift a patient? AJN. 2007;107(8):53-58.

Weinel D. Successful implementation of ceiling-mounted lift systems. Rehab Nurs. 2008;103(2):63-87.

WorkSafeBC. High-risk Manual Handling of Patients in Healthcare. Workers’ Compensation Board of British Columbia; 2006. www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/handling_patients_bk97.pdf. Accessed May 23, 2010.

Ninica L. Howard is a Senior Researcher at the Sharp Program in the Washington State Department of Labor and Industries in Olympia.