Figuratively speaking, nursing is a backbreaker. The manual lifting and moving of patients is linked to a range of career-killing musculoskeletal disorders (MSDs)—and to the hemorrhage of nurses from the profession. The outlook, nonetheless, isn’t bleak. Two prominent figures in the safe patient handling (SPH) movement see continuing challenges, but also improving attitudes in the healthcare industry. Both experts have wish lists.
The progress is uneven. Manual lifting persists, and many states are in no hurry to legislate against it. Prompted by the Handle With Care Campaign of the American Nurses Association, eight states have enacted safe patient handling legislation, and it is being considered in several other states.
Despite the efforts of the SPH movement, California’s—SB 1151, the “Hospital Patient and Health Care Worker Injury Protection Act—is a yearly casualty. It was recently vetoed for the fifth time in as many years. Among other things, the bill would have established a zero lift policy and lift teams within general hospitals.
Interviewed by the Ergonomics Report® in December, Anne Hudson, RN, BSN, the founder of Work Injured Nurses’ Group USA (WING USA), reported that many hospitals are installing safe lifting equipment “and successfully implementing safe patient handling policies and programs—with great reductions reported in injuries and related costs.” Hudson and William Charney, a healthcare industry consultant and an author and pioneer in the FPH movement, co-edited the 2003 book, “Back Injury Among Healthcare Workers: Causes, Solutions, and Impacts.” The WING USA founder, a leader in the SPH movement, credits the work of thousands of people across the country for the changing attitudes.
A new Veterans Health Administration (VHA) program illustrates the magnitude of the movement in our country, Hudson said. Audrey Nelson, Ph.D., RN, FAAN, Director of the VISN 8 Patient Safety Center of Inquiry, Ergonomics Research Laboratory, reports that the VHA has funded a three-year $205 million initiative to implement a comprehensive safe patient handling program at all VA Hospitals. The plan includes installing ceiling lifts over most inpatient beds, outpatient exam rooms, therapy clinics and diagnostic areas. Unit Peer Leaders and Facility Champions are being designated as part of the program, which is billed as “the largest safety initiative ever funded.”
Lynda Enos, RN, MS, COHN-S, CPE, an ergonomist-nursing practice consultant for the Oregon Nurses Association (ONA) and the Principal of the Oregon-based Humanfit consultancy, is another leader in the SPH movement. She told the Ergonomics Report® that the coalition she heads in Oregon, which includes the Oregon Occupational Safety and Health Division (OR-OSHA), has been able to “achieve pretty good success in a collaborative approach” without pushing for legislation. “In the last four years we’ve seen a big change in acute care, and definitely support and buy-in for these programs.” She sees a definite shift in thinking. “We’ve still got a long way to go, but it is moving in the right direction.”
Encouraging the Right Direction
The SPH movement has established its own industry, specialists and advocates. They will meet in March in Florida for the 9th Annual Safe Patient Handling & Movement Conference. Sessions will cover best practices and new equipment for taking the load off healthcare workers’ backs. The conference agenda also lists sessions that focus on the business case for zero lift policies, and on ways to drive home the message that the nursing shortage can be addressed by minding nurses’ backs.
The American Nurses Association estimates that 12 percent of nurses leave annually due to back injuries, and greater than 52 percent complain of chronic back pain. The shortage is widely described as critical. The Department of Veterans Affairs reports a 10 percent shortage.
Reducing the shortage promises financial benefits for the industry, according to the American Association of Colleges of Nurses (AACN). The organization points out that more nurses would mean less hospital-related mortality and shorter patient stays.
Dabbling in Safe Patient Handling
A half measure found at some facilities is the practice of employing lift teams as a way of easing the load on nurses’ backs, but expecting them to lift patients without assistive lifting equipment. Ergonomist Enos has significant misgivings about the practice. She explained that we have the science now to know the manual lifting of patients, regardless of gender, age and fitness level, is dangerous “I am not a proponent of lift teams without equipment. Even when they have equipment, they cannot be everywhere on all shifts.”
Two facilities she works with had lift teams for a few years. When I looked at their injury data, she said, the injuries showed up in the lift teams and also in the nursing units. The lift teams’ programs have been revised. “They’ll be the in-house experts for lifting, but they’ll be using equipment, and the nurses and aides will have equipment as well.” The ergonomist describes the arrangement as a quasi lift team model, and says it is working “pretty well.” Now “the lift team can focus on the safe and comfortable transportation of patients and lateral transfers. And on the units, the staff have enough equipment and the right program approach.”
Enos’ biggest argument against the un-reformed lift-team model—a very important one that has not really been published around this issue, she said—is that it leaves individuals who are not licensed health care professionals with the responsibility for assessing how the patient can and should be moved. “So you have someone who is acutely ill, and they come in and move them. If that nurse is not around to help, or that the patient’s mobility assessment is not communicated, we have a potential patient safety issue, and that’s not been talked about a lot. But I’m seeing that in my practice.”
Programs that focus on "correct" manual patient lifting technique and body mechanics, both performed without lifting equipment, also persist in the industry. From personal experience, WING USA founder Hudson knows such programs are inadequate. As a nurse, she cared for acutely ill hospital patients until a spinal injury from lifting patients ended her hospital career. She speaks from the heart when she describes the immediate risk from manual handling as a painful, possibly disabling injury, that is followed by potential loss of job, or entire career, along with loss of health insurance and retirement benefits. “The emotional and financial toll is great, along with the physical pain and new limitations. Nurses sometimes lose their possessions, car, home, and even their spouse under the strain of a newly disabled partner who no longer provides an income.”
Victorian Labor Conditions
Though known well as an activist in the safe patient handling movement, Hudson is probably better known for her lobbying efforts on behalf of nurses and aides who have lost their careers because of work-related MSDs. Her organization’s website, www.wingusa.org, keeps nurses abreast of developments in patient handling issues. It also provides a space for nurses who have been disabled from manual lifting to share their case histories. Some of these date from a time before the SPH movement gathered its present momentum, but they remain instructive: Collectively they tell a story of Victorian working conditions for many healthcare staff, and describe attitudes that still need to be overcome in some corners of the healthcare industry.
“Beyond Heavy-Duty Physical Labor” ruptured three discs when trying to assist “a very large patient … going through alcohol issues,” who had fallen. Only following therapy, which did not restore full function, was the nurse made aware of the employer’s working requirements; that nurses be able to lift 200 pounds, repeatedly from floor to chest, for a 12-hour shift. They are required to be able to stand or sit for 90 percent of the shift, which means standing or sitting the entire time. The telling conclusion of her account will sound familiar to many—if not most—health care staff: “My doctors told me that a large part of why I ended up with the complications that I did, was from years of lifting patients and walking on concrete floors.”
“Went to Work Fine, Came Out Disabled” had been a medical/surgical nurse for 16 years, on 12- to 16-hour shifts, when the need to manually reposition an overweight patient in bed injured both the nurse and an assisting staffer. Extended treatment did not address the injury. “I would have never dreamed that one day I would go to work and face the possibility of never walking or feeling the ground below my feet again,” the nurse explained. “To this day, I cannot feel my hands or the lower one-half of my body and I catheterize myself six to eight times a day. My career is over, since I cannot lift more than 10 pounds. You can go to all the lifting education that is offered, but we can’t control all the variables of our patients.”
“Hospital Requires Lifting 75 Pounds” is no longer allowed to lift more than 35 pounds because of annular tears in two lumbar discs. “My hospital requires that nurses be able to lift 75 pounds. … We do have lift equipment in the hospital but it is usually only used for bariatric patients. It might take anywhere from 10 minutes to an hour to find all the pieces to get a patient lifted. That’s why it’s only used for bariatric patients.”
“Job Says Can’t Return with Lifting Limit” is not allowed to lift more than 20 pounds after an on-the-job injury. Now the nurse is caught in a tussle between an insurance company that says he or she must go back to work and an employer who insists the job requires 100 percent lifting ability.
“Moved 900-Pound Patient as Instructed,” an agency nurse, was left without help when moving a morbidly obese patient in a bariatric wheelchair to another department. The journey required manhandling the chair into an elevator that was not flush with the floor.
“You Give So Much” broke 12 discs when helping to move a patient from a bed to a stretcher.
“In Other Words, It Was All Our Fault” had her final back injury in 2001 after working in Critical Care for 13-plus years. “I was unaware that I was day-by-day experiencing what would finally become a permanent injury and disability. All those little back strains that we thought were a part of being an active nurse. When we did report an injury, immediately we were told that we just must not be lifting correctly, not using proper body mechanics. In other words, it was all our fault. Then, after working an 8 or 12 hour shift, you were sent to ER to wait 6 to 8 hours before being seen, most times released to return to work the next day after getting 2 to 3 hours sleep. Many injuries went unreported and I’m sure that has not changed even to this day.”
A Wish List for 2009
The new year brings a change of administration in Washington, and both of the interviewed experts see prospects for legislative efforts to coax laggards in the healthcare industry into practices that protect backs.
Hudson sounds a hopeful note: “It is shameful that the United States, which is said to have the best healthcare in the world, is not leading, but rather lags behind other countries more advanced on the safe handling of patients and residents. Hopefully this will turn around under the new administration.” According to Hudson, there is no question that national legislation is necessary to extend protection from preventable patient handling injuries to healthcare workers, patients, and residents throughout the nearly 6,000 hospitals and 18,000 nursing homes in America. The bill national bill introduced by Representative John Conyers, HR 378 “Nurse and Patient Safety and Protection Act,” is slated for re-introduction after President-elect Obama is inaugurated in January, she said. “With one co-sponsor so far, hopes are high that many more co-sponsors will come on board, and that legislation for the safe handling of patients and residents throughout the country will finally be enacted under the new administration.”
Enos is also optimistic about the new administration, and her wish list includes expanding protection to nurses and aides in acute care, long-term care and home health. “It needs to be across the board,” she explained. “For example, we have home health workers and families attempting to take care of bariatric patients with no ability to access lift equipment due to lack of Medicare reimbursement and nursing homes that are not equipped to take care of bariatric patients.”
WING USA’s Hudson sees value in lobbying. “The number one reason people enter long-term care is the inability of family and caregivers to lift and move them. Home lifts, including ceiling lifts, and a variety of other innovative patient-handling equipment, are needed to protect home caregivers and dependent persons in their care. It is time to lobby insurance companies to cover such equipment, to help families stay together, and keep costs down, by assisting dependent persons to remain in their own homes through use of modern technology.”
With President-elect Barak Obama in and once we get through some of the challenges with the economy, Enos said, I think we will see greater support for a national safe patient handling law. She wants it to be a federal mandate, rather than just legislation enacted state by state, and wants it attached to a grant system and monetary support. Traditionally, she said, a Democratic government … is a little more supportive of safety and health.”
She also wants patient and employee safety promoted as a package. “We need to stop the silo-ing of staff safety versus patient safety. We have to put the two together because they are interrelated.”
Sources: Anne Hudson; Lynda Enos; WING USA; 9th Annual Safe Patient Handling & Movement Conference website; ANA; AACN
This article originally appeared in The Ergonomics Report™ on 2009-01-07.