6876443 Critical Care Nursing Clinics of North America Safe Patient Handling 2007

Index

Note: Page numbers of article titles are in boldface type.

A

Air-assisted devices, for lateral transfers, 179

American Nurses Association, ‘‘Elimination ofManual Patient Handling,’’ 214, 216

Antiembolism stockings, devices for, 209risk for and prevention of musculoskeletal

injury with, 138–139

Association of periOperative Registered Nurses(AORN), ergonomic guidelines of,131–132

for lateral transfer, 134–135

B

Back injuries. See also Low back injury andproblems.incidence of, 213

Bariatric patient, education for care of, 239pericare of, technological solutions for,

183

Bariatric patient handling, 223–240admission process and, 227, 231case study, 230–235

admission, 231equipment provided, 237–239history, 230–231

systems status and care in, 231–235tasks and daily care plan, 237

emotional support for nursing personnel

and, 239equipment for, in case study, 237–239

patient assessment and equipment fit, 238resources for, 224–234

algorithms, 224, 229–233assessment tool, 234equipment pool, 224

injury prevention training support, 227policy and procedure manual,

224–228

work procedures, 224

tasks in, 235, 237

problems and solutions associated with,236–237

Bed design, for bariatric patient, 238

Bed making, musculoskeletal injury in,137–138

Bed mattress, for bariatric patient, 238

Bed space. See Space.

Bed-to-chair transfers, 181–182

Body mechanics, in manual handling, 197

C

Ceiling lifts. See also Lift(s).for bed-to-chair transfers, 181–182for lateral transfers, 177–178

for limb holding, 184for repositioning in bed, 181for toileting in bed, 183–184in University of Iowa Hospitals and Clinics

program, 217, 219

Change, behavior analysis techniques for, 202case studies of, 201

implementation of, in Netherlands program,209–210

incentives for, 201–202

leadership role in, 201models for, 198–200motivation for, 200–201

resistance to, 202–203training for, 200

Change process model(s), building trust andemotional commitment, 198

collaborative, 199communication in, 199–200

social marketing and, 199–200

comparison with nursing process, 198–199leadership top down, 198

Chronic pain, psychosocial factors in, 147–148

0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/S0899-5885(07)00021-4 ccnursing.theclinics.com

Crit Care Nurs Clin N Am 19 (2007) 241–245

Coaches, for assistive equipment use, in

University of Iowa Hospitals and Clinicsprogram, 219, 221in safe handling program, Netherlands, 209,

211

Coaching, for safe patient handling, 202, 209, 211

Compressive forces, in patient handling,biomechanical evidence for, 188–189

reduction of, with lifting devices for patienthandling, 189, 191

Compressive forces, in patient handling, 188–189

Coping skills, musculoskeletal disorders pain anddisability and, 148

D

Disability and return to work, psychosocialfactors in, 147–148

E

Education, for bariatric patient care, 239for patient handling tasks, 190–191

Equipment, for bariatric patient, 238–239

ErgoCoaches, in safe patient handling program,in Netherlands, 209, 211

Ergonomic assessment of critical care unit,

155–165CCU background, 155–156CCU/ICU background, patient-focused

vs. health care worker protection,

156high-risk patient handling tasks, prioritization

of, 161

musculoskeletal disorders risks in vs. in nursinghomes, 163

presite visit unit profile, equipment inventory,

159patient population/staffing/equipment use,

158–160space/maintenance/storage, 158

recommendations, change from patient focusto nurse/patient safety dyad, 163dissemination of information on

musculoskeletal disorders incidence, 164education about need for assistive

equipment, 163

use of Lewin’s model of planned change,164

recommendations for, formulation of, 160, 162

risk analysis of, 160

study of medical ICU in Las Vegas hospital,

156study protocol, collection of baseline data, 157

identification of high-risk tasks, 157, 161

identification of high-risk units, 157presite visit data on high-risk units, 157–159

team site visit for ergonomic assessment, 160unit summary sheet, 160, 162

Ergonomics, in acute care, 204

Ergonomics program, sustaining staff nursesupport for, 197–204

change process models and, 198–199coaching in, 202communication in, 198–199

incentives for, 201–202motivation in, 200–201peer leaders/unit champions for, 202

social marketing for, 199–200training for, 200

F

Floor-based lifts, for bariatric patient pericare,

183for bed-to-chair transfers, 182

Friction-reducing sheets, for repositioning in bed,

180

H

High-risk tasks, musculoskeletal disorders from,131–143. See also Musculoskeletal disorders(MSD), tasks with high risk for.on CCU, identification of, 161

space reqirements for. See also Spacerequirements, for high-risk tasks.

space requirements for, 167–175technology solutions for, 177–186

in bed-to-chair transfers, 181–183in lateral transfers, 177–179

in limb holding, sustained, 184in patient transport, 184–185in repositioning, 179–181

in toileting in bed, 183–184

I

Injury(ies), incidence rate for, 187

low back, 188–189, 188–190overexertion, 187, 213–214overuse, 214unreported, 187–188

242 INDEX

Iowa model, for safe patient handling, 213–222baseline data collection for, 217–219dissemination of results, 220–221education of staff, 219

equipment selection in, 218–219equipment trials and evaluation, 217expert opinion and, 216–217lessons learned, 221

management support and, 219outcome evaluation, 219–220patient outcomes, 220

pilot the change, 217policies and procedures development in, 219practice guidelines and implementation of

change, 218priority of topic, 216research and related literature in, 216

securing financial support for, 217–218staff outcomes, 220team formation for, 216unit assessments, 217

vendor fair for equipment, 217knowledge-based triggers for, ANA

‘‘Elimination of Manual Patient Handling,’’

214, 216OSHA Ergonomics OSHA Guidelines for

Nursing Homes, 214VA Patient Care Ergonomic Resource Guide,

214of evidence-based practice for quality care,

214–215

problem-based and knowledge-based triggersfor, 214

J

Job satisfaction, in reduction of musculoskeletaldisorders, 148

Job strain, as musculoskeletal disorders risk

factor, 148–149, 189–190

L

Lateral transfer, 208–209. See also Transfers.air-assisted devices for, 179Association of periOperative Registered

Nurses� guidelines for, 134–135ceiling lifts for, 177–178friction-reducing devices for, 179

mechanical transfer devices for, 178physical demands of, 134–135safe performance of, 136space requirements for, 177–179

Lateral transfer devices, in University of IowaHospitals and Clinics program, 218–219

Lifters, for transfers, 208–209

Lifting, in critical care, 192weight limitations for, 213

Lifting/moving, heavy objects or equipment, risk

for and prevention of musculoskeletal injuryin, 139–141

Lift(s), ceiling. See Ceiling lifts.floor-based, 182–183

for bariatric patient, 238sit-to-stand, 182

Lift team, decrease in low back injuries with, 191

Limb support, ceiling lifts for, 184in critical care, 192–193

Low back, compressive and shear forces on, in

patient handling, 188–189perceived stresses on, during lifting and

repositioning, 190

Low back injury and problems, causes of,188–189nursing personnel perception of, 189–190work stress and, 189–190

MManeuvering heavy material, guidelines for,

transportation device for, 209

Manual handling, American Nurses Associationand elimination of, 214, 216of load, NIOSH guidelines for, 205–206

risks with, 213–214UK regulations for, 214

Manual patient handling, alternatives to, 142

internal loads in, 142musculoskeletal disorder risk in, 131

Minimal lift program, 187–196studies of, 191

Minimal stand assist device, in University of IowaHospitals and Clinics program, 218

Musculoskeletal disorders (MSDs), incidence of,

155pain in, cognitive-behavioral therapy for,

149–150

prevalence of, in Netherlands, 205–206psychosocial factors in, 145–153

as etiologic agents, 146case study of, 149–150

disability and return to work and,147–148

interventions to reduce, 148–149

243INDEX

Musculoskeletal (continued )reduction of, cognitive-behavioral therapy in,

149–150job satisfaction in, 148

risks for, job strain, 148–149, 189–190manual patient handling, 131

tasks with high risk for, 131–143applying antiembolism stockings, 138–139

lateral transfers, 134–136making occupied beds, 137–138moving heavy objects and equipment,

139–141pushing occupied beds, 132–134repositioning from side to side, 137

repositioning to head of bed, 136–137

N

National Institute for Occupational Safety and

Health (NIOSH), weight limits for lifting, 213

O

OSHA, Ergonomics OSHA Guidelines for NursingHomes, 214

Overexertion injury, 213–214costs of, 187

Overuse injury, 214

P

Patient handling, in critical care, 192shear and compressive forces in, biomechanical

evidence for, 188–189

Patient handling tasks, education and training for,190–191

intervention program for, assistive devices in,191

lift team for, 191minimal lift program for, mechanical lifts in,

191perioperative, 192–193

Patient transport, physical demands of, 132–133

powered technologies for, 184–186safety tips for, 133–134

Positioning. See also Repositioning.for treatment, 209

Psychosocial factors, definitions of, 145–146in musculoskeletal disorders, 145–153

case study, 149–150cognitive-behavioral therapy in reduction

of, 149–150

conceptual models of, 146–147

contribution of, research evidence lackingfor, 146

evidence for, as etiologic agents, 146

in disability and return to work, 147–148

R

Repositioning. See also Positioning.from side to side, 137guidelines for, in safe handling program, in

Netherlands, 208in bed, 189

devices for, 180–181manual, 179–180

in critical care, 192

nursing personnel perception of stresses in, 190on side, 181to head of bed, physical demands of, 136

tips for, 137

S

Safe handling program(s). See also Iowa Model.creating culture of change for, 213–222in Netherlands, analysis of ergonomic situation

and, 205–207implementing change for, 209–210observation of ergonomic problems in, 207

peer leaders in, 205–211physical load exposure and, 206–207practice guidelines for, 207–209

preliminary results, 210–211prevalence of musculoskeletal disorders

and, 205–206pushing and pulling and, 207

task force for, 207–208sustaining staff nurse support for, 197–198University of Iowa Hospitals and Clinics,

213–222

Shear forces, in patient handling, 188–189

Shoulder, perceived stresses on, during lifting and

repositioning, 190

Sit-to-stand lifts, for bed-to-chair transfers, 182

Sling design, for bariatric patient, 238

Social marketing, application to safe patienthandling, 200for change, 199–200

Space, in ICU, evidence-based practice in health

care architecture and, 168–169historical perspective, 167–168recommendations in USA and UK, 168

planning, for bariatric patient, 239

244 INDEX

Space requirements, for high-risk tasks, 167–175areas, 171functional space experiments, 169–170length, 171–173

link analyses for, 170resuscitation, 169–172transfer from bed to bed, 169–172washing and dressing patients, 169–172

width, 171, 173for lateral transfer, 177–179

Stand assist device, in University of Iowa

Hospitals and Clinics program, 218

Stresses, on low back and shoulder, nursesperceptions of, 190

T

Total assist devices, portable, in University ofIowa Hospitals and Clinics program, 218–219

Transfers, guidelines for, 208–209

in critical care, 192manual, in Netherlands, 206–207manual and mechanical, compressive and

shear forces in, 188–189

Transfer(s), lateral. See Lateral transfer.mechanical, 188–189

Transport, in critical care, 192

of bariatric patient, 238–239technological solutions for, 184–185

Transportation device, for heavy objects, 209–210

U

University of Iowa Hospitals and Clinics. See alsoIowa Model.safe patient handling program, 213–222

V

Veterans Administration, Patient Care ErgonomicResource Guide, 214

Veterans Administration Medical Center, Florida,

tasks with high risk for musculoskeletaldisorders, 131–143. See also Musculoskeletaldisorders (MSDs), tasks with high risk for.

W

Weight limits for lifting, 213

Workload, and patient safety, 121–129assessment of, systemic, 127

dimensions of, 121–124cognitive, 122–123emotional, 123physical, 121–122, 125

quantitative and qualitative, 123–124relations between, 124time pressure and, 123

variability of, 124impact of, on health, 125

on patient safety, 126

on quality of working life, 125–126systemic, 126–127

perception of, 125sources of, 124–125

static or postural, 206–207guidelines for, 208–209

Work-related musculoskeletal disorders

(WMSDs), 131. See also Musculoskeletaldisorders (MSDs).incidence rates for health care workers, 131

risk for, 131

Work stress, low back problems and, 189–190

245INDEX

Workload and Patient Safety Among CriticalCare Nurses

Pascale Carayon, PhDa,*, Carla J. Alvarado, PhD, CICb,Systems Engineering Initiative for Patient Safety

aCenter for Quality and Productivity Improvement and Department of Industrial and Systems Engineering,

University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USAbCenter for Quality and Productivity Improvement, University of Wisconsin-Madison, 610 Walnut Street,

575 WARF, Madison, WI 53726, USA

Workload is a major characteristic of the work

environment of critical care nurses [1]. It also isone of the most important job stressors amongICU nurses [2–6], which may have negative conse-

quences for nurses and the patients they care for.An analysis of the Australian Incident MonitoringStudy data for ICUs shows that a nursing staff

shortage may lead to compromised quality ofcare [7]. The main cause of nursing staff shortagewas inappropriate staffing for patient load (81%of the incidents). Insufficient nursing staff was

linked to problems with incorrect matching of pa-tient needs and staff experience, suboptimal stan-dard of nursing care and patient supervision,

inadequate supervision of inexperienced staff,and subsequent inadequate documentation. Thenursing shortage and the resulting understaffing

can create conditions of high workload for criticalcare nurses.

A lot of work has been done to developmeasures of workload in ICUs. These measures

often are focused on ICU patient needs, patientacuity, or severity of illness [1]. These patient-levelmeasures of workload include the Therapeutic In-

tervention Scoring System [8,9], Nursing Man-power Use Score [10], Nursing Activities Score[11], and Comprehensive Nursing Intervention

Score [12]. There is increasing recognition thatmeasures of nursing workload in ICUs at the pa-tient level are not sufficient and need to include

measures of organizational and system factors

[1,13]. Spence and colleagues [13] identified severalsystem factors that contribute to nursing work-load as measured by the Patient Dependency

Score (an estimate of the nursing hours requiredfor patient care at different levels of dependency).The most significant factors were related to the or-

ganization of work (ie, organization of managers,cooperation with doctors, cooperation with peernurses, use of relief staff, and planning of shiftschedules).

This article describes the various types ofworkload faced by critical care nurses, includingthe physical workload of patient handling. The

objective is to show that safe patient handling canbe achieved by examining the entire work systemof ICU nurses and the various types of workload

they experience. The links between workload andpatient safety also are described.

Dimensions of workload

Table 1 shows the various dimensions of work-load of critical care nurses and provides examples

of each of the dimensions.

Physical workload

Physical workload of ICU nurses not only is

related to nursing practice, including moving,lifting, and bathing patients, but also to disjointedsupply sources and missing and nonfunctioning

equipment [14]. Disjointed supply sources (sup-plies or equipment needed for a task located in

* Corresponding author.

E-mail address: [email protected] (P.Carayon).


doi:10.1016/j.ccell.2007.02.001 ccnursing.theclinics.com


mailto:[email protected]

another area of a unit or hospital) and missing ornonfunctioning equipment require repetitivetravel around units or even to distant locationsin the hospital, such as other patient care units

or the central equipment reprocessing area, add-ing miles of walking to nurses’ activities.

Almost all critical care nurses find their work

physically strenuous. The physical and ergonomiclayout of ICUs often is poor; the limited spacebetween patient beds and ICU equipment is

especially problematic. The causes of severestnurse physical workload distress are lifting, work-ing in awkward postures, and stooping [15]. With

an increase in bedside procedures and technolo-gies in ICUs, nurses often are required to moveheavy equipment in and out of patient areas.There is little or no acknowledgment that this

type of task requires heavy lifting and moving;nurses under task and time constraints often findit easier to move equipment alone than to wait

for additional help.Although most ICU nurses receive some nurs-

ing school education about ergonomics and body

mechanics contributing to musculoskeletal injury,few nurses are aware of the amount of lifting theywill do in ICUs and the safest ways to performthese tasks. The American Nursing Association

believes that the essential functions for mostnurses should depend on knowledge and carejudgment not physical strength [16]. In defining

the clinical role of critical care nursing practice,Brilli and colleagues [17] focus on nurses’ under-standing and support for technical medical care,

including diagnosis, treatment, care planning,and priority setting; no mention is made of theneed for physical lifting and moving equipment.

Trinkoff and colleagues [18] have examineda comprehensive array of nursing task physicaldemands, such as lifting and awkward postures.

Nurses practicing in hospital emergency, criticalcare, or operating room/post-anesthesia carespecialties stated the highest level of physical de-mands in their work. As the number of self-

reported physical demands increased so did thelikelihood of inadequate sleep, pain medicationuse, and absenteeism.

Cognitive workload

Cognitive workload is related to the need forICU nurses to process information, often in a shortperiod of time. For instance, code situations

require quick decision making and a lot of in-formation that needs to be processed quickly [19].

Critical care nurses do the majority of familycommunication, patient assessment, evaluation,

and care in ICUs. Through their cognitive skills,nurses readily recognize clinical changes thatprevent further deterioration in patients [17].

Nurses perform many cognitive adjustmentsacross patients throughout an assigned period ofcare. These adjustments are planned (eg, work

shift changes or morning reports for assigned pa-tients) and unplanned (eg, stable patients sud-denly changing status to an unstable condition)

[20]. This constant conscious shift in thinkingfrom one patient to another extends far beyondactual bedside care. Nurses often perform cogni-tive tasks while waiting on other systems or pro-

cesses (eg, delivery of medications, laboratoryresults, and retrieving necessary patient supplies).This cognitive and physical multitasking, al-

though common in ICUs with high patient acuity,often is overlooked in management decisions ad-dressing nurse staffing ratios.

Additionally, interruptions disrupt nurses’concentration and cognitive processing. Humanbeings find it difficult to stay attentive, vigilant,

Table 1

Dimensions of workload

Dimensions of workload Definitions and examples

Physical workload Amount of physical work, including patient handling

Cognitive workload Information overload

Time pressure Working under temporal constraints and tight deadlines

Emotional workload Dealing with emotional issues, such as patient death, end-of-life care,

and family demands

Quantitative workload Amount of work

Qualitative workload Difficulty of work

Workload variability Changes in workload: increase in workload (eg, code situation) and

decrease in workload (eg, night shift)

122 CARAYON & ALVARADO

and productive, particularly when they are inter-rupted, fatigued, or in a work overload situation[21]. Nurses whose attention constantly is shiftingfrom one item to another may not be able to for-

mulate a complete and coherent picture of tasks athand or complete assigned care activities [22].Some interruptions are necessary, such as point-

ing out critical monitor changes or emergentneeds of other patients assigned to a nurse’scare. Most interruptions are about communicat-

ing information or asking questions about pa-tients, however; for instance, asking aboutinformation and questions about patients who

are soon to be admitted to or discharged froma unit. The stream of constant interruptions dis-rupts nurses’ ability to identify and assess patientneeds, increasing the cognitive workload [20], even

potentially leading to patient error.Increased understanding of the work complex-

ity in ICU environments and nurses’ cognitive

workload are critical to successful patient safetyimprovement efforts and the recruitment andretention of critical care nurses [14].

Time pressure

Time pressure relates to the need to work fast,

under tight deadlines and temporal constraints.High time pressure is related to burnout experi-enced by ICU nurses [23]. Time pressure is related

to the number of tasks ICU nurses have to per-form under temporal constraints. ICU nursesperform a large variety of tasks, including assess-

ments, measurements, documentations, and thera-pies on a regular or frequent basis. Changes instandards of care for ICU patients sometimescan introduce additional tasks for ICU nurses,

therefore adding to the already high time pressure.One example is the introduction of glycemic con-trol, which involves insulin infusions and monitor-

ing of blood glucose levels. This requiresadditional work by ICU nurses, up to 2 hoursfor a single patient during a 24-hour period [24].

Emotional workload

Emotional workload is prevalent particularly

in critical care environments because of patientacuity and severity. Critical care nurses deal withvery sick patients and are the main interface with

the families of those patients. ICU nurses areeducated and trained to provide highly technicalexpert care and also need to deal with end-of-life

care [25]. Often, ICU nurses experience obstaclesto providing end-of-life care that can add to theiremotional workload. The following obstacles arereported by ICU nurses: continuing aggressive

treatment even when advanced directives exist,physicians too optimistic to a families, and deal-ing with angry families.

Critical care nurses report that dealing withfamily demands is related to increased workload[26]. Families play an important role in ICUs,

such as watching out for the patients or just ’’be-ing there.’’ Sometimes the perspectives of thenurses and the families are not aligned, however,

and conflicts or problems may arise [27]. For in-stance, nurses may experience time limitations intheir capacity to handle some of the family situa-tions or demands.

Verbal and physical assaults by patients andtheir families also can be a source of emotionalworkload [28]. A study by May and Grubbs [28]

examines reports of verbal and physical assaultsby a group of 86 emergency department, ICU,and general floor nurses. Approximately 85% of

the ICU nurses reported verbal assaults by pa-tients and family members and 78% reportedphysical assaults.

Quantitative and qualitative workload

Frankenhaeuser and Gardell [29] differentiatequantitative workload from qualitative workload:quantitative workload is defined as the amount of

work, and qualitative workload is defined as thedifficulty of the work. Quantitative workload ofcritical care nurses can be measured using the var-

ious patient-level measures of workload (discussedpreviously); these measures provide some measureof the amount of work critical care nurses have to

perform. Quantitative workload also is related towork hours: the amount of work performed in-creases with increasing work hours. Scott and col-

leagues [30] found that critical care nurses tend towork much longer than their scheduled workshift: in a study of 502 nurses who provideddata for 6017 work shifts, they found that in

86% of the shifts, nurses worked longer thanscheduled. Longer work duration was related toincreased risk for errors and difficulty in staying

awake. Fatigue also can contribute to musculo-skeletal injuries.

Qualitative workload of critical care nurses is

related to the rapid pace of knowledge in criticalcare medicine and nursing and implementation ofnew technologies and devices. Schaufeli and

123WORKLOAD AND PATIENT SAFETY

colleagues [31] found that intensive use of sophis-ticated technology was related to high burnoutamong ICU nurses. In addition, critical care

nurses need to carry out procedures accuratelyand react to urgent situations efficiently [19].This time pressure can add to the qualitativeworkload experienced by nurses.

Workload variability

Workload variability is the extent to which

workload continually changes during a period oftime [32]. Among critical care nurses, one cause ofworkload variability is related to shifts (eg, day

shift versus night shift). ICU nurses who workday shifts report higher levels of perceived work-load than ICU nurses who work during nightshifts [26]. The higher day shift workload may

be correlated directly with other patient care ser-vices availability. Many hospital departments areclosed or staffed only for emergency care during

night shifts. Night shift nurses often describe theshifts as more relaxed, with more time spentwith patients because there tend to be fewer inter-

ruptions and things are less hectic. Nurses reportexperiencing a greater sense of autonomy and in-dependence on night shifts as they have control of

their work and task time. Night shifts often leavethe nurses with sedentary tasks, however, such ascharting, organizing supplies, or monitoring sleep-ing patients. Many night shift nurses admit to de-

veloping bad eating patterns. They note thathospital cafeterias are closed at night, leavingthem with high-calorie vending machine snacks

or takeout pizza as typical meal options in addi-tion to lack of physical exercise in their worktasks. Geliebter and colleagues [33] observed night

shift nurses reported gaining more weight, exercis-ing less, and increasing food intake than the dayshift group since starting their jobs on their cur-

rent shift.Code situations are another example of work-

load variability. Workload suddenly increasesbecause health care providers need to concentrate

on the patients in danger, therefore reducing thenumber of staff available to care for otherpatients. Additionally, critical care nurses’ role

in the code may vary from finding and assessingpatients, initiating cardiopulmonary resuscita-tion before a code team’s arrival, to then re-

cording the events and interventions on the officialresuscitation record that documents all events andinterventions.

Relations between the dimensions of workload

The various dimensions of workload are notindependent of each other. For instance, quanti-tative workload, or the amount of work, is related

to physical workload: the more work criticalnurses have to perform, the more likely they areexposed to physical workload. The number ofpatients nurses care for and the nursing require-

ments of the patients also are related to physicalworkload.

Time pressure combined with physical work-

load may increase the risk for musculoskeletalinjuries significantly for critical care nurses. Inrushing to perform a task, nurses may not have

the time to use lifting devices. Moreover, a liftingdevice itself may add to nurses’ workload, as thedevice used must be decontaminated and madeready for the next patient in a physical environ-

ment not designed to facilitate optimal cleaningand disinfection. Nurses actually might choosenot to use a safety device as its cleaning or

decontamination seems too onerous a task giventhe physical environment and time pressure.

The cognitive workload associated with con-

sistent adherence to patient care guidelines mayincrease physical workload as nurses encounterproblems and barriers to guideline compliance in

an ICU. Critical care nurses often are the primarycare providers responsible for ensuring compli-ance with these guidelines. The Institute forHealthcare Improvement [34] is conducting a na-

tionwide effort to save lives by implementingstrategies to facilitate guideline compliance. A sig-nificant attribute of this program is nurses’ role in

monitoring care guideline compliance and takingcorrective action with ICU care teams. Althoughthe empowerment of nurses to ‘‘stop the proce-

dure’’ is critical to guideline compliance, it alsoadds to their cognitive, quantitative, and qualita-tive workloads.

Sources of workload

Understanding that the way work is organized

can contribute to workload is critical for de-veloping interventions aimed at reducing (ormanaging) workload and its impact on critical

care nurses. A range of patient care factors alsomay contribute to high workload in ICUs, such asthe number of postoperative events [35].

The authors propose that the work systemmodel of Carayon and Smith [36–38] can be usedto describe sources of workload and define the


interrelationships between the dimensions ofworkload (Fig. 1). The work system comprisesfive elements [36,37]:

� Individual critical care nurses� Performance of various tasks (ie, direct care,

indirect care, and other tasks; patient carecharacteristics)� Use of various tools, equipment, devices, andtechnologies

� Physical environment (eg, the patient roomand the nursing station)� Specific organizational conditions (eg, shift

schedules, nursing management, teamwork,communication with physicians and otherhealth care providers, and interruptions)

Physical workload is related particularly to thetasks and their physical characteristics (eg, lifting

patients), the availability of equipment and de-vices, and the layout of patient rooms. Thesemicroergonomic factors also are related to the

macroergonomic characteristics of the work sys-tem, such as an organization’s management beingcommitted to providing the right equipment tonurses. Cognitive workload is affected by the

characteristics of the tasks of critical care nurses:those tasks, in particular operational tasks (eg,patient care and psychologic support of patients),

can be demanding and at the same time satisfying[39].

Improving the design of nurses’ work system

(eg, nurse-physician collaboration) is suggested asa strategy to reduce workload and deal with thenursing shortage crisis [40]. Laschinger and Fine-

gan [41] identified ‘‘empowerment’’ as a predictorof nurses’ perception of workload. Empowermentwas conceptualized as a characteristic of work en-vironments that provide nurses with access to

information, resources, and support necessaryfor accomplishing their work in a meaningfulmanner [42]. Organizational factors and other as-pects of the work environment of critical care

nurses can affect workload.

Impact of workload

Workload experienced by critical care nursescan lead to various outcomes: (1) impact on health

of the nurses, (2) quality of working life (eg, jobdissatisfaction, stress, burnout, and turnover in-tention), and (3) patient safety (see Fig. 1).

Impact on health

A major impact of working conditions on

health of critical care nurses is work-relatedmusculoskeletal disorders, such as back disorders.Physical workload is a working condition that is

a primary contributor to work-related musculo-skeletal disorders of critical care nurses [18]. Thepsychosocial aspects of work, however, such as

time pressure and emotional workload, also canbe contributors to work-related musculoskeletaldisorders [43]. Time pressure and emotional work-

load are job stressors that could lead to increasedrisk for work-related musculoskeletal disordersvia the following mechanisms [43]: (1) jobstressors that could lead to physiologic changes

(eg, increased muscle tension), which can makecritical care nurses more vulnerable to work-re-lated musculoskeletal disorders, (2) job stressors

that may heighten the impact of physical work-load, and (3) job stressors that may increasenurses’ sensitivity to pain and, therefore, increase

the likelihood that nurses experience and reportmusculoskeletal pain.

Fig. 1. Model of workload of critical care nurses.


Impact on quality of working life

Workload also can affect the quality of work-ing life experienced by critical care nurses, such asjob satisfaction, stress, burnout, and attitudes,

such as turnover intention. In particular, burnoutis recognized as a problem among ICU nurses andis related to high workload [44]. Burnout may becontagious: ICU nurses who perceive that their

colleagues are experiencing burnout more likelyreport burnout, even after controlling for the im-pact of job stressors (eg, workload) [45].

Physical workload experienced by nurses canaffect not only physical health, such as musculo-skeletal disorders, but also turnover intention or

turnover. Fochsen and colleagues [46] conducteda longitudinal study to identify the predictors ofturnover among Swedish nurses. Nurses who re-ported musculoskeletal problems of the neck and

shoulder or knees and those who had limited useof transfer devices were more likely to leave theirjob. A multifaceted intervention aimed at reducing

physical workload of patient handling and work-related musculoskeletal disorders in nursing homecare units and spinal cord injury units was shown

effective (eg, decrease in musculoskeletal injuries)and to lead to increased job satisfaction [47].

Impact on patient safety

Medical errors are widespread in critical caresettings. A prospective observational study byBracco and colleagues [48] of consecutive patients

admitted during 1 year to an ICU examined 777critical incidents. The cause of the incidents wasclassified as equipment, patient, or human related.

The cause was classified as equipment relatedwhen the incident was attributed to a technicalequipment failure not associated with human mis-

use. The cause was classified as human relatedwhen actions did not go as intended or an in-tended action was not the appropriate one. In

all other cases, the incident was classified aspatient related. Thirty-one percent of the incidentswere human-related incidents, 2% equipment-related incidents, and 67% patient-related inci-

dents. A recent study by Rothschild and colleagues[49] examined a total of 391 patients admitted overa 1-year period in a medical ICU and a coronary

care unit. They found 120 adverse events among79 patients (20%). The most serious medicalerrors were found in the category of medication

ordering or execution of treatment.Several studies have examined specific types of

error in ICUs, such as medication errors. Cullen

and colleagues [50] compared the frequency of ad-verse drug events (ADEs) and potential ADEs inICUs and non-ICUs. Two medical and three sur-

gical ICUs and four medical and two surgicalgeneral care units participated in the study. Therate of preventable ADEs and potential ADEsin ICUs was 19 events per 1000 patient days,

nearly twice the rate in non-ICUs. When adjust-ing for the number of drugs used, however, nodifferences were found between ICUs and non-

ICUs.Several studies have linked medical errors and

patient safety to nursing workload. Giraud and

colleagues [51] conducted a prospective, observa-tional study to examine iatrogenic complications.A total of 382 patients for 400 consecutive admis-sions provided data. Thirty-one percent of the ad-

missions had iatrogenic complications. Humanerrors were involved in 67% of the major iatro-genic complications. The risk for ICU mortality

was approximately twofold higher for patientswho had iatrogenic complications. A major con-tributing factor was high or excessive nursing

workload. A study of medication administrationby Tissot and colleagues [52] detected 132 medica-tion errors in a total of 2009 observed events

(6.6%). The researchers attributed the errors notonly to deficiencies in the overall organization ofthe hospital medication track but also to the nurs-ing work overload.

Scott and colleagues [30] examined the effectsof critical care nurses’ work hours on their vigi-lance and risk for making an error. Longer shift

durations (in particular more than 12.5 consecu-tive hours) were associated with increased riskfor errors and near errors and with increased dif-

ficulty staying awake at work. This study did notfind an association between decreased vigilance(eg, difficulty staying awake at work) andincreased risk for errors. Longer shift durations

increase the exposure of critical care nurses tothe various dimensions of workload.

Systemic impact of workload

The impact of workload on various outcomesis systemic. According to the Systems EngineeringInitiative for Patient Safety (SEIPS) model of

work and patient safety [53], the various outcomesare affected by the characteristics of the work sys-tem and also are inter-related. Therefore, the var-

ious dimensions of workload likely affect morethan one outcome, and the outcomes are relatedto each other. Nurses who experience back pain


because of physical workload may not be able todedicate their full attention to their tasks (cogni-tive workload) and, therefore, may be more likelyto commit an error (impact on patient safety).

Therefore, it is important to examine workloadof ICU nurses using a systemic approach.

A systemic approach to the assessment of

workload should fulfill the following objectives:

1. Evaluate the different dimensions of work-

load experienced by critical care nurses.2. Identify the work system factors contributing

to different facets of workload.

3. Understand the relationships between thedifferent dimensions of workload.

4. Assess the impact of workload on nurses’

and patient outcomes.

In the introduction, various measures of pa-

tient-related workload were described. This articleemphasizes the need to go beyond those measuresand include measures of workload that represent

the various dimensions of workload. The Na-tional Institute of Occupational Safety and Healthhas created a Web site where various measures ofworking conditions and job stressors are de-

scribed [54]. This is a resource for many measuresof workload, such as quantitative workload [32]and cognitive demands [55]. Gurses [26] has devel-

oped a questionnaire to assess performance obsta-cles experienced by critical care nurses; thisquestionnaire can be used to identify the various

sources of workload in the work system (ie, per-formance obstacles).

Summary

Interventions aimed at improving the safety ofcare provided by nurses to critical care patients

need to consider the work environment, inparticular the various types of workload. Sluiterand colleagues [56] implemented a multidisciplin-

ary structured process to evaluate work shifts toenhance team communication. Benefits of the in-tervention included increased satisfaction withteam communication and reduction in emotional

exhaustion. This multidisciplinary structured pro-cess was used to address the following issues:dealing with pressure of ICUs, teamwork, work

roles, and organizational aspects. Such a processcould be used to identify the work elements thatcontribute to different dimensions of workload,

to propose interventions to reduce workload,and to plan implementation of these interven-tions. According to the model of workload of

critical care nurses presented in Fig. 1, an inter-vention tackling workload should aim to under-stand the work system factors that contribute toworkload and the various outcomes resulting

from the different types of workload.

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Patient Handling Tasks with High Riskfor Musculoskeletal Disorders in Critical Care

Thomas R. Waters, PhDa,*, Audrey Nelson, PhD, RN, FAANb,Caren Proctor, BSNc

aDivision of Applied Research and Technology, National Institute for Occupational Safety and Health,

4676 Columbia Parkway (MS-C24), Cincinnati, OH 45226, USAbPatient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL 33612, USA

cSurgical Intensive Care Unit, James A. Haley VAMC, Tampa, FL 33612, USA

Nursing remains one of the top 10 highest risk

occupations in the United States for work-relatedmusculoskeletal disorders (WMSDs) [1]. Com-pared with those in other occupations, nursing per-

sonnel are among the highest at risk.Nursing aides,orderlies, and attendants rank first and registerednurses sixth in a list of at-risk occupations for

strains and sprains that includes truck drivers(first), laborers (third), stock handlers and baggers(seventh), and construction workers (eighth) [2].Additional estimates for the year 2000 show that

the incidence rate for back injuries involving lostworkdays was 181.6 per 10,000 full-time workersin nursing homes and 90.1 per 10,000 full-time

workers in hospitals, whereas incidence rates were98.4 for truck drivers, 70.0 for constructionworkers, 56.3 for miners, and 47.1 for agriculture

workers [3]. In 2001, for cases involving daysaway from work among registered nurses, 4547were categorized as overexertion in lifting and14,832 were listed as sprains or strains [4].

Work-relatedmusculoskeletal disorders (WMSDs)in nursing persist as one of the leading and mostcostly occupational health problems in the United

States. Nurses suffer a disproportionate amount ofmusculoskeletal disorders attributed to overexer-tion from lifting unsafe loads and to the potential

cumulative effect of repeated patient handling

tasks [5]. A variety of patient handling tasks exist

within the context of providing nursing care,such as lifting, transferring, and repositioning pa-tients. Continuous, repeated performance of these

activities throughout a working lifetime withoutthe use of mechanical assistive equipment resultsin the development or exacerbation of musculo-

skeletal disorders. Because patient handling tasksconventionally are performed manually withoutthe use of assistive equipment, nurses are exposedto high levels of biomechanical loads on the spine.

Although nurses historically have been educatedand trained to use ‘‘proper’’ body mechanics andmanual techniques to prevent injury from lifting

and transferring patients, questions arise regard-ing the value of these methods and applicabilityto the practice of nursing [6,7].

The risk for development of WMSDs associ-ated with manual patient handling crosses allspecialty areas of nursing. No nurse effectively isfree from the risk for injury. The purpose of this

article is to describe high-risk patient handlingtasks performed frequently in critical care units,delineate the physical demands associated with

each task, identify technologic solutions, andoutline useful tips for making each task safer.

Background

The Association of periOperative RegisteredNurses (AORN) organized a task force that in-

cluded representatives from AORN, the NationalInstitute for Occupational Safety and Health(NIOSH), the Patient Safety Center of Inquiry at

the James A. Haley Veterans Administration

The findings and conclusions in this report are those

of the authors and do not necessarily represent the views

of the National Institute for Occupational Safety and

Health or the Veterans Health Administration.


E-mail address: [email protected] (T.R. Waters).





Medical Center (VAMC) in Tampa, and theAmerican Nurses Association to develop an ergo-nomic guideline for lifting and moving people and

objects in perioperative work environments. Thetask force formulated clinical tools and algorithmsfor high-risk tasks in perioperative settings thatincorporate current ergonomic safety concepts,

scientific evidence, and available technology, in-cluding safe patient handling equipment and de-vices [8]. This article expands on the work done by

the AORN for perioperative settings by applyingthe ergonomic principles proposed by AORN tonursing tasks in critical care settings.

Another ergonomic task force, ledby thePatientSafety Center of Inquiry at the James A. HaleyVAMC in Tampa, identified tasks associated withhigh risk for musculoskeletal disorders on five

critical care units (two surgical ICUs, two medicalICUs, and one cardiac ICU) at two large medicalcenters to identify tasks with high risk for muscu-

loskeletal disorders. The criteria used to identifypotential high risk for WMSDs for critical caretasks included (1) high force, (2) awkward postures,

or (3) repetitive loading. Data were collectedthrough direct observation of physical work envi-ronment, technology, and work practices; digital

photography; interviews with ICU nurses andnurse managers; and a 2-year review of WMSDsreported in ICUs. Based on this evaluation, sevenhigh-risk patient handling tasks in critical carewere

identified as having high risk for musculoskeletaldisorders. These include

1. Pushing occupied beds or stretchers2. Lateral patient transfers (eg, bed to stretcher)3. Moving patients to the head of a bed

4. Repositioning patients in bed (eg, side toside)

5. Making occupied beds

6. Applying antiembolism stockings7. Lifting or moving heavy equipment

For each of these high-risk critical care nursingtasks, a brief description of the task is provided,the physical demands discussed, solutions pro-

posed, and helpful tips for performing each tasksafely provided.

High-risk task #1: pushing occupied beds

or stretchers

Description of the task

Critical care nurses identified ‘‘road trips’’ asone of the most physically demanding tasks

performed. These trips involve pushing an occu-pied bed or stretcher off the unit for diagnostictesting, surgery, or other procedure. In addition to

the weight of patients and beds or stretchers, thesetasks are compounded by adding the weight ofmedical devices, such as intra-aortic balloonpumps, intravenous pumps, and portable ven-

tilators. In addition, nurses may be expectedto monitor patients while performing these tasksor manually ventilating patients while walking

or pushing. Typically, these tasks require two ormore persons for safety, and at least one personusually is walking backwards. The required force

to push or pull an object is the same, but pushingis preferred over pulling because pulling often isdone with one hand and with a twist of the trunk,resulting in unbalanced loads on the spine [9]. For

this reason, pulling force limits for these tasks arenot provided.

Physical demands

Factors that contribute to the physical demandof these tasks include distance traveled, weightbeing pushed, and uneven gradients (eg, slopes or

thresholds). The wheels of beds and equipment getstuck in elevator and door thresholds. The poten-tial physical risk factors associated with this task

include excessive pushing or pulling and liftingdemands. The likely result of excessive pushing,pulling, or lifting forces generated during thistask is high-resultant spinal anterior-posterior

shear and compression forces that likely exceedthe recommended spinal tissue load tolerancelimits. These limits are proposed as 3400 N (770

lb) for spinal disc compression force [10,11] and1000 N (225 lb) for spinal shear force [12]. Push-ing force requirements associated with four pa-

tient transport tasks proposed by the AORN arelisted in Table 1 [8]. Table 1 also provides a seriesof recommendations for the number of nurses and

equipment needed to perform a task safely. Theserecommendations are based on pushing forcelimits recommended by researchers at the LibertyMutual Insurance Research Institute for Safety

[13]. Additional information about pushing forcelimits is discussed later.

Another problem with transporting patients is

lifting occupied beds over small barriers, such asa door or elevator threshold. A basic biomechan-ical analysis (Fig. 1) shows that lifting an occupied

bed over a barrier or door threshold requiresa high amount of lifting force that easily couldexceed the recommended weight limit (RWL) for

132 WATERS et al

safe manual lifting, even when two nurses performthe lift under ideal lifting conditions.

The following example is provided to show

how a task easily could exceed the recommendedlifting limits: if W (ie, the weight of the bed plusthe weight of the patient) is 300 lb and the lift oc-curs at point B (the end of an occupied bed), then

according to static equilibrium (see Equation 1 inFig. 1), L is equal to 150 lb. This exceeds the RWLfor lifting, as defined by the NIOSH lifting equa-

tion (NLE), even with two nursing personnel lift-ing the end of the occupied bed over a barrierunder ideal conditions [10,11]

Proposed solutions

Two primary solutions are available for re-

ducing the physical demands associated withtransporting patients that exceed the recommen-ded push/pull force limits for one person. These

include the use of two or more persons to performa task or the use of a powered transport device. Ifthe required force exceeds the push/pull force

limits for two caregivers or a task is performedfrequently, then a powered transport device issuggested, although it is recognized these pieces of

equipment are not available for every type ofdevice that is transported with patients. If trans-porting patients requires lifting a bed or stretcherover a barrier, then a powered transport device

reduces the risk for musculoskeletal disordersignificantly for caregivers.

Safety tips

1. The height of a bed or stretcher should be po-sitioned so that the hands are at a middlepush point of 3 ft (0.92 m) from the floor.

For tasks where the push point is lowerthan 3 ft (0.92 m), maximum and sustainedpush forces should be decreased by approxi-

mately 15% [8,13].2. Manual patient transport tasks should not be

performed more frequently than once every

30 minutes. For transport tasks performedmore frequently than once every 30 minutes,a powered patient transport device is the best

solution [8].3. Pushing tasks are less physically demanding

than pulling tasks [9].4. If push force limits for one caregiver are ex-

ceeded (see Table 1), it is necessary to usetwo or more caregivers to complete the taskor use a powered transport device. In some

cases, even multiple caregivers may not beable to perform a task safely, especially ifa bed or stretcher must be lifted over

a door or elevator threshold [8].5. The wheels on beds or stretchers need to be

maintained properly to facilitate easier

Table 1

Physical demands and recommendations for safe patient transport

Transport task Pushing force lb/(kg) Max push distance ft/(m)

Ergonomic

recommendation

Pushing an occupied

stretcher

43.8 lb (19.9 kg) O200 ft (60 m) Task is acceptable

for one caregiver

Pushing an occupied bed 50.0 lb (22.7 kg) !200 ft (30 m) Minimum of two caregivers

required

Pushing an unoccupied

specialty surgical bed

69.7 lb (31.7 kg) !100 ft (30 m) Recommend use of a

powered

transport device

Pushing an occupied

specialty surgical bed

112.4 lb (51.1 kg) !25 ft (7.5 m)

Reprinted with permission fromAORN.AORNGuidance Statement: Safe Patient Handling andMovement in the Peri-

operative Setting. Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.

= L

(Eq. 1)

A BWeight of Occupied Bed + Patient (W)

Weight of Load Lifted (L) y

6 ft

3 ft

x

2

36

0)3()6(

WMomentz

WLMomentz

WLMomentz

Fig. 1. Simple biomechanical model of lifting occupied

bed over barrier.

133WMSD RISK IN CRITICAL CARE

transport. Wheels that are too small, castersthat do not face forward easily, or wheelsthat are maintained poorly increase the

amount of effort needed to complete the task.6. When possible, select a transport route that

has a minimum number of inclines, declines,or barriers, such as door or elevator thresh-

olds to traverse.7. Use bariatric equipment if patient weight

exceeds the acceptable weight capacity for

conventional patient handling equipment(the weight capacity usually is listed on theequipment). This may require special plan-

ning related to getting the equipment throughstandard-size doorframes and elevators.Bariatric equipment is designed speciallywith greater weight capacity than normal

lifting assist equipment.

High-risk task #2: lateral patient transfers

(eg, bed to stretcher)


Nurses in critical care units often engage inlateral patient transfers (eg, laterally movinga patient in a lying position from one surface to

another). This task often is completed with two ormore caregivers pushing or pulling a patientlaterally toward the destination position.

Physical demands

Both caregivers often must reach out with

extended arms, either at the start or end of thetask, to push or pull a patient from one surface(eg, a stretcher) to another surface (eg, a bed). The

potential risk factors for this task include exces-sive pushing or pulling forces and extendedreaches. These tasks may be more difficult when

the height of nurses working together is disparateor when a patient resists movement, such as whena patient is confused or may be guarding a surgicalwound. The likely result of excessive pulling or

lifting forces generated during this task is highresultant spinal shear and compression forces thatmay exceed the recommended spinal compression

or shear force load tolerance limits of the spinaltissues or excessive shoulder loading. The amountof pulling force required for this task is dependent

on patient weight and the coefficient of frictionbetween the sliding surfaces, which is a measure ofthe degree of slipperiness between a patient and

bed surface or between the sheet under a patientand a bed surface. As the slipperiness or smooth-ness between the surfaces increases, the required

pulling force decreases. Data for determining themaximum pulling force limit is published byresearchers at the Liberty Mutual Insurance Re-search Institute for Safety. According to these, the

maximum pulling force acceptable to 75% ofwomen is 51 lb (23 kg) for maximum initial pulls;the 51-lb maximum pulling force value is for one

caregiver. The actual required pulling force maybe difficult to determine. As a rule of thumb, with-out a friction-reducing device, the required pulling

force to move a patient is approximately 75% ofa patient’s body weight [14]. With newer slidingsheets, the required pulling force may be as lowas 25% of a patient’s body weight [14].

Based on published pulling strength data, theAORN published an ergonomic tool for assessinglateral transfers of patients between a stretcher

and an operating room bed. The ergonomic tool isshown in Fig. 2. According to the AORN re-commendation, the desirable approach for lateral

transfer of patients involves use of a lateral trans-fer device, such as friction-reducing sheets, sliderboards, or air-assisted transfer devices. If only

a draw sheet is used without a lateral transferdevice, care providers exert a pull force up to72.6% of patient weight [8]. The AORN recom-mendation assumes that one caregiver or anesthe-

sia care provider supports a patient’s head andneck to maintain the airway during lateral trans-fers. The remaining mass of the patient’s body

equals 91.6% of his or her total body mass [8].The rationale for the AORN recommendation isbased on research indicating that for a pulling

distance of 6.9 ft (2.1 m) or less, where the pullpoint (ie, starting point for the hands) is betweena caregiver’s waist and nipple line, and the taskis performed no more frequently than once every

30 minutes, the maximum initial force requiredequals 57 lb (26 kg), and the maximum sustainedforce needed equals 35 lb (16 kg) [8]. According

to the AORN recommendation, each caregiversafely can contribute a pull force required totransfer up to 48 lb, equal to 35 lb/0.726 (dis-

cussed previously). For one caregiver plus ananesthesia care provider, the maximum patientweight that safely can be transferred manually is

52.6 lb, equal to 48 lb/0.916 (described previ-ously). For two caregivers plus an anesthesiacare provider, a patient safely can be transferredmanually weighing up to 104.8 lb, equal to

(48 lb � 2)/0.916 (described previously). If there

134 WATERS et al

are three caregivers plus an anesthesia care pro-vider, then a patient safely can be transferred

manually weighing up to 157.2 lb, equal to (48lb � 3)/0.916 (described previously). If a patientweighs more than 157 lb, then the tool suggests

that either a mechanical lifting device, mech-anical lift with supine sling, mechanical lateral

transfer device, or air-assisted lateral transfer de-vice and a minimum of three to four caregiversbe used.

* The rationale for this tool is provided in the AORN Guidance document [8].

Start

Canpatient

transfer withoutassistance?

Caregiver assistance notrequired. Stand by for safety

as needed.

* One of the caregivers may be the anesthesia providerThe number of personnel to safely transfer the patient should be adequate to maintain the patient's body alignment,support extremities, and maintain patient's airway.For lateral transfers it is important to use a lateral transfer device that extends the length of the patient.Current technologies for supine to prone include: Jackson Frame, Spine Table, etc.Destination surface should be slightly lower for all lateral patient moves.A separate algorithm for prone to jackknife is not included as this is assumed to be a function of the table.If patient's condition will not tolerate a lateral transfer, consider the use of a mechanical lift with a supine sling.During any patient transferring task, if any caregiver is required to lift more than 35 lbs of a patient'sweight, assistive devices should be used for the transfer.While some facilities may attempt to perform a lateral transfer simultaneously with positioning the patientin a lateral position (ie, side-lying), this is not recommended until new technology is available.The assumption is that the patient will leave the operating room in the supine position.

No

Yes

What is thestarting

position?Prone

Use 2-3caregivers*

Use assistive technology(min. 3-4 caregivers)*

A mechanical device is preferable

for this task. Additional

technologies are needed

for turning a patient from supine to

prone and from prone to supine.

Is weight > 73 lbs?

Yes

No

Is weight>157 lbs?

Supine

Yes

Will patientstay supine?

Yes

No

Use one of the following:mechanical lift with supine sling,

mechanical lateral transferdevice or air-assisted lateral

transfer device(min. 3-4 caregivers)*

Use lateraltransfer device

(min. 4caregivers)*

No

Note: < means less than; > means greater than

See Rationale* See Rationale*

Fig. 2. AORN ergonomic tool for assessing lateral transfer between stretcher and operating room bed. (Reprinted with

permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting.

Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.)


Proposed solution

The best solution for a lateral transfer thatexceeds the acceptable pulling force limits for oneperson is to add one or more nurses to do the job,

use a friction-reducing device to reduce the pullingforce, or use a powered lateral transfer device.

Tips for performing lateral patient transfer

tasks safely

1. Previous research shows that there is no safe

way to lift a patient manually from a bed toanother bed, even with two nurses and ideallifting conditions [12]. Therefore, this task

should not be performed as a manual lift.2. Historically, nurses have completed this task

using a standard draw sheet or creatively in-serting a plastic trash bag under the draw

sheet to reduce friction. These strategies,however, do not reduce the risk sufficiently.Forces associated with excessive reaching

and lumbar hyperflexion are reduced by48% when a friction-reducing device is usedcompared with a draw sheet or trash bag.

Subjective evaluations by nurses demonstratethat they preferred the use of a friction-re-ducing device to a standard draw sheet as

a way to minimize musculoskeletal discom-fort [15,16].

3. A friction-reducing device reduced effort sig-nificantly, by 25% for the spine and 33% for

the shoulders [14].4. Observations of nurses using these devices re-

vealed the friction-reducing device was not

intuitive in its use, and, despite training,nurses did not use it to its full capacity.Nurses should be required to demonstrate

proficiency in the use of friction-reducing de-vices to assure appropriate use at onset andover time to fully use this type of patientcare equipment [16].

5. Friction-reducing devices with long handlesor straps reduce reach and associated forceson the back, shoulders, and arms signifi-

cantly and are preferable to friction-reducingdevices without long handles or straps [15].

High-risk task #3: moving patients

to the head of a bed


Patients who are physically dependent and inbed need to be repositioned frequently to prevent

pressure ulcers and other adverse events associ-ated with immobility. Despite careful reposition-ing, over time, patients tend to shift downward in

the bed and need to be pulled back to the head ofthe bed for comfort and safety.

Physical demands

This task is similar to the lateral transfer task(described previously), where a caregiver is stand-ing at the side of a patient’s bed. Because of theline of action of pulling a patient to the head of

the bed, however, hand forces are parallel to thebody rather than in-line with the front of thebody, creating large lateral shear and torque

forces on the spinal tissues. Additionally, toaccomplish the task, caregivers often have towork with their arms extended fully, increasing

the loads on the muscles, ligaments, and joints ofthe shoulder. When the arms are extended, themechanical moment for the task is increased. An

increase in the moment arm results in larger tor-que forces on the spine and shoulder. No limitsfor maximum acceptable torque forces on thespine are proposed, but studies show that axial ro-

tation during lifting can increase the risk for lowback pain in some workers [12]. Examination ofthe required muscle forces at the shoulder reveal

that the maximum recommended force that an av-erage woman is able to pull laterally across thebody with arms extended fully is 22 lb (10 kg) or

11 lb (5 kg) per hand [8]. It is likely that the shoul-der strength is exceeded before the lateral shearforce limit is reached for most repositioning tasks,

such as this. In addition, only approximately 44%of women have the torso strength capacity to dothis task. The 44% value was determined usinga 3-D strength prediction program developed by

researchers at the University of Michigan [17].

Proposed solutions

There are only a few solutions available for thistask. The best overall solution is to use a floor-based or ceiling-mounted patient lift that elimi-nates the need to pull or lift patients manually.

Using a floor-based lift, however, is time consum-ing and may not be accepted readily by nurses.Use of a ceiling lift with a ‘‘disposable’’ reposi-

tioning sling that can stay under a patient im-proves the acceptance of such lift use. Skinintegrity always is a concern when leaving slings

under patients and must be considered. An alter-native is to use a friction-reducing device and ad-ditional caregivers. This approach may reduce the

136 WATERS et al

maximum required forces, but it does not solvethe problem of pulling across the body.

Tips for moving patients to the head of a bed safely

1. This task requires two or more caregivers. It

is unsafe to move an occupied bed away froma wall and attempt to lift a patient unassisted.

2. The task should be performed with caregiverspositioned at the sides of a bed.

3. Pulling patients up in bed is made easier bylowering the head of the bed and raising thepatient’s knees [16].

A. The forces on the shoulder can be de-creased by 40% by raising the bed to anappropriate working height and angling

the head of the bed downward to facilitatethis repositioning task [16].

B. The amount of musculoskeletal discomfortin performing this task also can be de-

creased by nearly 31% by angling thebed surface and raising a patient’s kneesbefore sliding them [16].

4. Additional research is needed to design tech-nologic solutions for the high-risk, high-vol-ume patient handling task of repositioning

patients to the head of a bed.

High-risk task #4: repositioning patients

in bed (eg, rolling from side to side)


Patients who are physically dependent and inbed need to be repositioned frequently to preventpressure ulcers and other adverse events associ-

ated with immobility. Typically, this task isperformed at least once every 2 hours, alternatingbetween prone, right-side lying, supine, and left-

side lying, as tolerated by patients. Thus, this taskrequires rolling patients from side to side.

Physical demands

This task is similar to the lateral transfer task

described in task #2 and can be completed eitherby sliding patients to the center of a bed or liftingand moving patients to the center of a bed. For

this task, however, it is likely that the arms aremore extended for the maneuver than for a trans-fer from bed to bed. The same risk factors are

involved and the same limitations apply as for thelateral transfer task. As with the transfer task, therequired pulling force is dependent on patient

weight and the coefficient of friction betweena patient, or sheet under a patient, and bedsurface. If the task is performed with armsextended directly in front of the body, then the

shoulder strength or anterior-posterior shear onthe spine likely is the limiting factor for this task.If, alternatively, the task is performed laterally by

pulling across the body, then the limiting factorlikely is shoulder strength or lateral shear (dis-cussed previously).

Proposed solutions

There are few solutions available to reduce thephysical demands associated with rolling patientsfrom side to side in a bed. It may be possible to

use a ceiling-mounted lift to assist in rollingpatients from side to side, but use of a ceilinglift typically requires a manual rolling activity to

place a sling under a patient. Alternately, twocaregivers may be able to roll a patient manuallywithout exceeding recommended pushing andpulling force limits, but the best technique is to

use a lift with a repositioning sheet or strap to rollpatients from side to side. Friction-reducing de-vices may be helpful with larger, heavier patients.

Tips for repositioning a patient in bed safely

1. Performing this task manually may requiretwo or more caregivers, depending on patientweight.

2. A friction-reducing device or a mechanical

lifting device should be used for bariatric pa-tients or for patients whose pain or discom-fort does not allow them to tolerate manual

performance of the task.3. One caregiver safely can reposition a patient

laterally with the aid of a friction-reducing

device or a ceiling-mounted lift.

Additional research, however, is needed to

develop efficient, safe, user-friendly devices forassisting in rolling patients from side to side,especially as the average weight of patients

continues to increase.

High-risk task #5: making occupied beds


Patients who are physically dependent and incritical care often are unable to get out of bedbecause of illness, pain, fatigue, or medical

contraindications. Regardless, linens need to bechanged regularly, particularly if patients areincontinent, bleeding, or perspiring. The task of


making an occupied bed can be challenging,particularly when patients are obese, hooked tomultiple lines, or combative or uncooperative.

This task often requires that caregivers rollpatients from side to side to make a bed.

Physical demands

To perform this task, nurses usually approachpatients from the side of a bed, roll patients onto

their side, slide a sheet under patients, then moveto the other side of the bed to roll patients backonto the sheet and then onto their other side, then

pull the sheet out from under the patients, finallyrolling patients onto their back to finish makingthe bed. The potential risk factors for this task areexcessive pushing and pulling forces, excessive

reach, and twisting. The other problem is thatnurses often have to hold patients up with onehand while using the other hand to arrange the

sheet. The pushing/pulling forces required toperform this task are dependent on the individualand how much assistance can be provided by

patients. Again, the task likely is performed witharms in a fully extended position. The pushing orpulling force limit for this task likely is determined

by shoulder strength limits for most women ratherthan the spinal shear force. Also, the task mayneed to be performed with one arm, because theother arm may be needed to hold patients on their

side while inserting or removing a sheet under thepatient.

Proposed solutions

There are few solutions available to reduce the

physical demands associated with making anoccupied bed. It is possible to use a ceiling-mounted lift to lift the patient off the bed,

allowing for a hands-free approach to makinga bed. As discussed previously, one of the moststressful elements of this task is rolling patientsonto one side to get the sheet under them and then

holding them in place. As discussed previously forthe patient rolling task, two caregivers may beable to roll patients manually without exceeding

recommended pushing and pulling force limits.Reaching and pulling patients, however, shouldbe avoided when feasible.

Tips for making occupied beds safely

1. Raise the bed to an acceptable comfortable

working height (about the level of the elbow)[15]. When two or more nurses are complet-ing this task and they are of disparate

heights, the acceptable bed height should beset approximately at the average elbowheight of the two nurses.

2. Further, avoid twisting and excessive reachwhile performing this task. Nurses whomove back and forth along the side of thebed, rather than twist in place, reduce muscu-

loskeletal strain by 58% (60% back and 57%shoulders) [16].

3. This task is more difficult with some air mat-

tresses or overlays, which can cause increasedexternal forces when rolling patients towardand away from a caregiver, as required dur-

ing the execution of this task [16].

High-risk task #6: applying antiembolism

stockings


Many patients in critical care units are at riskfor developing a deep vein thrombosis. One

strategy used to prevent deep vein thromboses isthe use of antiembolism stockings. In critical care,this task nearly always is performed while patients

are supine.

Physical demands

The physical demands of this task are associ-ated with (1) lifting and holding a leg for anextended period, (2) the awkwardness of perform-

ing a task that takes two hands (sliding thestockings up the leg) while holding a leg in place,(3) resistance of extending tight elastic stockingsopen to fit a leg inside, and (4) long duration of

the task. The risk factor for this task is lifting andholding the weight of a leg for an extended periodof time and the excessive force needed to apply

stockings that intentionally are tight fitting.Guidelines for lifting a leg have been developedbased on acceptable muscle strength and muscle

fatigue guidelines for women. The limits areshown on Table 2 [8].

As can be seen in Table 2, the only acceptable

manual lift of a leg is a two-handed lift for pa-tients weighing less than 54 kg (120 lb) and fora holding duration of 1 minute or less. Performinga two-handed lift and applying the antiembolism

stockings are not recommended for one caregiver.

Proposed solutions

One solution for lifting and holding a leg isa mechanized lift with a strap or sling designed for

138 WATERS et al

lifting body parts. For applying antiembolismstockings, there are commercially available prod-ucts; one device works like a shoehorn, making

the task easier, whereas another is simply a plasticsleeve placed over the foot before application toreduce friction.

Tips for applying antiembolism stockings safely

1. Applying antiembolism stockings from thebottom of the bed with a pushing movementsignificantly reduces muscle activity by 25%

compared with applying stockings from theside, where a combination of lifting and pull-ing is required [16].

2. Applying lotion to the legs, before manualapplication of the stockings, is found to re-duce the force needed to apply the stockingsslightly, although this may be contraindi-

cated if there are wounds or other skin condi-tions on or near the legs.

High-risk task #7: lifting or moving heavy objects

and equipment


Patient care often includes use of equipment,

devices, and supplies that need to be brought toa bedside. Often, these items are heavy or awk-ward to carry or push and the distance can besignificant.

Physical demands

Critical care nurses often are required to lift

and move various heavy objects and equipmentmanually, often in awkward body postures. Therisk factor for this task is potential excessive

spinal compression force or shear force. As theweight of an object or the horizontal distance ofthe load relative to a worker increases or as the

posture becomes more awkward, the compressionforce increases and the acceptable amount ofweight that can be lifted safely decreases. Therevised NIOSH lifting equation (NLE) is an

assessment tool used to evaluate the physicaldemands resulting from specified two-handedmanual lifting tasks [10,11]. To use the NLE, spe-

cific information is needed, such as the weight ofthe object, the horizontal reach distance, the verti-cal height from which the object will be lifted, and

other factors described in the NLE applicationsmanual [10,11]. The principal products of theNLE are the recommended weight limit (RWL)

and the lifting index (LI) for a specified lift. TheRWL is defined for a specified lift as the weightof load that nearly all healthy workers can per-form for that task over a substantial period of

time (eg, up to 8 hours) without an increasedrisk for developing lifting-related low back pain.The LI value is a term that provides a relative es-

timate of the level of physical stress associatedwith a particular manual lifting task and is definedas the weight of load to be lifted (L) divided by

the RWL (ie, LI ¼ L/RWL). According toNIOSH, it is likely that lifting tasks with an LIgreater than 1.0 pose an increased risk for lift-ing-related low back pain for a fraction of the

population and that many workers are at risk ifthe LI value exceeds 3.0.

As with several other tasks (discussed pre-

viously), the AORN developed a series of recom-mendations for a set of lifting tasks performedoften in operating rooms [8]. These recommenda-

tions are based on the LI values calculated forthese tasks (Table 3). The NLE can be used to

Table 2

Recommended limits for lifting legs




calculate the RWL and LI for other two-handedmanual lifting tasks performed by critical carenurses not listed in Table 3, such as lifting intrave-nous pumps to attach to a bed for patient trans-

port; moving chairs to accommodate visitors;lifting equipment to the end a bed; transportingmonitors; moving heavy bottled gas tanks; and

lifting beds and carts over electric cords or cablesin patient rooms. Those interested in more detailsof the NLE should refer to the NIOSH applica-

tions manual [10,11].Nurses also often have to push or pull wheeled

equipment or carts. These tasks have risk factorsas described for pushing an occupied operating

room bed (discussed previously). The amount offorce required to push or pull these items deter-mines whether or not they can be done safely.

The AORN presented a recommendation forpushing and pulling wheeled items in an operatingroom work environment (listed in Table 4). For

items not listed in Table 4, the guide in Table 5can be used to assess the acceptability of a specificpushing task. If the required pushing force ex-

ceeds the value in Table 5 for the selected distance,then the task should not be performed by onecaregiver. Pushing force limits for multiple

caregivers can be calculated by multiplying thevalues in Table 5 by the number of caregivers. Itis not recommended, however, that more thantwo caregivers push equipment. As noted in Table

4, the appropriate solution is to use a powered as-sist device.

Proposed solutions

The best approach for lifting loose objects and

equipment is to have two persons perform the liftor use lifting assist equipment (see Table 3). Thedeterminant of whether or not to use a single

lifter, multiple lifters, or assistive equipment isthe weight of the load to be lifted, the frequencyof lifting, and the accessibility to reach and lift

the equipment. As a rule of thumb, for lifts thatare performed often or every day, assistive liftingtechnology likely is the best choice.

Tips for lifting or moving heavy equipment safely

1. Pushing tasks ergonomically are preferred

over pulling tasks.2. Ensure that push handles are at a correct

push height of approximately 3 ft (0.92 m).

Table 3

National Institute for Occupational Safety and Health lifting index value for typical lifting tasks performed in operating

rooms



140 WATERS et al

3. For tasks where the vertical height of thepush point is less than 3 ft (0.92 m) abovethe floor, maximum and sustained push

forces are decreased by approximately 15%.4. For tasks performed more frequently than

once every 30 minutes, maximum and sus-

tained push forces are decreased by approxi-mately 6%.

5. If push force limits are exceeded, it is neces-

sary to reduce the weight of the load, usetwo or more caregivers to complete the tasktogether, or use a powered transport device.

Powered transport devices are built intosome beds and stretchers; additionally, thereare devices available commercially to moveequipment [18].

6. Equipment or casters need to be maintainedproperly to assist in moving equipmentmore easily.

7. These recommendations are based on the Lib-erty Mutual psychophysical limits for pushforces, where hands are positioned at a middle

push point of 3 ft (0.92 m) from the floor orabove and tasks are performed no more fre-quently than once every 30 minutes [13].

Discussion

Many manual handling tasks performed bycritical care nursing staff (eg, handling andmoving patients, beds, and equipment) require

high levels of physical effort, resulting in signifi-cantly high internal loads on muscles, ligaments,and joints of the body, especially the shoulder and

low back. These high internal loads significantlyincrease the potential for development of WMSDsfor these workers.

Table 4

Association of periOperative Registered Nurses recommendations for pushing wheeled equipment




Fortunately, there are alternatives to unsafemanual handling tasks, such as use of floor-basedand ceiling lifts, lateral transfer devices, slip sheets,

antiembolism stocking applicators, and poweredtransport devices [19]. In addition, new technolo-gies rapidly are being developed for a wide range

of health care settings. As discussed in this article,solutions for many of the high-risk tasks found incritical care nursing currently are available.

Critical care nurses often are asked to performcomplex tasks that are time sensitive and requirea rapid response. There may not always be time tolook for the proper equipment to perform a task

unless the assistive equipment is in close proximityto workers. Therefore, it is important that ade-quate equipment is available and that the most

appropriate equipment is selected for the task.For example, for transferring tasks requiringa full-body lift, a ceiling lift might be preferred

over a floor-based lifting device, because theceiling lift always is in close proximity to thework area, and nurses do not have to go looking

for the lift. In addition, the problem of storage offloor-based lifts is eliminated by the use of ceilinglifts, which are stored on an overhead track anddo not take up any floor space. It is important

that the culture of the work environment incritical care settings be changed so that caregiversand management make a significant effort to

provide adequate equipment and training neces-sary to prevent the equipment from simply beingstored in a back room.

In this article, tasks with high risk for muscu-loskeletal disorders in critical care settings areidentified clearly and appropriate solutions pre-

sented. Previous studies have shown that imple-mentation of a safe patient handling andmovement program that incorporates the use ofthis new technology can pay for itself in a short

period of time and provide a long-term benefit forhealth care facilities and the nursing staff [20,21].

Efforts to improve the safety of critical carenurses are essential to assure quality patient care.Nurses who are injured or suffer from musculo-

skeletal pain may not be able to provide rapid andeffective responses when urgent patient care isneeded. Insuring the health and safety of critical

care nurses also will help alleviate the currentnursing shortage by keeping nurses on the joblonger, reducing the risk for disruption of nursing

practice, and reducing the risk for a prematurecareer-ending injury.

References

[1] Collins JW, Menzel NN. Scope of the problem. In:

Nelson A, editor. Safe patient handling and move-

ment: a practical guide for health care professionals.

New York: Springer Publishing; 2006. p. 1–26.

[2] U.S. Department of Labor, Bureau of Labor Statis-

tics. Lost-work time injuries and illnesses: character-

istics and resulting time away from work, 2000.

Washington, DC: U.S. Department of Labor, Bu-

reau of Labor Statistics; 2002.

[3] U.S. Department of Labor (Bureau of Labor

Statistics). (2000). Table R6: incidence rates for non-

fatal occupational injuries and illnesses involving

days hawai from work per 10,000 full-time workers

by industry and selected parts of body affected

by injury or illness, 2000. Accessed September 13,

2006. Available at: http://www.bls.gov/iif/oshwc/

osh/case/ostb1039.pdf.

[4] U.S. Department of Labor. Bureau of Labor Statis-

tics. (2004). Nonfatal cases involving days away

from work: selected characteristics. Accessed Sep-

tember 13, 2006. Available at: http://data.bls.gov/

labjava/outside.jsp?survey¼cd.[5] Smedley J, Egger P, Cooper C, et al. Manual han-

dling activities and risk of low back pain in nurses.

Occup Environ Med 1995;52:160–5.

[6] Nelson AL, Fragala G, Menzel N. Myths and facts

about back injuries in nursing. American Journal

of Nursing 2003;103(2):32–40.

Table 5

Push force limits

Adapted from Snook SH, Ciriello VM. The design of manual handling tasks: revised tables of maximum acceptable

weights and forces. Ergonomics 1991;34(9):1197–213; with permission.

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[7] Nelson AL, and Baptiste A, (2004). Evidence-based

practices for safe patient handling and movement.

Online J Issues Nurs, 19 (3) Manuscript 3. Available

at: www.nursingworld.org/ojin/topic25/tpc25_3.htm.

[8] AORN. AORN Guidance Statement: Safe Patient

Handling and Movement in the Perioperative Set-

ting. Denver (CO): AORN Publications; 2007.

[9] Chengalur SN, Rodgers SH, Bernard TE. Kodak’s

ergonomic design for people at work. 2nd edition.

New York: John Wiley & Sons, Inc; 2004.

[10] Waters T, Putz-Anderson V, Garg A, et al. Revised

NIOSH equation for the design and evaluation of

manual lifting tasks. Ergonomics 1993;36 no 7:

749–76.

[11] Waters T, Garg A, Putz-Anderson V. Applications

manual for the revised NIOSH lifting equation

[DHHS(NIOSH) Pub. No. 94–110]. Cincinnati

(OH): Department of Health and Human Services,

National Institute for Occupational Safety and

Health, Division of Biomedical and Behavioral Sci-

ence; 1994.

[12] Marras WS, Davis KG, Kirking BC, et al. A com-

prehensive analysis of low back disorder risk and

spinal loading during the transferring and reposi-

tioning of patients using different techniques. Ergo-

nomics 1999;42(7):904–26.

[13] Snook SH, Ciriello VM. The design of manual han-

dling tasks: revised tables of maximum acceptable

weights and forces. Ergonomics 1991;34(9):

1197–213.

[14] Lloyd JD, Baptiste A. Biomechanical evaluation of

friction reducing devices for lateral patient transfers.

AAOHN J 2006;54(3):113–9.

[15] Baptiste A, Boda S, Nelson A, et al. Friction-reduc-

ing devices for lateral patient transfers: a clinical

evaluation. AAOHN J 2006;54(4):173–80.

[16] Nelson AL, Lloyd J, Menzel N, et al. Preventing

nursing back injuries: redesigning patient handling

tasks. AAOHN J 2003;51(3):126–34.

[17] Chaffin DB, Andersson GBJ, Martin BJ. Occupa-

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Wiley & Sons, Inc.; 1999.

[18] VISN 8 Patient Safety Center of Inquiry. (2005).

Technology resource guide. Accessed September

14, 2006. Available at: http://www.visn8.med.va.

gov/visn8/patientsafetycenter/safePtHandling/default.

asp.

[19] Safe patient handling and movement: a practical

guide for health care professionals. In: Nelson A,

editor. New York: Springer Publishing; 2006.

[20] Collins JW, Wolf L, Bell J, et al. An evaluation of

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[21] Nelson AL, Owen B, Lloyd J, et al. Safe patient han-

dling & movement. American Journal of Nursing

2003;103(3):32–43.


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Psychosocial Factors in Musculoskeletal DisordersNancy N. Menzel, PhD, RN, COHN-S

University of Nevada Las Vegas School of Nursing, 4505 Maryland Parkway, Box 453018,

Las Vegas, NV 89154-3018, USA

Work-relatedmusculoskeletal disorders (MSDs)have a multifactorial etiology that includes notonly physical stressors but also psychosocial

risk factors, such as job strain, social supportat work, and job dissatisfaction. Once an injuryhas occurred, psychosocial factors, such as de-

pression and maladaptive pain responses, arepivotal in the transition from acute to chronicpain and the development of disability. Inter-

ventions to prevent MSD incidence and addresspsychosocial risk factors for delayed recovery aredescribed. There is broad agreement that work-

related MSDs have a multifactorial etiology, withworkplace and nonwork risk factors playinga role in their cause [1–3]. In its preamble to itsErgonomics Standard, the Occupational Safety

and Health Administration (OSHA) defineda risk factor (stressor) as

a characteristic of the work environment that

research has shown to be associated with an

elevated occurrence or severity of MSDs. Risk

factors can involve purely external exposures,

such as shock or percussion, that act on the

musculoskeletal system. They can also involve

intrinsic response to a load or task, such as lifting

or rapid and awkward movement. The effect of

a risk factor may be modified by personal

characteristics, such as anthropometry and phys-

ical conditioning, or by concurrent or previous

non-work exposure. Risk factors can also involve

work organizational or social factors [4].

OSHA [4] defines biomechanical stressors as‘‘the physical aspects of workstation, work piece,

tools, and work process that exert stress on thebody.’’ OSHA does not define ‘‘psychosocial riskfactor.’’ It justifies its exclusive focus in the

standard on biomechanical risk factors by con-cluding that they ‘‘contribute independentlyfrom psychosocial factors, and exposure to bio-

mechanical risk factors has been observed to begenerally stronger than for psychosocial factors’’[4].

Similar to the conclusions drawn by OSHA,there is widespread scientific agreement about therole of biomechanical risk factors in causing

MSDs in nurses, with strong research studiesand a comprehensive epidemiologic evidencereview supporting this conclusion [2,5–7]. The

evidence is not so clear, however, about psychoso-cial risk factors, such as stress, as causative fac-tors. Although many studies find an association,the role these factors play in causation is unclear:

Are they independent factors or do they act as ef-fect modifiers, altering the association betweenphysical stressors and MSDs? If they are indepen-

dent factors, what is the mechanism by which theyare believed to produce MSDs?

Psychosocial factor definitions

Psychosocial factors are defined in a variety ofways. The National Institute for Occupational

Safety and Health [2] points out that it is a ‘‘catch-all term’’ for the following: ‘‘1) factors associatedwith the job and work environment, 2) factors as-

sociated with the extra-work environment, and 3)characteristics of the individual worker.’’ It pointsout further that these factors are believed to inter-

act with each other, affecting health and job per-formance. Some factors specific to nursingpersonnel that are identified in the literature fallinto all three categories.

Work-related factors include job satisfaction[8], job strain (performing psychologicallyE-mail address: [email protected]





demanding tasks under time pressure while havinglow control over the job) [9–11], time pressure[12,13], high mental pressure [14,15], work rela-

tionships with coworkers [16], support at work[11,15,17], and stress [18,19]. An extra-work envi-ronment risk factor, amount of leisure time exer-cise, was correlated negatively with low back

pain in Chinese nurses [18]. Individual (notwork-related) characteristics include pain copingskills [20], premenstrual tension [14], having chil-

dren [14], and affective states (depression and anx-iety) [21,22].

Why the contribution of psychosocial risk factors

remains unclear

The reasons that psychosocial factors lacka supporting body of research evidence are

many. One is imprecision in psychosocial con-struct definition. For example, work-related stressin health care is defined and measured differently

in many articles on this topic, which may useother terms, such as burnout or strain, instead ofstress [23].

A second problem is measurement of psycho-social constructs. Whereas there are establisheddefinitions of physical force and shear and how to

measure them, the opposite is true of constructs,such as job strain or stress coping ability. Unlikeusing objective computer programs with biome-chanical models to calculate spinal compression

from lifting or strain gauges to measure push-pullforces, to cite two ways to measure physicalstressors, psychosocial stress in nursing (and other

occupations) is measured using self-report (sub-jective) instruments. These include diaries of un-known reliability and validity [24], interviews that

leave the definition of stress up to the interviewee[25], and instruments with acceptable psychomet-ric values (reliability and validity), such as the Per-

ceived Stress Scale [20]. Finally, many of thestudies that have been done on psychosocial fac-tor association with MSDs are cross sectional;cross-sectional designs preclude inferring cause

and effect because it is not possible to determinetemporal plausibility. For example, a direct pa-tient care provider may report back pain and de-

pression. Is the caregiver depressed because ofthe pain or did the depression cause the pain?

A third problem is the lack of knowledge

about the biologic plausibility of psychosocialfactors as etiologic agents. In epidemiologicstudies, biologic plausibility occurs when the

association between two factors is consistentwith current medical knowledge. For examplehow a psychosocial factor, such as job dissatis-

faction, is associated with the incidence of MSDsis unknown, based on the state of the science ofthe mind-body connection.

Four pathways for biologic plausibility are

hypothesized. The first is that psychosocial factorsresult in muscle tension and increase spinalloading; there are laboratory studies demonstrat-

ing this link [26–28]. The second hypothesizedpathway is that psychosocial factors may influ-ence body awareness and result in reporting of

musculoskeletal pain or attribution of work fac-tors as the cause. Third, psychosocial factorsmay influence that transition from the originalacute injury to chronic pain, even after the origi-

nal muscle damage heals [29]. Finally, psychoso-cial demands may be associated with physicaldemands, making it seem that psychosocial fac-

tors are associated with MSDs when, in fact,they may be confounders (not part of the real as-sociation between exposure and disease) or effect

modifiers [30].A fourth difficulty is the variability in outcome

definition and measurement, with some studies

using MSD pain but most using reported injuryincidence or lost days because of injury. Giventhat occupational injuries are shown to be under-reported by orders of magnitude, the latter out-

come is an unreliable and lagging indicator ofmusculoskeletal stress and pain [31].

Because of the lack of standardization of terms,

tools, and outcomes, it is difficult to use meta-analyses (the highest level of evidence) to assemblea body of evidence using the same construct

definitions and the same measurement instrumentsfor psychosocial factors. One meta-analysis, how-ever, does find an increased risk of prevalence ofoccupational back pain from job dissatisfaction in

the general working population [8].

Conceptual models

The Institute of Medicine (IOM) [3] Panel onMusculoskeletal Disorders and the Workplacepublished a conceptual model for MSD etiology

that emphasizes physical risk factors, sideliningindividual risk factors outside the main causalpathway. Although several other conceptual

models are proposed for the role of psychosocialfactors in the development of work-relatedMSDs [32–34], there is none that has received

146 MENZEL

widespread acceptance, which hinders hypothesisgeneration and research.

What is the evidence for psychosocial factors

as etiologic agents?

According to the Institute of Medicine [3], job

strain is the most prominent among the psychoso-cial risk factors for upper-extremity disorders.Other studies similarly have identified job strainas a psychosocial risk factor for developing

MSDs [10,11,35,36].Job dissatisfaction is associated with MSDs in

Norwegian nursing aides [37] and in Japanese, Ca-

nadian, and Icelandic nurses [14,38,39]. Similarfindings are reported for other occupationalgroups [40–42]. Limited social support at work

is another psychosocial factor that has emergedas a risk for MSDs among nurses [11,15,43].

Some individual factors are shown through

longitudinal studies to be associated with thedevelopment of back pain: psychologic distressor stress [19,44–46] and negative coping styles [46].No extra-work risk factors are identified consis-

tently as etiologic risk factors.

What is the evidence for psychosocial factors

in disability and return to work?

There is evidence that psychosocial factors areimportant in determining length of disability,

transition from acute to chronic pain, and returnto work, once a nurse or other worker reports anMSD [17,47–50]. In a longitudinal study of more

than 1800 Canadian nurses, job strain and low so-cial support at work were associated with sickleave incidence and length [51] (although the study

does not identify the work-related injury that pre-cipitated the absence). In another longitudinalstudy of more than 4000 Norwegian nursing aides,

low support at work was associated with long-term low back pain–related sick leaves [17]. Ina systematic review of six cohort studies of lowback pain, distress, depressive mood, and somati-

zation were associated with the transition fromacute to chronic pain [48]. For low back pain,there is strong empiric evidence from prospective

studies that psychosocial factors are the predomi-nant risks for developing chronicity and disability,leading to calls for intervention early in the con-

tinuum of disease [49,50,52].These empiric findings support the multidi-

mensional view of pain adopted by the pain

research community and reflected in the Interna-tional Association for the Study of Pain [53] defi-nition of pain, which states that pain is ‘‘Anunpleasant sensory and emotional experience as-

sociated with actual or potential tissue damage,or described in terms of such damage.’’ Key tothis definition is the recognition that pain is mul-

tidimensional and includes not only sensory inputbut also cognitive and emotional components.Pain is a psychologic construct, not a physical di-

agnosis of tissue damage or other physical pathol-ogy. When considered from this perspective, it isnot surprising why psychosocial factors, such as

emotion [54], work satisfaction [49], and psycho-pathology [50], are important determinants ofpain chronicity and related disability. Further-more, pain is a significant predictor of disability

[49,50], offering a direct path for the emotionalcomponent of pain perception to influencedisability.

Because pain is a symptom that has sensory,affective, and cognitive dimensions, its clinicalassessment depends on subjective reports. Because

disability is defined as restricted function, it can beassessed reliably by self-report or work absence/modification [55]. In chronic pain, in particular

low back pain, there may be no discernible struc-tural impairment [55]. Tate and colleagues [56]found that disability in back-injured nurses pre-dicted the incidence of lost time, whereas self-

reported pain predicted how much time was lost.A study by Waddell and coworkers [57] shows

little association between pain and disability.

Fear-avoidance beliefs about physical activity(kinesiophobia) and work, however, were associ-ated strongly with work loss and disability in ac-

tivities of daily living. These findings arereplicated in other studies [47,58,59].

In addition, pain catastrophizing (an exces-sively negative orientation toward pain) is associ-

ated with chronic low back pain and disability[47]. According to a conceptual model developedby Vlaeyen and colleagues [58] and adapted by

Pincus and coworkers [48], when pain from anoriginal injury is interpreted as threatening (paincatastrophizing), it results in fear of re-injury,

which leads to movement avoidance, hypervigi-lance, and muscle reactivity, which lead to disuse,depression, and disability, all of which maintain

pain. Individuals who do not catastrophize theirpain return to daily activities and recover quickly[48,58].

These studies highlight the relationship be-

tween physical disability and psychosocial

147PSYCHOSOCIAL FACTORS IN MSD

function. Much like pain, disability is not a phys-ical diagnosis and has only a loose associationwith tissue damage and measurable physical

pathology. This largely is because, from patients’perspective, disability results from an appraisal oftheir functional abilities, the associated risks andbenefits of function, and the expectations of the

consequences of function. Like pain, disability canbe considered a psychologic construct influencedby psychosocial factors as demonstrated in the

empiric literature.Coping skills is a term found in the literature

on MSD pain and disability. Coping is defined by

Lazarus and Folkman [60] as ‘‘constantly chang-ing cognitive and behavioral efforts to managespecific external or internal demands that are ap-praised as exceeding the resources of the person.’’

When a stressful situation is viewed as unchange-able, emotion-focused coping is used to minimizeemotional distress. Examples of emotion-focused

coping are using alcohol or drugs, overeating, orparticipating in a distracting activity. If a stressfulsituation is viewed as changeable, then problem-

focused coping is called up to assess the situationand choose among the best solutions. In meaning-focused coping, a third strategy, stressed individ-

uals modify interpretation of a stressful situationby drawing on values, beliefs, and goals [61]. Al-though escapist strategies often result in poormental health outcomes, other strategies, such as

seeking social support or choosing to changea stressful situation, may have positive or negativeoutcomes depending on individual appraisal of

the impact of the ‘‘important goals [that] havebeen harmed, lost or threatened. These appraisalsare characterized by negative emotions that are

often intense’’ [62]. Cognitive-behavioral therapy(CBT) is effective in teaching coping skills [62].

According to this brief overview (above), psy-chosocial factors, not tissue damage, are the most

important factors in determiningwhether or not in-dividuals develop disability and chronic pain afteranMSD. In addition, they are paramount in deter-

miningwhether or not injured individuals take timeoff from work and the length of that leave. Despitethis evidence, theworkers’ compensation treatment

paradigm does not include approaches to addressthese factors until individuals have progressed sofar into disability and psychologic deterioration

that the chance for recovery and return to work isremote [63]. Given the high cost of rehabilitation(tertiary prevention) compared with screeningand early intervention (secondary prevention),

this treatment approach is not evidence based.

Interventions to reduce psychosocial risk factors

for the incidence of musculoskeletal disorders

In the psychosocial risk factor domain, only

factors associated with the job and work environ-ment are under the appropriate control of em-ployers. Although it might be possible to screenfor and refuse to hire nurses who have personal or

extra-work risk factors, it is not legal, underfederal equal employment opportunity laws, andimpractical in light of the nursing shortage.

Although evidence for the role of work-relatedpsychosocial risk factors in the etiology of MSDsis not as strong as for physical risk factors,

employers are well advised to address the factorsthat have emerged simply as good businesspractices that may reduce turnover and increaseproductivity, no matter what their musculoskele-

tal health benefits.Job strain is a conceptual model developed by

Karasek and colleagues [64–68] that states that

work conditions involving the greatest mental de-mand and lowest control over those conditionsproduce the largest physical responses. They devel-

oped the Job Content Questionnaire to measurejob strain and other concepts [69] and found thatjob strain is most severe among nursing aides,

who are at the lowest level of the health care hier-archy. Registered nurses (RNs), however, also feellittle control over their work environment. Em-ployers can address job strain through increased

participation, by letting nurses have a role in mak-ing assignments and agreeing on staffing ratios andby allowing nurse representation when important

management decisions are made.Job satisfaction for nurses involves several

variables, including pay [70,71], work organiza-

tion and workload [70,71], autonomy [72], stress,and leadership issues [73]. Remedies for all theseissues are under employers’ immediate control,based on an assessment of which ones are the

most vexing to nurses in their institutions. Exitsurveys, conducted whe nurses leave employment,are one way to gather this information.

Low social support at work (from supervisorsand peers) is identified as an MSD risk factor inmany studies. Such support is vital to retain new

graduates [74]. Social support equally is impor-tant, however, for all nurses because it serves asa coping mechanism, reducing stress from the de-

manding job of nursing [75]. Employers shouldpromote social support by encouraging collegial

networks and offering management training thatemphasizes nonpunitive approaches to leadership.

148 MENZEL

Interventions to reduce psychosocial risk factors

for musculoskeletal disorders and disability

Once an MSD is reported, the no-faultworkers’ compensation system is activated.

Nurses receive immediate medical care at nocost. Treating health care providers determinewhether or not nurses can return to full or

modified duty or should remain away from workfor a specified number of days until a follow-upvisit. Whether or not nurses are paid for the days

away from work depends on whether or not theyhave any paid sick leave and jurisdictions’ waitingor elimination period for indemnity (wage re-

placement) benefits. The treatment providedfollows the jurisdiction protocol and other occu-pational health guidelines, depending on the in-jury. These protocols and guidelines focus on

rapid return to work. In the acute stage of injury,the guidelines do not recommend any screeningfor psychosocial risk factors, despite evidence that

these determine whether or not the pain transi-tions to a chronic state, whether or not disabilitydevelops, and the length of time workers stay out

of work. One reason for this avoidance is the fearof employers and insurers that any referral forpsychologic assessment will result in a costly

workers’ compensation claim for stress or mentalhealth issues, such as depression. No studies havebeen conducted, however, to validate or disprovethis concern.

Cognitive-behavioral therapy

CBT is shown effective as treatment forchronic pain and depression [76–79]. CBT is based

on the premise that thought influences emotionand behavior. Several cognitive styles, such aspain catastrophizing, are related to poor outcome

[80]. CBT is a psychologic treatment approachaimed at reducing distorted thinking patternsand behaviors by replacing them with more realis-tic substitute patterns that are critical to adjusting

to pain and injury (eg, exercise, relaxation, oravoidance). Linton and Ryberg [81] found thatCBT prevented low back pain disability [82].

Hasenbring and associates [82] replicated thisfinding.

Psychosocial stress and affective responses topain cause or worsen MSDs and associateddisability in direct patient care providers. CBT isshown effective in helping individuals cope with

stress and pain and preventing or reducing MSDsand disability [20]. Fig. 1 is a conceptual model ofhow CBT is believed to work. Accordingly, em-

ployer and workers’ compensation insurers shouldconsider asking occupational health care pro-viders to screen those who have new MSDs for

psychosocial risk factors and refer them toa pain center for CBT. Screening tools includethe Beck Depression Inventory [83], Fear-Avoid-

ance Beliefs Questionnaire [57], Tampa Scale forKinesiophobia [58,84], Pain Catastrophizing Scale[85], and the Pain Disability Index [86].

Case study

Kathy is a 58-year-old RN who has worked in

a medical ICU at a large, tertiary-care medical

center for 15 years. Although she has had work-

related back pain intermittently for the past 5

years, she has not reported it because of fears of

reprisal or job loss. Staff members who report

workers’ compensation injuries are shunned by

other staff members, who feel they have to

assume additional work for the person who is

on modified duty or absent. Her goal is to

complete 4 more years of work until she turns

62, then apply for social security retirement. She

does not like her nurse manager and her author-

itarian style. Kathy is older than all the other

RNs on her unit and finds little in common with

them. She lives alone, after a divorce 10 years

ago. She has no outside activities and spends her

days off watching television and eating to excess.

Because she works in a unit with mandatory

overtime, the nurse manager tells her she must

work 16 hours on a day that later requires her to

push an occupied stretcher. As she maneuvers the

stretcher around a corner, she assumes an awk-

ward posture and feels intense pain in her lower

back. Pain radiates down her right leg; she is

unable to complete the patient transport and calls

for assistance. Too much in pain to complete her

work assignment, she goes to the employee health

department for evaluation and treatment. Be-

cause of her incapacity, she is sent home from

work with a prescription for pain and muscle

relaxants.

CBT CopingSkills

StressPain

MSDDisability

Fig. 1. CBT to reduce MSDs.


The next day, she has difficulty arising from

bed without incurring severe pain and decides to

stay in bed all day not only that day but also the

next 2 before her follow-up appointment. She

barely is able to show up for her appointment, so

afraid is she of pain from moving. At the same

time, she has thought with dread about the effect

this injury will have on her plans for working 4

more years until retirement. She is certain that

she has suffered a career-ending injury, which will

have profound economic consequences.

The treatment provider refers her to physical

therapy to assist her in movement, but she misses

most of the appointments because of fear of pain

from travel and therapy. A radiograph of the

back reveals no damage other than age-related

degenerative changes in the spine. The workers’

compensation adjuster calls her to threaten claim

denial if she misses any more appointments.

Kathy calls an 800 number flashed on a television

advertisement for a workers’ compensation at-

torney and retains counsel. Her nurse manager

calls to ask when she will be coming back to work

because they are short staffed. Kathy is unable to

cope with the stress and spends her days in bed

crying and overeating. After Kathy has missed 3

months of work and received extensive medical

testing and treatment, she is referred to a neuro-

surgeon for back surgery evaluation. The neuro-

surgeon treats her chronic pain by operating on

her spine. The result is no improvement. At 6

months, the adjuster sends Kathy to a functional

rehabilitation program, but she fails the prepro-

gram psychologic screening tests for likelihood to

benefit from the program. Kathy never returns to

work.

Analysis: The work-related psychosocial risk

factors for back injury incidence were obvious

and unaddressed, making an MSD inevitable,

given the interaction of those factors with a phys-

ical stressor and the nature of cumulative trauma.

The employer could have improved social sup-

port for Kathy and similar experienced nurses by

forming a ‘‘brain trust’’ that meets periodically to

network and plan mentoring programs for new

graduates. The employer could have eliminated

its mandatory overtime policy, which creates job

dissatisfaction and stress.

Once Kathy experienced pain severe enough to

report an injury, the health care provider failed to

assess or intervene in any domain but the

physical. Kathy was exhibiting signs of depres-

sion even before the injury; once the acute injury

occurred, the depression worsened and resulted in

disability. She developed pain-related fear of

movement and pain catastrophizing, which

served to maintain the pain state. Her coping

skills consisted of distracting behaviors and were

no match for the perceived threat of the injury.

No amount of neurosurgery could cure her

depression and maladaptive pain-related behav-

iors, but when all you have is a hammer, every-

thing looks like a nail. Had the health care

provider done some simple screening tests at the

first follow-up visit, when it was obvious that

Kathy was not making progress, the outcome

would have been much different had she been

referred to appropriate resources with the cost

covered by workers’ compensation.

Summary

Epidemiologic studies provide only supportingevidence of the causes of a disease, not direct

proof [87], a fact that tobacco companies wereable to exploit for many years in getting the publicto believe there was scientific uncertainty that cig-arettes cause lung cancer. For diseases, such as

MSDs, that have multifactorial origins, a singlesmoking gun never will be discovered. What isneeded is a conceptual model that acknowledges

the contributions of each factor and allows hy-pothesis generation and empiric testing. Controlof psychosocial risk factors by federal regulators

is not on OSHA’s agenda, after its ErgonomicStandard to control physical risk factors was re-scinded by Congress and the White House in

2001. With no mandatory control imminent,health care employers, treatment providers, andrisk managers should use the precautionary prin-ciple (taking protective action in the face of lack

of scientific proof of a threat) to act as if psycho-social factors were important contributors to theincidence and severity of MSDs and provide ap-

propriate interventions for job strain, job dissatis-faction, and inadequate social support at work.Once injury occurs, workers’ compensation in-

surers should support holistic treatment and notfocus exclusively on physical risk factors. Moodstate and abnormal reactions to pain complicateor prevent recovery if they are not addressed along

with measures that promote physical healing.

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Ergonomic Assessment of a Critical Care UnitSheri Stucke, PhD, APN,

Nancy N. Menzel, PhD, RN, COHN-S*University of Nevada Las Vegas School of Nursing, 4505 Maryland Parkway,

Box 453018, Las Vegas, NV 89154-3018, USA

Direct patient caregivers experience a high in-cidence rate of musculoskeletal disorders (MSDs)and a high prevalence of musculoskeletal pain [1].

The back is the body part injured most frequently,but injuries to the shoulder, neck, arm, and kneesalso are reported. Nursing assistants have higher

rates of injuries than licensed nurses, but registerednurses (RNs) are a perennial finisher in the Top 10of most MSDs reported [2]. Although patient han-dling is the reason cited most recently for MSDs,

shift work and long work hours are known to pre-dispose to injury [3,4].

Unlike the body of knowledge that documents

the musculoskeletal risks associated with manualpatient handling in nursing homes [5–7], there arefew studies about similar risks for critical care

nurses. There is, however, some evidence that crit-ical care nurses experience MSDs at least as muchas other nurses. One study from Canada founda back pain point prevalence of 25% for critical

care nurses compared with 30% for orthopedicnurses [8], whereas another study in the Nether-lands found a 12-month prevalence of low back

pain of 75% in intensive care nurses comparedwith 76% for nonspecialized nurses [9]. Intensivecare nurses in an Australian study had a manual

patient handling injury incidence rate of 52%[10]. As researchers, administrators, and legislatorsimplement safe patient handling interventions for

nursing homes and other areas with high incidencerates of injury, such as orthopedics, the incidenceand severity of injuries to the back, neck, and

shoulder in those workplaces will begin to decline.The next challenge is protecting the health andsafety of nurses working in lower-risk specialty

areas, such as operating rooms and critical careunits (CCUs). Because nurses under-report work-related injuries [11,12], the true injury incidence

rates of these units likely are much higher thannow supposed.

Background

As with many modern approaches to nursingcare, the concept of intensive care originated from

innovations implemented by Florence Nightingalein the Crimean War, when she grouped thesoldiers injured most seriously together and pro-vided revolutionary approaches to the prevention

of infection and epidemics [13]. Today, criticalcare nursing is not limited to a specific unit orarea but is located wherever critically ill patients

are receiving care. This may be emergency rooms,operating rooms, cardiac catheterization labora-tories, progressive care units, telemetry units,

postanesthesia care units, or CCUs, also knownas ICUs. CCUs are special areas designed tocare for patients who are medically unstable and

at risk for death. They are characterized by highnurse-to-patient ratios, such as 1:1, 1:2, or 1:3,the most common ratio being 1:2. Even thoughCCUs may vary significantly by their number of

beds, specialty, and design among hospitals, theyare designed to provide constant nursing andmedical surveillance of patients who have multiple

problems and are receiving multiple treatments.According to the American Association of

Critical Care Nurses statement to the Institute

of Medicine Committee on Work Environment


E-mail address: [email protected]

(N.N. Menzel).





for Nurses and Patient Safety [14], there are nearly1.3 million RNs taking care of hospitalized pati-ents, with an estimated 403,000 of them critical

care nurses. CCUs are staffed with highly trainedRNs. These RNs receive advanced education byattending critical care courses, usually offered bythe hospitals where they are employed. These

courses offer advanced education in systems,such as neurology, cardiovascular, respiratory,gastrointestinal, nephrology, and in areas, such

as hemodynamic monitoring and 12-lead EKGinterpretation, among other topics. The focus isexclusively on the care of complex patients, not

on recognition of and protection from the specialoccupational risks faced by critical care nurses.

A report released by the Health Resources andServices Administration (HRSA) found that pa-

tients in acute care hospitals currently receivemore than 18 million days of care in ICUs everyyear [15]. During the next decade, the demand for

ICU services is projected to grow rapidly becauseof increased acuity of hospitalized patients andthe growth of the aging population. According

to the HRSA, the number of available physicianswho specialize in critical care, also known asintensivists, likely will not meet the demands of

the aging population by the year 2020 [15]. Thishas a direct impact on nursing because this short-age will place increased demands on critical carenurses, who already are scarce because of the

current and projected nursing shortage [16]. Aspatient load or hours of work increase, the riskfor MSDs from manual patient handling exposure

increases.Many of the patients located in critical care

areas are physically dependent and require spe-

cialized medical equipment, such as cardiac mon-itoring, ventilator support, multiple intravenous(IV) infusions, and possibly other technology thatcan crowd the work area around patients. This

abundance of machines can make it difficult fornurses to provide direct patient care withoutmaneuvering the equipment. A typical patient

room in a CCU (often retrofitted from anotheruse) has many pieces of equipment and furnitureat the bedside, which can restrict access to patients

and force nurses to assume awkward postureswhen delivering care. There are many cables andIV poles that also put nurses at risk for tripping.

Critical care nurses may be at high risk for MSDsfrom repetitive movements, such as lifting heavyloads and frequent patient repositioning.

Ergonomics is the science of adjusting job

tasks to match the capabilities of the worker.

The nursing workforce is approximately 95%female [16], meaning that work tasks should bedesigned to accommodate a workforce that is

shorter and has less upper body strength, a shorterreach, and less grip strength than a workforcewith a higher percentage of men. Health care,however, has lagged behind many other indus-

tries, such as warehousing and transportation,that long ago instituted protections for their pri-marily male workers from heavy, frequent lifting

and holding awkward postures. Reasons thatnurses have not received similar protections in-clude a singular focus on patient (not worker)

health; a tradition in nursing schools of teachingineffective lifting procedures, such as bodymechanics [17]; lack of occupational health andsafety regulation; and a primarily female work-

force kept at the bottom of a hierarchic manage-ment structure [18].

Because the nursing shortage is severe and

persistent, some institutions have begun to look atways to improve retention of their existing nursingworkforce. One key is reducing the number and

severity (length of absence) of work-relatedinjuries, of which MSDs are the most costly andmost likely to result in days lost from work or on

modified duty [19]. The most effective way toreduce these injuries is by conducting a thoroughergonomic assessment that identifies hazardoustasks and conditions and instituting an ergonom-

ics program designed to reduce these risks.

Purpose

Because of the dearth of knowledge aboutspecific risks associated with the provision of

critical care, the authors conducted an ergonomicassessment of a 23-bed medical ICU in 409-bed,acute-care hospital in Las Vegas. The second

purpose was to evaluate the applicability tocritical care settings of the instrument, ErgonomicWorkplace Assessment Protocol for Patient Care

Environments in the Patient Care ErgonomicsResource Guide (the Guide) [20].

Methods and materials

This was a qualitative study. The researchers

followed steps 1 through 7 of the protocol de-scribed in the Guide:

1. Collect baseline injury data.2. Identify high-risk units.3. Obtain presite visit data.

156 STUCKE & MENZEL

4. Identify high-risk tasks.5. Conduct team site visit at each high-risk unit.6. Perform risk analysis.7. Formulate recommendations.

8. Implement recommendations; involve endusers in selecting equipment

9. Monitor results; evaluate program; continu-

ously improve safety.

Steps 1 and 2: collect baseline data and identify

high-risk units

Because this was purposive and conveniencesampling, the authors did not select among areasfor the one with the highest injury rate. Thehospital allowed the researchers access to its 23-

bed medical ICU (MICU), where the staffing ratiowas one nurse for every two patients.

Step 3: obtain presite visit data on high-risk units

After receiving Institutional Review Boardapproval, the authors requested that the CCU

manager complete the Pre-Site Visit Unit Profile(Fig. 1) before their visit. Because of a recentchange in the position, however, the new nurse

manager did not feel she had the required knowl-edge or time to complete the questionnaire. She,therefore, designated another management-level

RN (the supervisor) who assists with the MICU(and also is the facility’s risk manager) as theperson to complete the Pre-Site Visit Unit Profilebefore the visit.

The Occupational Safety and Health Adminis-tration log showed no MSDs for the MICU in2004, 2005, and the first 9 months of 2006. The

maximum number of RN full-time equivalent RNsassigned to the unit was 51. The supervisor did notanswer the question about the percent of full-time

equivalents filled. On the day of the focus groups,two participants from the MICU were not regularemployees (one agency nurse and one travel nurse).

There were no planned changes to staffing levels orbed numbers. Themanager checked the box next to‘‘dependent’’ without filling in a percentage. Infocus groups with staff members, nurses estimated

the percentage of dependent patients as 85% to90%. For patient handling equipment, the super-visor listed fourHoyer lifts (‘‘rarely used’’) and two

slide boards (‘‘frequent use’’). The Hoyer lifts werestored on another floor, however. Staff seemedunaware of their existence. She did not identify

built-in scales in the beds. The supervisor identifiedas a problem area the inability of patients to moveand a need for ‘‘improved beds.’’ Although she

identified storage as a problem, she felt there wasadequate room in patient units to carry out patientcare tasks.

Step 4: identify high-risk tasks

The authors then conducted three focus groups

with 11 RNs (two men) working on the 12-hourday shift (7:00 AM to 7:00 PM) on August 18, 2006,to identify high-risk tasks. The focus groups wereconducted in the nurses’ break room, which was

located within the MICU. This was a private, con-venient location. Participation in the focus groupswas voluntary. Breakfast items were offered to

those RNs who inquired or participated in the fo-cus groups. After a prospective participant readthe informed consent and had an opportunity to

ask questions about the study, the researchersgave a $20 gift card to a local store to thosewho agreed to participate. Both researchers were

present during the entire interview process. Thefocus group outline, modified from the one inthe Guide, is as follows:

1. What conditions or situations in critical careput you at risk for back strain and injuries?

2. What critical care lifts or transfers are themost difficult and present the highest risk?

3. What are the factors that make a lift or trans-fer a high-risk activity?

4. What types of critical care patient conditionscontribute to high-risk situations?

5. What do you think can be done to reduce or

minimize a high-risk situation?6. What are the barriers to risk reduction? In

other words, what are some of the reasons

that you don’t take precautionary steps?

Although the protocol recommends this step

only for identifying high-risk tasks, other issues,such as staffing, emerged during the focus groups.The data were reduced to common themes. The

most frequent or most intensely reported themesfor MSD risks were

1. Patient characteristics: heavy (obese), depen-dent, resistant/combative

2. Hazardous tasks

� Transporting patients and their extensiveequipment (while manually ventilatingthem on occasion) in beds with balky wheels

and IV poles that do not glide� Frequent turning and repositioning patientsin bed

157ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT

Fig. 1. Pre-site visit unit profile.

158 STUCKE & MENZEL

� Reading body fluid levels 6 inches off the

floor� Emptying urine drainage every hour from 6inches off the floor

� Having to maintain awkward postures forprolonged periods of time during procedures

3. Equipment

� Lack of safe patient handling and liftingequipment, in particular self-propelled beds� Need to get help from other staff members

for manual patient handling because oflack of equipment

Fig. 1 (continued)


4. Staff� Not enough staff to allow nurses to helpother nurses reposition or transport their

patients. Causes delays in patient care.� Large variation among caregivers in heightand strength� 75% of staff complaining of current or

recent musculoskeletal pain� Staff reluctance to report MSDs because offear of management repercussions (‘‘being

blackballed’’)5. Maintenance� Wheels on beds are not well maintained to

ease push/pull stress of bed transports� IV poles broken

6. Shift length and scheduling� 12-hour shifts and frequent overtime con-

tribute to fatigue and musculoskeletal pain7. Unit layout� Extensive walking required

� Limited opportunities to sit

Some of the participants had misconceptions;namely, that body mechanics are effective inpreventing injury and that if a nurse was injured,

it was because of his or her lack of fitness ortechnique. The facility perpetuates this belief byproviding annual training in body mechanics. Staff

members did not know that there was a recommen-ded weight limit for patient handling or what thatrecommendation was, which is a maximum of 35

pounds [17].From the preliminary questionnaire and focus

group data, the authors prioritized high-risk

patient handling tasks according to the protocol(Table 1). The researchers did not include all ofthe tasks in the Guide, as many were not applica-ble or uncommon in this MICU (eg, lifting a pa-

tient from the floor or bathing a patient ona shower trolley). Instead, the researchers addedtasks to the list that were more common in the

MICU.

Step 5: conduct team site visit for ergonomicassessment

Aftermeeting with the acting supervisor and thehead nurse, the researchers toured the MICU to

evaluate observable risks. The unit seemed to havebeen converted from a standard semiprivate med-ical-surgical floor by removing one bed from each

room to create single rooms. This layout reducedor eliminated visibility of patients from the nurses’station, however, so staff nurses established

makeshift substations near their assigned patients.The medication carts were not height adjustable.The hallways were crowded with furniture and

medical equipment, making navigating an occu-pied bed to or from the elevator difficult. The staffreported that the doors to the CT scan room areopened manually, requiring nurses to hold an

awkward posture with hips and feet to keep thedoor open until the bed is pushed through.

Based on information from the supervisor,

focus groups, and the site visit, the researcherscompleted a unit summary sheet (Table 2).

Step 6: risk analysis

After reviewing the baseline injury, presitevisit, focus group, observational data, and the

identification of high-risk tasks, MSD risk factorswere identified. These include

1. Lifting/moving heavy loads2. Reaching and lifting with loads far from the

body

3. Pushing a load a significant distance4. Squatting5. Maintaining awkward postures

Environmental hazards included cluttered hall-ways, broken bed wheels, monitors not adjustableto accommodate the gaze of the shortest nurses,

and a physical layout that required nurses to walklong distances for medications, supplies, andcharting. Walking more than 3.5 miles per shift

is considered a risk factor for musculoskeletaldiscomfort [21].

Step 7: formulate recommendations

The Guide suggests that recommendationsshould be achievable and simple and includes

two categories: engineering design and adminis-trative solutions. Engineering controls involveexternal changes to the way a job is performed,

for example, the use of a mechanical lift to movea patient from a bed to a stretcher. Administrativecontrols affect the way work is done or the hoursof exposure to risk. For example, if a hospital

offers 8-hour shifts instead of 12-hour, eachcaregiver’s exposure to hazardous MSD risks isreduced by 4 hours per day, allowing adequate

recovery time between work periods.The researchers made the following recom-

mendations. Because ergonomic concepts are new

to this facility, the first step is for the supervisor tobring her concerns about staff safety and risks tohospital management for further discussion.

160 STUCKE & MENZEL

Table 1

Prioritization of high-risk patient handling tasks

Patient description

Unit

description

Miscellaneous

information Equipment Problems identified Solutions

Medical patients with

multiorgan system failure,

80%–85% dependent,

many on ventilators

and all attached to monitors,

IVs, and other equipment

23-bed medical

ICU, all

private rooms

with private

baths

Recent

change in

unit manager

2 slide/surf

boards; 4

specialty

beds on

order for

trial

High risk from transporting

patients in beds

Self-propelled beds or ERGOtug Medical

Mover. Clear halls of extra equipment. Put

electric doors on CT scan room

For profit hospital

Staff is unionized Turning side to side in bed

or pulling up in bed a problem

Explore value of friction-reducing devices

No preventive maintenance on

bed wheels

Institute routine maintenance program

Large proportion

of obese patients

On admission for patients over 250 lb, rent

bariatric beds or consider purchase if

percentage of bariatric patients exceeds

30% in a 3-month period

Transferring patients from

stretcher to bed

Powered lateral assist device or AirPal

Fatigue from long shifts Limit overtime; provide seating and break

opportunities

Reading urinary output bags

or chest tube drainage when

stooped

Provide mirrors on poles to visualize levels

without stooping. Change emptying

frequency to every 3 hours once level

is read and recorded.

Extensive walking Redesign unit layout with mini–nurse stations.

Provide chairs reserved for nurses in recessed

hall areas and in nurses station, where chairs

often are taken by medical residents

High reported prevalence of

MSD pain but zero injury

reporting for 2.5 years

Encourage early reporting and intervention

for MSDs

Awkward postures from applying

femoral pressure manually

Rearrange standing medical order form to list

Femstop first to encourage this choice over

manual pressure

Awkward postures from using

medicine cart

Obtain height adjustable cart

Awkward postures from reading

cardiac and other monitors

Increase downward height adjustability of

monitors or provide short staff with step stools

161

ERGONOMIC

ASSESSMENT

OFA

CRIT

ICALCARE

UNIT

Without management support, no program inergonomics will succeed.

Prior to meeting with hospital management,

the supervisor should prepare a business case(cost-benefit analysis) for intervening by compil-ing information on the direct and indirect costs of

MSDs in the facility’s staff for the past 2 years.Direct costs usually include workers’ compensa-tion medical care and wage replacement (data

available from insurer), whereas indirect costsinclude the cost of hiring replacement nursesto cover absences, among many other consider-

ations. Indirect costs are estimated as equal todirect costs [22]. In this facility, with a nearly3-year record of no reported injuries, the supervisormust recognize that there has been suppression of

reporting, based on the prevalence of MSDs thestaff described during the focus groups and theirfear of reporting. A better indication of the direct

cost of MSDs in this facility is the number of un-scheduled absences (ie, the number of days whennurses call in sick or take a personal day with

no prior notice). These absences translate intocosts for overtime and agency nurses. An addi-tional cost is turnover; when a nurse feels herhealth is at risk, she may move to an area

with less perceivedMSDrisk.This is aphenomenoncalled the ‘‘healthy worker effect.’’ A management

approach based on ergonomics is to encourageearly reporting, when intervention can be moreeffective, rather than waiting until pain and dis-

ability are severe. In addition, the supervisorshould have a cost estimate for engineeringand administrative controls recommended.

The supervisor also should come prepared withevidence that ergonomic interventions actuallyreduce injuries, absenteeism, and turnover [5,23].

The supervisor can find resources at the PatientSafety Center’s Web site [24].

Once hospital management is convinced that

there is a costly problem that can be prevented orlessened, the facility can embark on a participatoryergonomics program involving staff nurses in allareas. Staff nurses’ participation is vital to the

success of any program because they must havea say in engineering and administrative controls toensure they will be accepted.

Discussion

The researchers found challenges in followingthe Guide’s protocol; some steps seemed out of

sequence or redundant. In particular, the unitsummary sheet in step 5 calls for a list of solutionsbefore risk analysis is completed or

Table 2

Unit summary sheet

Patient handling task Frequency of task Stress of task Ranka

Transporting patient

off unit

H H 1

Repositioning patient

from side to side

H H 1

Lifting patient

to head of bed

H H 1

Bathing a patient in bed M H 1

Transferring patient:

bed to stretcher

M H 1

Transferring patient:

bed to chair

L H 1

Making an occupied bed H H 1

Weighing a patient M L 10 (beds have built-in

scales)

Emptying catheter

drainagebH H 1

Reading chest

tube drainagebL H 1

Applying pressure

on femoral arterybM H 1

Abbreviations: H, high; L, low; M, moderate.a 1 indicates high risk; 10 indicates low risk.b Indicates high-risk task added to list in the Guide under ‘‘Other.’’

162 STUCKE & MENZEL

recommendations formulated. In addition, step 4calls for identifying high-risk tasks by ‘‘job obser-vation, questionnaires to employees or brain-storming sessions with patient handlers’’ before

the site visit occurs in step 5, which implies two sitevisits. The protocol’s list of high-risk tasks in step 4seems most appropriate for a nursing home

setting, not critical care. Judging from missing orinappropriate responses, some questions on thePre-site Visit Unit Profile form were difficult for

the supervisor to understand. The protocol shouldbe edited to make it more generic and easier tofollow. Finally, it should be expanded to include

gathering information on other risks that affectMSD incidence, such as the average number ofhours a nurse works, the facility’s climate forreporting work-related injuries and other signs

that lifting burdens may be too great, such as staffturnover.

The researchers noted the following differences

between MSD risks in this MICU and nursinghomes.

1. In this MICU, almost all patients werecompletely dependent. In nursing homes,some proportion of residents can assist at

least partially.2. Nursing home patients almost always are

ambulated or transferred to wheelchairs

daily. In this MICU, patients are not trans-ferred out of bed as frequently.

3. Bed transport is frequent in MICU, infre-quent in nursing homes.

4. Staff are all RNs in MICU; the majority arecertified nursing assistants in nursing homes.

5. Medical procedures are performed more fre-

quently at bedside in MICU.6. MICU patients have much more equipment

attached to them than those in nursing homes.

7. Nurse-to-patient ratio is 1:2 in MICU; it maybe 1:12 or more in nursing home.

8. MICU patients do not require feeding very

often; caregivers often must feed nursinghome patients (awkward postures).

The data were obtained from one CCU in onehospital during one shift in one city, so thefindings are of limited generalizability. They do

indicate, however, that MSD risks are present incritical care environments. To preserve the valu-able resource of highly skilled practitioners safeand at the bedside, hospital administrators must

begin to pay attention to the special risks theyface and provide effective interventions. The

nurses who work in these areas also shoulddemand these protections. A major nurse union,United American Nurses, is a cosponsor withthe American Nurses Association for the Handle

with Care campaign to eliminate manual patienthandling. It also passed a resolution to takepolitical action to seek federal and state legislation

to protect nurses from the hazards of manual pa-tient handling [25].

Recommendations

Judging from this small study and a search of

the articles published in critical care nursingjournals, critical care nurses are only minimallyaware of the MSD risks they are exposed to during

their shift. During the focus group interviews inthe MICU, nurses were able to articulate theimportance of properly arranging patients and

necessary equipment before procedures are per-formed to prevent awkward positioning of theirbodies. Most nurses were unaware, however, of

the special equipment available to assist them inpreventing musculoskeletal injuries, when trans-ferring patients, for instance. Critical care nursesmust be educated about the urgent need for

assistive equipment in their specialty areas, sothey can demand this equipment and safer workpractices. Nurses seeking to change employers

should inquire about ergonomic protections avail-able in their potential new workplaces and refuseto work where they do not exist.

It is necessary for critical care nurses to changetheir paradigm from patient focus to the nurse/patient safety dyad. Nurses need to be aware that

although they need to provide safe care to theirpatients, they also need to protect their own safetyand that of their peers. The men in the studyreported that they were asked more frequently

than female staff members to help with patientmovement, thereby increasing their exposure tohazardous tasks. With the current nursing

shortage, retention of critical care nurses is vital,especially with the elderly population growing atsuch a fast rate. Two younger nurses in the focus

groups recognized they are at risk for muscu-loskeletal injuries by stating they currently do nothave back pain but realize they probably will inthe next few years. This resigned way of thinking

must change to one of optimism for a long career,given proper workplace protection from thehazards of manual patient handling, awkward

postures, and repetitive motion leading to cumu-lative trauma.


Even with the safe patient handling initiativesthat have been introduced during the past fewyears, critical care nurses still are unaware of

the alarming statistics regarding MSDs in healthcare. Dissemination of new knowledge is pre-sented to the nursing community at conferencesthrough poster presentations and oral presenta-

tions. Many nurses may not attend conferencesand, therefore, miss the information presented.Another method for distribution of new knowl-

edge is through articles published in clinical andresearch journals. When nurses read professionaljournals, it usually is a journal in their field of

practice and expertise; therefore, publishingarticles related to musculoskeletal injuries (suchas this one) in critical care journals (such as thisone) is one way to reach this specialty. Some

nurses may not read journal articles, howeverda dissemination dead end.

Another way to distribute information to

critical care nurses is through their professionalorganizations. Local chapters of professionalorganizations, such as the American Association

of Critical Care nurses, are a good venue fordisseminating information to nurses who special-ize in critical care. For instance, chapters have

meetings and educational offerings at local facil-ities that are more convenient for nurses to attendthan national conferences, especially if continuingeducation credits are offered.

A change in paradigm may create some re-sistance, especially when the change involvessomething that has been accepted and done the

same way for many years. Lewin’s model ofplanned change describes a three-step frameworkfor instituting change. The initial step is the

unfreezing stage or preparation for change [26].During this step, unions and professional organi-zations inform nurses about MSD statistics inhealth care, MSD hazards from manual patient

handling, critical care tasks and environmental fac-tors that have the highest risks, actions they cantake to prevent injuring themselves, and modern

technologic assistance available to reduce the risksthat lead toMSDs. This is the step where nurses areinfluenced and become interested in engaging in

change to improve their current practices.The second step in Lewin’s model of planned

change is movement or changing. During this step,

nurses shift their behavior to a new level. They canspeak with their nurse managers regarding thenecessary changes needed to initiate a comprehen-sive ergonomic program in their facility, including

trying out available assistive devices to determine

what equipment is most beneficial for high-riskcritical care tasks. Feedback from end users iscrucial, because they are the nurses who use the

equipment every day. Equipment that requiresdistant storage or that slows down the time it takesto deliver care is destined to be abandoned. If staffnurses are not comfortable or satisfied with the

equipment, then the equipment goes unused andthe nurses revert to manual patient handling.

The final step in Lewin’s model of planned

change is the refreezing stage. During this step,nurses have implemented the new changes in theirpractice with the equipment they have chosen to

be most beneficial for them. Because the nursesactively were involved with this change from thebeginning and should be experiencing the benefitsof reduced pain and fatigue, they are more likely

to accept and continue the new safe patienthandling practices.

Summary

Although the ergonomic assessment tool pro-vided a good foundation for assessing a CCU, itshould be revised to improve its clarity, sequencing,

and applicability in a range of settings. Thisqualitative study indicates that even in a criticalcare area where there are no reported injuries,

MSDs can be prevalent. The critical care workenvironment may involve risks in addition to thosepresent in all nursing workplaces by virtue of the

preponderance of dependent, obese patients; thechallenge of delivering multiple, concurrent in-terventions to patients surrounded by a collection

of modern technology inserted into an architec-tural space not designed to accommodate it; theneed for bed transports to centralized technologyor services; expenditures for high-tech equipment

for patient care and not worker safety receivingbudget priority; and the frequency of repetitivetasks involving awkward postures. Hospital

administrators, professional organizations, unions,researchers, and equipment vendors should turntheir attention to protecting critical care nurses

from manual patient handling, an antiquatedwork practice unable to meet the demands ofa twenty-first century work environment.

References

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nel: measurement issues. AAOHN J 2004;41(8):

54–65.

164 STUCKE & MENZEL

[2] Lost work-time injuries and illnesses: characteristics

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factors for neck and upper limb disorders: results

from 24 years of follow up. Occup Environ Med

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[4] Lipscomb JA, Trinkoff AM, Geiger-Brown J, et al.

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[7] Zhuang Z, Stobbe TJ, Hsiao H, et al. Biomechanical

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[8] Vieira ER, Kumar S, Coury HJ, et al. Low back

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[9] Bos E, Krol B, van der Star L, et al. Risk factors

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nurses, IC nurses, operation room nurses, and X-

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[10] Retsas A, Pinikahana J. Manual handling practices

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[11] Blegen MA, Vaughn T, Pepper G, et al. Patient and

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[12] Brown JG, Trinkoff A, Rempher K, et al. Nurses’

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[13] Gallesio A, Ceraso D, Palizas F. Improving quality

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[14] American Association of Critical Care Nurses.

Written statement to the InstituteofMedicineCommit-

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2003. Available at: http://www.aacn.org/AACN/

pubpolcy.nsf/92712bceed60b1878825688e00776c1f/

1138e880af4cafe788256cc60001ff73?OpenDocument

[15] The critical care workforce: a study of the supply and

demand for critical care physicians; 2006, US

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nursing schools. Nurse Educ, in press.

[18] Gordon S. Nursing against the odds: how health

care cost cutting, medial stereotypes, and medical

hubris undermine nurses and patient care. Ithaca

(NY): Cornell University Press; 2005.

[19] Nelson A, Matz M, Chen F, et al. Development and

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prevent injuries associated with patient handling

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handling andmovement; 2001, Patient Safety Center

of Inquiry, Veterans Health Administration and

Department of Defense, Rev. 8/31/05.

[21] Chengalur S, Rodgers S, Bernard T. Kodak’s

ergonomic design for people at work, 2nd edition.

Hoboken (NJ): John Wiley & Sons, Inc.; 2004.

[22] Occupational Safety and Health Administration.

OSHA’s ‘‘$afety Pay$’’ program. Available at: http://

osha.gov/dts/osta/oshasoft/safetwb.html. Accessed

August 22, 2006.

[23] Garg A. Long-term effectiveness of a ‘‘Zero-Lift

Program’’ in seven nursing homes and one hospital.

NIOSHCooperative Agreement Final Report; 1999,

NTIS Accession No. PB99–173007.

[24] Available at: http://www.visn8.med.va.gov/visn8/

patientsafetycenter/safePtHandling/default.asp.

[25] UAN. Resolution protecting nurses from occu-

pational musculoskeletal injuries; 2006. Available

at: http://www.uannurse.org/who/resolution/2006/

08.html. Accessed March 30, 2007.

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http://www.aacn.org/AACN/pubpolcy.nsf/92712bceed60b1878825688e00776c1f/1138e880af4cafe788256cc60001ff73?OpenDocument



http://osha.gov/dts/osta/oshasoft/safetwb.html

http://osha.gov/dts/osta/oshasoft/safetwb.html



http://www.uannurse.org/who/resolution/2006/08.html

http://www.uannurse.org/who/resolution/2006/08.html

Evaluation of Critical Care Space Requirementsfor Three Frequent and High-Risk Tasks

Sue Hignett, PhD*, Jun Lu, MArch, BEngHealthcare Ergonomics and Patient Safety research Unit (HEPSU), Department of Human Sciences,

Loughborough University, Loughborough, Leicestershire, LE11 3TU, UK

Many investigators have identified that staff

and patient safety can be compromised if in-sufficient space is provided [1–5]. Even if sufficientspace is available, the layout and ergonomic de-

sign of workspace may restrict activities and con-tribute to adverse events [6,7]. In the UnitedKingdom (UK), there are health and safety lawsthat, for example, require ‘‘every room [to] have

sufficient floor area, height and space for the pur-poses of health and safety’’ [8]. This is a cross-industry regulation that appliesmostly to employee

activities but also to all users of a space, includ-ing patients and visitors.

Many guidance publications are available to

assist designers (architects) in planning hospitalspaces; they include topics on health and safety,hospital design, and clinical guidance. The recom-

mendations for bed space (single rooms or cubiclesin shared rooms) have increased since 1992, butlittle empiric evidence is published to support theproposed dimensions.

To test the space requirements for critical caretasks, three frequent or space-critical tasks weresimulated in a full-size mock-up. The mock-up was

based on the measured dimensions from four UKcritical care units built since 2000. The selectedtasks were determined by a previous field study [9]:

washing and dressing patients and moving them

from a bed to wheelchair using a lifter (bed wash/

lifter task); transferring patients from bed to an-other bed (bed-to-bed task); and resuscitatingpatients (resuscitation task).

Background

Patient bed space (room or cubicle) is the most

important and largest repeating space envelope ina health care facility because it is the center ofnursing activity [10,11]. The design of hospitals hasbeen viewed as an important and integral part of

the therapeutic environment since the time of Flor-ence Nightingale, with the effectiveness of healthcare delivery determined, in part, by the design

of the physical environment and the spatial organi-zation of work [12,13].

The first ICUs were built in the early to mid-

1950s, with open wards and no partitions exceptcurtains or screens. The second- and third-gener-ation ICUs (1970s and 1980s) had individual

rooms, moving from walled cubicles to foldingor sliding doors with increased level of control. Itis predicted that the future ICUs will have in-dividual rooms with increased privacy [14]. The

challenge is to design critical care units that facil-itate the provision of care and also provide a lowstress environment for patients and their families

or significant others [15,16]. In the United Statesof America (USA), there are recommendationsto decrease patient transfers through the use of

adaptable acuity design [17–20]. This allows pa-tients to be accommodated in the same singleroom throughout their stay with the room adjustedfor the requirements of care and treatment. The di-

mensions and configuration of the room includea patient area, family area (including recliner bed

This work was supported by Grant no: B(02)13/

HUJBA from the Department of Health Estates and

Facilities Management Directorate (UK).

The views and opinions expressed in this article do

not necessarily reflect those of the Department of

Health.


E-mail address: [email protected] (S. Hignett).





and so forth), caregiver area, and hygiene area[15,17]. The critical care bed space needs to haveworking space for staff, appropriate clinical equip-

ment and furniture, and movement space for rou-tine and emergency care [17].

There is a difference in professional spacerecommendations in the USA and the UK. In the

USA, the recommended space envelope has in-creased from 13.94 m2 (rooms) [21] in 1996 to 16.72m2 (rooms or cubicles) [22] in 2001 and 36 m2 for

universal (acuity adaptable) rooms (Fig. 1) [18].In the UK, the recommended space has increasedfrom 20.25 m2 (cubicles) [23] in 1992 to 26 m2

(rooms or cubicles) [24] in 2003. No empiric re-search was located to support the space recommen-dations shown in Fig. 1.

The development of evidence-based health care

has paralleled the availability of information, withtechnology increasing the availability of researchfindings. These concepts are starting to be seen in

20.25

12

25

20

13.94

15.75

25.5

20

23.23

33

16.72

39.48

25.08

18

26

37.16

22.5

36

30

40

0 5 10 15 20 25 30 35 40 45

1992 (HBN 27[23]: cubicle[UK])

1993 (Marans[35]:room[USA])

1995 (Wedel et al[34]: room[USA])

1995 (Wedel et al[34]: cubicle[USA])

1996 (AIA[21]:room [USA])

1998 (Koay[33]: room[Singapore])

1997 (Intensive CareSociety[32]: room [UK])

1997 (Intensive CareSociety[32]: cubicle [UK])

1999 (HermanMiller forHealthcare[31]: room [USA])

2001 (Hamilton[30]: room[USA])

2001 (AIA[22]: room/cubicle[USA])

2001 (Stichler[29]:room[USA])

2001 (Gallant & Lanning[28]:room [USA])

2003 (Held[27]:cubicle[Switzerland])

2003 (HBN 57[24]:room/cubicle [UK])

2003 (Sponsler[26]:room[USA])

2004 (Hendrich[18]:roomwithout family space [USA])

2004 (Hendrich[18]:room[USA])

2004 (Takrouri[25]: cubicle[Saudi Arabia])

2004 (Takrouri[25]: roomwith storage [Saudi Arabia])

Area of room/cubicle in square metres

Fig. 1. Recommendations for bed space in ICUs (m2). Data from Refs. [26–35].

168 HIGNETT & LU

health care architecture, where it is recognizedthat health care architects must aim to achieve thesame high standards as clinical evidence-basedpractice [36,37]. There are several narrative re-

views summarizing the literature [38–43] but nosystematic reviews looking at health care design.As health care treatment and care procedures pre-

dominantly are evidence based, the lack of a sys-tematic review to present a critical appraisal ofdesign research limits the usability of this research

for clinicians and designers (architects).

Aim

The aim is to determine the space requirements

for critical care bed space envelope (rooms orcubicles) for three space-critical high-risk tasks:(1) washing and dressing patients and then mov-ing them from bed-to-wheelchair using a lifter, (2)

transferring patients from bed to another bed, and(3) resuscitating patients.

Method

Functional space experiments (FSEs) were de-veloped to test the space required. This method ofspace testing originally was used in 1955 [44] and

has been used to recommend minimum patienthandling space requirements in bed spaces [11]and shower or toilet rooms [45].

The importance of clinical staff participating in

health care building design is highlighted byseveral investigators [7,10,46–48]. The use ofmock-ups as part of the participatory design

process is recommended by several investigatorsto enable staff to experience all aspects of the de-sign, including getting the feel of the space, evalu-

ating various aspects, and providing feedback[10,49–53].

The templates for the FSEs were derived fromfour UK hospitals built or refurbished since 2001.

The bed spaces (defined by boundaries of walls orcubicle curtains) were measured in each ICU, asshown in Table 1. As more recent guidance rec-

ommends that rooms and cubicles need the sameamount of space for clinical activities [22,24]; noallowance is made for room and cubicle space

envelopes in these experiments.

Participants

Participants were recruited from the cardiacICU of a large regional hospital (with more than11,500 total staff on three sites). A poster

advertising the FSE and seeking participation

was displayed on the cardiac ICU notice boardfor several weeks before the start of the FSEs.Eighteen nurses were recruited, including sevenregistered nurses, eight health care assistants, and

three student nurses. Their experience working incritical care ranged from 6 months to 20 years,with an average of 5.3 years. Participating nurses

were given an information sheet and signeda consent form at the FSE.

Tasks

Patient rooms are described in terms of fourzones: patient area, family area, hygiene area, andcaregiver area [15,17]. This experiment looked at

the patient (bed, bedside table, and chair) andcaregiver areas but excluded the family and hy-giene areas and in-room storage.

Data from a previous observational study wasused to determine the tasks to be used in the FSEs[9]. Three task scenarios were chosen: (1) washingand dressing patients and then moving them from

bed to wheelchair using a lifter (bed wash/lifter),(2) transferring patients from bed to another bed(bed to bed), and (3) resuscitating a patient; the

techniques and equipment used for the three taskswere based on recommendations for practice bythe Royal College of Nursing [54].

The task scenarios were reviewed with the helpof expert nursing staff in prepilot and pilot stagesto determine, for example, how many participants

were needed for a task, what equipment would beused, the start and end points of the task, themock-up design, and camera locations.

Six groups of nurses tested the layouts by

performing the three tasks repeatedly. Differentcolored tapes were used to mark the laboratoryfloor to represent the boundaries of the bed space

templates with additional parallel lines at 20-cmintervals on both sides of a boundary line to recordand measure the exact space required for nursing

tasks (Fig. 2). The mock-up used in this FSE useda module rail (gantry), as the bed space templateshad gantry systems rather than headwall services.

Table 1

Critical care unit bed space templates

Layout Date Width (m) Length (m) Area (m2)

1 (room) 2002 5.28 5.10 26.93

2 (room) 2001 6.12 4.10 25.09

3 (room) 2002 4.64 4.37 20.28

4 (cubicle) 2001 3.30 4.00 13.20

169EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS

A 17-kg fully articulated mannequin was used asthe patient in all the FSEs.

Data were collected using video recording fordetailed frame-by-frame analysis. Link analysis

was used to record the movements of components(ie, nursing staff, equipment or device, and furni-ture) and the participants’ (nurses’) movements

between equipment or device, furniture, and pa-tient. Links were defined as movements of positionand components [55,56]. AutoCAD was used to

draw the link diagrams as output to convey spatialinformation.

Ethical issues

Ethical approval for this study was granted byLoughborough University and National HealthService (MREC 04/MRE09/31 and LCPRA

05/Q2501/45). Research governance was grantedby the participating NHS Trusts and honorarycontracts were issued to both researchers.

Results

The multidirectional video data (from fourcameras) were analyzed frame by frame using link

analysis. The movement of each nurse was plottedindividually and then overlaid with that of theircolleagues for each task and template to give 48

data sets of the composite link analyses; Fig. 2ashows the bed-to-bed transfer, Fig. 2b the bedwash/lifter, and Fig. 2c resuscitation. The average

space occupied was measured for each trial andan average calculated for each task; Fig. 3 showsthe area, Fig. 4 the width, and Fig. 5 the length.

Fig. 2. Link analyses for bed-to-bed transfer (a), bed wash/lifter (b), and resuscitation (c).

170 HIGNETT & LU

The complexity of the task scenarios was empha-sized during the link analysis where the movementof individual nurses could be plotted from the mul-

tidirectional data before combination with thedata for the other nurses. The overlaid diagrams(see Fig. 2) are detailed but give a true reflection

of the complexity of the working activities.The bed-to-bed transfer task occupied the most

space, with an average area of 23.26 m2 (see

Fig. 3), followed by the resuscitation task (22.87m2) and the bed wash/lifter task (22.36 m2).Only layout one (26.93 m2) accommodated allthe average spatial requirements for all the tasks.

Layout two (25.09 m2) was exceeded for the bed-to-bed task but accommodated the bed wash/lifterand resuscitation tasks. Layout three (20.28 m2)

accommodated the bed-to-bed and resuscitationtasks but not the bed wash/lifter task. Layoutfour (13.2 m2) was exceeded for all the tasks. To

investigate the spatial requirements further, theaverage dimensions for width and length alsowere determined.

The results of width analysis found that theresuscitation task needed an average of 4.89 m(see Fig. 4), followed by the bed-to-bed transfer

task (4.87 m) and the bed wash/lifter task (4.81m). Again, layouts one (5.28 m) and three (4.64m) accommodated all the tasks. Layout two

(6.12 m) just accommodated the tasks, with thefull width used for the resuscitation task. Therewas concern that the data from layout two mightskew the results. This was checked in detail from

the video recording and it was concluded thatnursing task behavior was unchanged when com-pared with the other three layouts. Layout four

(3.3 m) was exceeded for all three tasks.The results of length analysis (see Fig. 5) found

that the bed-to-bed transfer task needed an average

24.4

5

25.6

5

23.3

1

24

26.1

6

27.3

8

19.5

2

21.1

3

21.3

21.4

5

20.0

8

19.4

822.3

6

23.2

6

22.8

7

1517.5

2022.5

2527.5

3032.5

35

Bed Wash/lifter Bed-to-bed Resuscitation

Layout 1 (26.93m2) Layout 2 (25.09m2) Layout 3 (20.28m2)Layout 4 (13.2m2) Average

Fig. 3. Bed space envelope dimensions: area (m2).

4.97 5.04

4.81

5.5

5.93

5.85

4.24 4.3

4.57

4.54

4.19 4.

34

4.81 4.87

4.89

3

3.5

4

4.5

5

5.5

6

Bed wash/lifter Bed to bed transfer Resuscitation

Layout 1 (5.28m) Layout 2 (6.12m) Layout 3 (4.64m)Layout 4 (3.3m) Average

Fig. 4. Bed space envelope dimensions: width (m).


of 4.80 m, followed by the resuscitation task (4.67

m) and the bed wash/lifter task (4.66 m). Most ofthe resulting dimensions approximated to squareshapes. Layout one (5.1 m) accommodated all the

tasks. Layouts two (4.1 m), three (4.37 m), andfour (4.0 m) all were exceeded for all three tasks.

Discussion

The average spatial requirement from all theFSEs was 22.83 m2 (average width of 4.68 m and

length of 4.71 m), similar to the recommendationfrom Hendrich and colleagues [18] for a roomarea of 22.5 m2, excluding family space. The result

is within the current UK recommendation (26 m2)but greater than the guidance [23] that would havebeen used for all the benchmark sites (20.25 m2).

One of the limitations of the FSEs was the exclu-sion of space considerations for family, hygiene,and in-room storage areas and it is likely that an

additional 3 m2 would be needed to accommodatethese areas. In comparison, recommendations foradaptable acuity rooms usually include storageand services, giving space recommendations of

36 m2 (of which 13.5 m2 is family space) [18]and 40 m2 (of which 10 m2 is storage space) [25].The shape of the bed space envelope was impor-

tant. The average spatial dimensions for the threetasks differed. The limiting factor was found to bethe length for layouts two (bed-to-bed transfer

task) and three (bed wash/lifter task) where theaverage area was insufficient for the specifiedtasks. The shape of the layout for all the tasks

resulted in a greater width than length, with the

resuscitation task needing 20 cm more widththan length and the bed wash/lifter task 15 cmmore width than length.

The three tasks offered frequent (bed wash/lifter and bed-to-bed transfer) and safety critical(resuscitation) challenges to the spatial require-ments. The resuscitation task required the greatest

width to accommodate the increased number ofstaff (up to six were available for the FSEs) andthe equipment and circulatory space around the

bed. It was anticipated that the bed-to-bed trans-fer and bed wash/lifter might require greater spacethan the resuscitation task because of the addi-

tional equipment (second bed and lifter). Thelength requirements are less surprising, with thebed-to-bed transfer requiring the largest dimen-

sion to accommodate the access and egress of thesecond bed. It was expected that the resuscitationtask might require a greater length than the bedwash/lifter task. A previous pilot study on adult

acute ward bed space envelopes identified thatwidth was the critical spatial factor when usinga lifter, whereas length was the critical factor for

resuscitation (bed-to-bed transfer spatial require-ments were not investigated) [11]. The results fromthe critical care environment suggest that width is

equally important for the resuscitation task andrequires more space than when using a lifter.This presents a challenge to hospital designers:Should a bed space envelope be designed for the

safety critical task, giving a larger envelope(23.80 m2)? Or for the frequent tasks, 23.23 m2

or 22.27 m2? The location of openings (doorways)

4.92 5.

09

4.85

4.36

4.41

4.68

4.61

4.91

4.664.73 4.79

4.494.

66 4.8

4.67

3

3.5

4

4.5

5

5.5

6

Bed wash/lifter Bed to bed transfer Resuscitation

Len

gth

(m

)

Layout 1 (5.1m) Layout 2 (4.1m) Layout 3 (4.37m)Layout 4 (4.0m) Average

Fig. 5. Bed space envelope dimensions: length (m).

172 HIGNETT & LU

within a layout was found to affect the results. Forexample, in layout two, the doorway was close tothe patient bed head and services (electricalpoints, oxygen, air, and so forth) and perpendicu-

lar to the bed. When the nurses wanted to movethe mobile lifter, the resuscitation trolley, secondpatient bed, or any other big equipment or furni-

ture into the bed space from outside, a lot of spacewas needed between the door and bed to maneu-ver the equipment without difficulty. It is sug-

gested that this might be the reason the architecthad to design the width of 6.12 m and why thedata from this layout seemed to skew the results.

It was important to give the results withspecific dimensions (length and width) and floorareas. For example, a 24-m2 room could be 4 m inwidth with 6 m in length (or 4 m in length � 6 m

in width) or 3 m in width by 8 m in length (or 3 min length by 8 m in width), depending on the func-tionality and usability. This might be a problem,

as architects and clients could talk about the floorarea of a room without taking account of theshape. This approach might work when designing

buildings, such as shops, museums, libraries, andeven residential buildings, because professionalknowledge, personal experience, and common

sense can inform the architect. But hospital build-ing design presents different challenges and archi-tects need to know that the lack of 0.5 m in thelength or width of a room could affect the safety

and efficiency of care and treatment.A limitation of this research was the lack of

evaluation for the designof the provisionof services

(electrical, vacuum, air, and oxygen). There are twoprincipal systems for the delivery of these services,a modular rail or power column [57,58]. A rail sys-

tem has the intravenous lines, tubes, and so forthfanning out from patients. The benefits of the railsystem (gantry) include minimal tangling, adjust-ability for different patients, access for right- and

left-handed caregivers, and freeing floor spacewith everything hanging from the rail but mustwork from both sides of the bed [7,49]. The power

column (pendant) has the lines, tubes, and so forthleaving a patient and converging in one area. Thiscan facilitate 360� access to patients, decrease the

amount of walking, and increase efficiency withcontrols at fingertips and equipment congregatedin one area, but the lines can get tangled [17,49,59].

The choice to provide care in rooms or cubiclesneeds to be considered in more detail to look atthe risk balance for safety and social issues. Twostudies report that isolated patients (in single

rooms) were visited half as often as nonisolated

patients (5.3 versus 10.9 visits per patient) [60] andwere twice as likely to have adverse events (31 ver-sus 15 events per 1000 patient days) [61]. Twostudies looking at patient stressors in ICUs (with

six bed units) found that lack of privacy was notconsidered a priority [62] and ranked only four-teenth as a stressor [16].

Summary

The provision of functional space in a critical

care environment is recognized as important forpatient and staff safety. This research providesempiric data to support a spatial requirement of22.83 m2, as the average task space based on the

average length (bed-to-bed transfer) and width(resuscitation) dimensions are given as 4.8 mand 4.89 m. The method of link analysis was

found effective for plotting the movements ofthe nurses and accounting for the complexity ofthe tasks. This method, in combination with ob-

servational field studies, provides a simple but ef-fective way of determining the functional spacerequirements for nursing activities.

Summary of important points

� There has been a gradual increase in the rec-

ommended dimensions for critical care bedspaces since 1992.� Empiric data are lacking to support the rec-

ommendations from professional guidelinesfor critical care bed space envelopes.� The use of mock-ups with systematic FSEs

provides a simple but effective method for de-termining the spatial requirements.� An average bed space envelope requirementof 22.83 m2 is recommended to accommodate

frequent and safety critical tasks in ICUenvironments.

Acknowledgments

The authors would like to thank JonathanMill-

man (Department of Health Estates and FacilitiesManagement Division) for his support during theproject; andMoira Durbridge and Allison Godfrey

Vallance and the staff from the Cardiac ICU atUniversity Hospitals of Leicester NHS Trust forfacilitating access and participating in the project.

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Technology Solutions for High-Risk Tasksin Critical Care

Andrea Baptiste, MA (OT), CIEPatient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL 33612, USA

Critical care units present a unique set ofchallenges to nurses and health care professionalswho work with this patient population. These

challenges come in various forms, ranging fromjob requirements, work organizational issues, en-vironment, and equipment. This article focuses onpotential technological solutions in critical care.

Before understanding the solutions to high-risktasks in critical care, the job content and thephysical demands of specific tasks that place

critical care nurses under stress should be un-derstood. The job requirements of intensive carenurses are different from those of other specialties,

resulting in different occupational hazards forintensive care or critical care nurses. A study inThe Netherlands analyzed the relationship be-tween the physical and psychologic work-related

risk factors and musculoskeletal complaints ofnurses from operating rooms and intensive care;x-ray technologists; and nonspecialized nurses.

Results indicate that intensive care nurses per-ceived fewer prolonged neck-shoulder complaintsthan nonspecialized nurses and that an ergonomic

environment seems predictive for low back com-plaints (odds ratio 1.11; 95% CI, 1–1.24) [1].

The findings of this study explained further

that intensive care nurses perceive force exertionand dynamic loads as high. Force exertion isdefined in this study as ‘‘lifting, pushing andpulling, carrying, forceful movements with arms,

high physical exertion, lifting with loads above thechest, lifting with bad grip, lifting with very heavyloads, short force exertion, or exerting great force

in hands.’’ Dynamic load is described as ‘‘trunkmovements, movements of the neck, shoulders or

wrists, reaching, make sudden and/or unexpectedmovements, pinching, working under, at or aboveshoulder level’’ [1].

Ergonomic environments predictive of lowback complaints is consistent with feedbackfrom nurses and can be seen by analyzing theuse of technology in critical care environments.

The reasons for these challenges are because notall units have the same patient population andrequire the same patient handling tasks. Types of

transfers vary and dependent on the needs ofpatient populations. For example, in nursinghomes, the demand for lateral transfers is greater

than in critical care units, because of the medicalconditions of critical care patients. The medicalstatus of patients is a determining factor inconsidering which type of equipment should be

used to perform patient transfers. Types of trans-fers typically performed in critical care units varybut most include the following high-risk tasks:

Lateral transfersRepositioning patients up or side to side in bed

Bed-to-chair or -wheelchair transfersPericare of bariatric patientsToileting in bed

Sustained limb holding for dressing woundsPatient transport

Lateral transfers

Lateral transfers can be a physically demand-ing task performed by nursing staff. Because ofthe frequency of this task, technological solutionsoffer a means to perform this labor-intensive task

with little or no impact on patients or caregivers.Lateral transfers can be performed more safelyE-mail address: [email protected]





through use of mechanical lateral transfer devices,ceiling lifts, air-assisted devices, and friction-reducing devices (FRDs).

Mechanical lateral transfer devices

There are many technological solutions for

performing lateral patient transfers safely, butunfortunately many caregivers still do this taskmanually, subjecting themselves and patients to

risk for being injured. The best, most preferablesolution to making lateral transfers safer is via theuse of an engineering solution, such as using

a mechanical device, such as a ceiling lift ormechanical lateral transfer aid. Both of thesetechnologies diminish the manual labor typicallyused by caregivers in such a task.

The mechanical lateral transfer device consistsof a rod that is rolled into a sheet and powered.Patients lie on this sheet and two retractable

straps are attached from the base unit to the rodin the sheet. Pressing a button on the base unit’scontrol panel retracts the straps, thus pulling

patients across to the destination surface withoutcaregivers moving patients manually. Fig. 1depicts the use of this type of mechanical lateral

device.

Ceiling lifts

An alternate solution to accomplish lateraltransfers is via use of a ceiling lift with a supinesling (Fig. 2). Ceiling lift systems function by

using an overhead track, which is mounted to

the ceiling. The track typically is positioned overa patients’ bed but may extend into the washroomif needed. There are two types of tracks: a single-

track design allows the lift to run along that ded-icated track only, whereas an X-Y track allowsmore versatility as two tracks intersect, permittingthe lift to change directions and allowing more

coverage in the room or bathroom.If a ceiling lift is used for a lateral transfer, the

track has to be perpendicular to the direction of

the bed or stretcher to safely move a patienthorizontally. In this case, a supine sling or slingcovering the length of the entire body is placed

under the patient while the subject is lying ona bed or stretcher. The patient then is elevated offthe bed, using the ceiling lift, then moved across tothe destination surface and then lowered. Care-

givers’ manual work is reduced drastically duringthe lateral transfer using this method. Thismethod still requires caregivers to position the

sling manually under a patient, however, whichstill is a physically demanding task. There needs tobe solutions that eliminate sling insertion and

removal, because these two tasks are deemedhigh-risk tasks. One might ask, ‘‘Why not leavethe sling under the patient?’’ Although there is no

evidence or literature on leaving slings underpatients, the following questions need to beconsidered:

Does the patient have compromised or thinskin?

How breathable is the material of the sling?

Fig. 1. Mechanical lateral transfer device. (Courtesy of VISN 8 Patient Safety Center of Inquiry, Tampa FL; with

permission.)

178 BAPTISTE

Does the sling present rough, uneven edgesthat can produce pressure points on thepatient?

Can the sling be left under a patient and tuckedinto the mattress when not in use?

Currently, manufacturers are working on ex-panding the types of slings that can be left underpatients to address these questions.

Air-assisted devices

If there is no mechanical solution (lift systemor mechanical aid) available, then the next best

choice to perform a lateral transfer of critical carepatients is the use of an air-assisted device. Thesesystems are composed of special mattresses, which

have no weight limit, often are radiolucent, andare constructed with material that offers reducedfriction during a transfer. The system consists of

a portable electric air pump, a hose, and aninflatable mattress. Air is pumped into the mat-tress via the hose by pressing a button. Oncea mattress is filled with air, patients (lying on the

mattress) can be pulled onto the destinationsurface with little effort. The reduced effort isdue to the holes underneath the mattress, which

allow air to escape, and in doing so, providea reduction of friction between the underside ofthe mattress and the bed.

Air-assisted devices were rated most preferablein a study in critical care units where eight deviceswere evaluated for lateral transfers. Caregivers

reported that the air-assisted products were best inoverall comfort, ease of use, effectiveness inreducing injuries, time efficiency, and patientsafety [2]. Because of the lack of weight restric-

tions, caregivers may be more likely to use theseproducts than others in transferring heavierpatients.

Friction-reducing devices

These products offer a remarkable, low-costsolution to performing lateral transfers when thepreceding two solutions are not possible. The

primary purpose of FRDs is to transfer patientsfrom bed to stretcher. These products also areused, however, to reposition patients up or side to

side in bed. The size, shape, and function of theseproducts determine how well they can performa transfer. For example, a FRD designed forlateral transfers may be able to reposition patients

in a chair but may not perform this task wellbecause of the physical length of the device. Whenpatients are pulled up in a chair, they slide back

down if the FRD is not removed quickly becauseof the low friction of the material. It is importantthat each product is used in its intended way to

promote and maintain safety for all participantsinvolved during transfer tasks.

FRDs are made from a slippery-type materialthat reduces friction, making it easier to move

patients. Some products are made with twoseparate sheets, where one slides over the other,whereas others are designed with one tubular

piece of material that rolls over itself. Some ofthese devices have handles or extended pull strapsmaking gripping easier and reducing reaching,

respectively. FRDs with extended pull straps areproved effective in reducing the biomechanicalstress at the low back, thus reducing the risk for

injury [3].Significant factors that affect the performance

of a lateral transfer device are caregiver andpatient characteristics, device design and features,

and organizational and environmental factors.

Repositioning

Repositioning patients up in bed

Ceiling lifts predominantly are used for verticaltransfers (bed to chair) in long-term care facilities;however, in critical care, there is a greater need to

reposition patients up in bed or turn them on theirside. Fig. 3 indicates the typical posture used bycaregivers who have to move patients up in bed

Fig 2. Ceiling. lift track. (Courtesy of Liko, Franklin,

MA; with permission.)

179TECHNOLOGY SOLUTIONS IN CRITICAL CARE

manually without any assistive devices. As seen in

this illustration, caregivers use a forward bentposition at the waist, the shoulders are extended,and the wrists are under the armpits of the

patient. This constitutes a poor posture and placescaregivers at a risk for potentially injuring theirwrists, shoulders, low back, or neck.

Fortunately, there are several technologicalsolutions to assist in the task of repositioningpatients up in bed. The first solution involves use

of repositioning aids.Repositioning patients in bed can be

performed safer and more efficiently by use ofthese aids. These devices vary in style, size, and

function. Some are made of a material that hasfriction-reducing properties to allow caregivers toslide patients up in bed easily. Some devices have

the ability to engage a specific area on the sheetitself to introduce friction and prevent patientsfrom sliding back down.

Another type of repositioning device is onethat attaches to a hospital bed. A sheet is fed froma roller at the foot of a bed to a roller at the headof a bed. A caregiver turns a handle manually,

which activates the roller, and moves the patientto the head of the bed. The handle can bedetached from the head end and reattached to

the foot end to facilitate repositioning in theopposite direction if needed (Fig. 4).

The benefit of using repositioning aids can be

seen in a study by Collins and colleagues [4];friction-reducing sheets were used to repositionpatients in bed. There is evidence showing that

use of such devices can reduce musculoskeletal

injuries associated with patient handling tasks.The purpose of this study was to test the effectof a best practices program, which involved use

of patient handling equipment, on staff injuries,workers’ compensation costs, and lost workdayinjuries. The study found that a best practices

musculoskeletal injury prevention program con-sisting of mechanical lifts and repositioning aids,a zero lift policy, and employee training on lift

usage significantly reduced resident handlinginjury incidence, workers’ compensation costs,and lost workday injuries after the intervention.

For further information on repositioning

devices, refer to the Web site, http://www.visn8.med.va.gov/patientsafetycenter/resguide/TechnologyResourceGuide.doc#RepositioningDevices [5].

Fig. 3. Manual repositioning of a patient up in bed. (Courtesy of VISN 8 Patient Safety Center of Inquiry, Tampa FL;

with permission.)

Fig. 4. Repositioning device on bed. (Courtesy of EZ

Way, Inc., Clarinda, IA; with permission.)

180 BAPTISTE

http://www.visn8.med.va.gov/patientsafetycenter/resguide/TechnologyResourceGuide.doc#RepositioningDevices



This link describes supine repositioning devices andthose used for repositioning patients in sitting.

Repositioning patients on the side

Technological solutions continue to improveand expand as health care manufacturers realizethat the manual effort of caregivers needs to be

eliminated. This realization is evident in a reposi-tioning product, which can replace or work witha bed sheet as it is placed under a patient and can

remain there when not in use. This sheet can beused to turn or move patients up in bed. Thesetwo tasks are accomplished by using an overheadceiling lift system and an appropriate spreader

bar. There are two versions available, one thataccommodates up to 440 lb and another forlarger, bariatric patients (up to 1100 lb). If the

latter sheet is used, it is essential that the lift usedhas the capacity to accommodate up to the sameweight as the sheet. Fig. 5 shows an example of

a repositioning sheet used for turning patients inbed.

Changing the type of lift, sling, and spreader

bar is another way to move patients up in bed oron their side. Fig. 6 shows a supine sling in

conjunction with a floor-based lift that is used tolift patients up off of a stretcher.

To accommodate turning patients to the side,the boom of the floor-based lift has to be high

enough to accomplish turning.Another mechanical device used to make this

task of repositioning in bed easier is the use of

a ceiling lift in conjunction with a supine sling. Byusing the mechanical lifts (floor based or ceilinglift), caregivers do not have to exert any effort

manually except to place a sling under a patient.Sling insertion and removal is a high-risk taskelement for caregivers and research is lacking in

this area. These forces affect the upper body joints(wrists, elbows, and shoulders) and neck, inaddition to caregivers using an awkward posture,which in turn, affects the low back negatively.

Mechanical equipment should be used if avail-able, as it can assist greatly in reducing injuries forcaregivers during the various repositioning tasks.

Use of such equipment also benefits patients,because there is no dragging or pulling of patientsmanually on a bed sheet to the head of a bed or

across to the side of a bed. As a result, frictionalforces are eliminated, which protects the skinintegrity of patients.

McGill and Kavcic [6], in 2006, looked at theeffect of a friction-reducing assistive device onlow back mechanics. They quantified and com-pared three lateral transfer devices by measuring

the coefficient of friction, muscle activity of care-givers, and spinal loading during the lateral trans-fer. Results showed that during a lateral transfer

of a mannequin (72.7 kg) on a cotton sheet, thecoefficient of friction was 0.45. In comparison tothis standard condition, the three assistive devices

reduced the coefficient of friction to 0.18 to 0.21.Consequently, there is evidence to prove the ben-efit of using FRDs for caregivers and for patients.

Frictional force studies are lacking and there

needs to be more research regarding the effect oftransferring patients manually across surfaces andthe direct impact on patients’ skin, especially

concerning pressure ulcers.

Bed-to-chair transfers

One transfer task common to critical care unitsis bed-to-chair transfers or vertical transfers.Moving patients who have been in bed for

a prolonged period of time from a lying position(bed) to a seated position in a chair can bea difficult task. This in part is because of the

Fig. 5. Repositioning sheet used for turning a patient.

(Courtesy of Liko; Franklin, MA; with permission.)


awkward posture used by caregivers and the

mass of the patients. This type of transfer can beunpredictable, as the functional strength andmobility of such patients is poor, as they usually

are weak from inactivity. There are severalsolutions, however, to making this transitioneasier. The ideal way is to eliminate the manual

work of this task by using a mechanical liftsystem.

The choice of lift used is dependent on

patients’ level of assistance, weight-bearing capa-bility, physical condition, level of cooperation,and comprehension.

For bed-to-chair transfers, three solutions are

offered: floor-based lifts, ceiling lifts, and sit-to-stand lifts.

Floor-based lifts

Floor-based lifts have served well in reducing

caregiver effort in transferring patients from bedto chair or vice versa. The original floor-based liftworked by activating a pump manually, which

raised and lowered a boom arm while the legs ofthe lift also were operated manually by a lever.These lifts have been replaced by electric floor-

based lifts, which operate by pressing a button

that elevates and lowers the boom and opens andcloses the legs. To transfer patients from a bed toa chair, caregivers apply a sling (appropriate for

the patients) while patients are lying in bed.Patients are log rolled and the sling is insertedunder them, the legs on the lift are opened for

stability, and the boom then lowered enough toattach the sling to the spreader bar. Patients areraised off the bed by pressing a button on the

control panel. The lift then is moved over a chairand patients then lowered. Once patients arepositioned properly in the chair, the sling then isremoved.

Floor-based lifts are useful in critical care forbed-to-chair transfers, picking patients up fromfloor level, and lifting a limb for a sustained

period of time when performing wound dressingchanges.

Ceiling lifts

The second solution to bed-to-chair transfers is

the use of a ceiling lift (discussed previously). Thesteps for transferring patients via a ceiling lift aresimilar to using a floor-based lift, except that the

Fig. 6. Supine sling with floor-based lift. (Courtesy of Arjo; Roselle, IN; with permission)

182 BAPTISTE

ceiling lift is the existing infrastructure hangingabove on the rail. A sling is inserted undera patient, the lift is lowered, and the sling isattached. Then, a caregiver presses a button and

the patient is raised, guided on the track, and thenpositioned over the chair. The caregiver thenlowers the patient into the chair and the sling is

removed.

Sit-to-stand lifts

Sit-to-stand lifts are useful provided patientsmeet the criteria for using such a lift. Patients

should be able to weight bear partially, under-stand and follow simple commands, and holdonto the handles of a lift. This type of lift can be

used in rehabilitation when teaching someonehow to transfer from sitting to standing. Usinga sit-to-stand lift requires some leg and arm

strength from patients but support still is providedin the event of patients losing their balance. A sit-to-stand lift works by attaching a sling aroundpatients’ back and waist, then placing their legs on

a stand while they are sitting on the edge of thechair or bed. A caregiver then presses a button toraise a patient up off the chair or bed and into

a standing position. The patient is moved to thedestination surface and lowered by pressing a but-ton on the lift, and the sling then is removed from

the patient. Sling insertion and removal remaina challenge and efforts are being made to designslings that can be left under patients withoutcompromising patients’ sling integrity or increas-

ing their risk for developing or aggravatingexisting pressure ulcers.

Pericare of bariatric patients

Pericare of obese patients presents a challenge

because of the amount and weight of redundanttissue, weight, and size of patients’ legs and thedifficult access of perineal area. Currently,pericare is performed manually after bowel move-

ments and urination and for patients who haveindwelling catheters. Pericare can be accom-plished without turning patients by spreading

apart the legs of patients for access to the genitalarea. This task requires caregivers to lean overa bed for a sustained period of time while moving

redundant tissue to gain access and provide theability to clean the genitals. This task can bemade easier with use of an abdominal binder,

limb straps, and an expanded capacity ceiling liftsystem.

Abdominal binders can be used to hold someof the redundant tissue from the leg together more

compactly, thus providing easier access to thegenitals. Limb straps can be attached to the ceilinglift, to lift and separate the legs and hold them in

a sustained position while a caregiver cleans thegenitals. This solution eliminates lifting and hold-ing of a heavy leg for a long period of time and

allows caregivers to concentrate on cleaningpatients more effectively and comfortably.

Another approach to this problem is using

a floor-based lift. The advantage of using a ceilinglift is that there is no storage needed for this lift, asit is stored on the track overhead. The process ofusing a floor-based lift is the same as discussed

previously except that the limb straps are con-nected to the floor-based lift versus the ceiling lift.

Toileting in bed

In critical care units, patients present a wide

array of dependency levels. If patients need totoilet and are able to lift their buttocks, caregiversslide a bedpan under patients’ buttocks. If

patients are unable to turn independently, care-givers turn patients to the side manually, thenplace a bedpan in position and turn patients backonto a bedpan with knees slightly bent. Once

toileting is complete, caregivers have to turnpatients on their side to clean them while ensuringbedpans do not spill. After toileting is completed,

patients are turned back to the supine position.The physical effort needed to turn dependentpatients manually makes this a high-risk task.

The manual turning involved in this task can beeliminated by using an overhead ceiling lift withturning straps. Straps are positioned under the

heaviest parts of a patient, typically the torso andupper legs. The straps used should be wide enoughso they do not cut into patients’ skin. Once inplace, these straps are attached to a ceiling lift via

a spreader bar. The ceiling lift is used to raise andlower patients in preparation for toileting. Oncepatients finish their bowel movement, the lift is

raised and bedpan removed. Caregivers shouldnot have to move the straps to access the genitalsto clean patients because of properly placing the

straps of the correct width beforehand. Straps areavailable in various widths and can accommodateup to 1000 lb. It is important that patients’ weight


does not exceed the capability and weight limit ofthe straps or the ceiling lift.

Sustained limb holding for dressing wounds

The sixth high-risk task discussed in this articleis holding a heavy limb for a sustained period of

time while dressing a wound. This task is consid-ered a high-risk task for many reasons. Some ofthese include the weight of the limb, position of

a caregiver’s hand while gripping that limb, andthe posture of caregivers during this task.Typically, caregivers bend at the waist, leaningover the bed, extending one arm to hold the limb,

and using the other hand to clean the wound andapply a dressing.

A preferable, alternate solution to assist care-

givers in sustained limb holding for dressingwounds is the use of limb straps with a ceilinglift system or floor-based lift (Fig. 7).

As shown in Fig. 7, a special sling used forholding limbs is placed under a patient’s leg andattached to a lift to suspend the leg in place.

This task can be accomplished with the use ofa floor-based lift or a ceiling lift. The benefit ofusing these special straps is that they are availablein different widths, and proper placement of the

straps on the affected limb can allow easier accessto dress a wound. The advantage of using eitherlift (ceiling or floor based) is that the weight of

the limb is held by the lift, which allows caregiversto use both hands, if needed, to take care ofpatients.

To illustrate the physical demands placed onsomeone holding a leg for a period of time, a study

was conducted simulating this task. This researchstudy was conducted in the biomechanics labora-tory at the VISN 8 Patient Safety Center of

Inquiry (James A. Haley Veterans’ Hospital) andevaluated the physical demands of patient transfertasks performed by nurses in a controlled labora-tory setting. Fifty-three tasks were analyzed and

broken down into subtasks to quantify the peakforce required to perform each subtask. One ofthese tasks was limb holding for a sustained

period of time. A 200-lb mannequin was used tosimulate a dependent patient. The anthropometryand weight of the mannequin’s limbs were compa-

rable to that of a human being. Results indicatedthat the amount of force required to lift and holdone leg is comparable to the force needed to pulla draw sheet through from under a patient (200

lb) who is lying on the side. In addition, use ofa ceiling lift device to raise and let down the lowerleg requires significantly less force than the force

needed to perform this task manually. These find-ings indicate the benefit of using a floor-based liftor ceiling lift to suspend a limb and avoid manual

limb holding. Use of such technologies shouldresult in less strain on the upper body joints, im-proved posture in the low back, and reduced

risk for injury to caregivers.

Patient transport

The last high-risk task in critical care does notinvolve handling patients directly but is related to

patient movement. Transport of patients hasbeen and continues to be a difficult task physi-cally because of the push forces required (weight

of transport vehicles plus patients), the workingcondition (steering, castors, and brakes) trans-port devices (beds or stretchers), and confined

spaces in transport routes. The excessive load inaddition to the frequency of the task and postureused by transporters all contribute to an in-

creased risk for injury. To alleviate the physicaldemands of this task, many facilities have startedusing powered transport technologies. Thesedevices are available commercially in different

types.The first type is a stand-alone, detachable, or

independent device that attaches to a bed, linen

cart, or trolley (Fig. 8). Once the unit is attachedsecurely to a bed or object to be powered, anoperator is able to move and steer the device.

A bed mover is powered by batteries andenables the device to move forward or backward.These devices have a wide range of weight

Fig. 7. Limb sling for dressing wounds. (Courtesy of

Liko, Franklin, MA; with permission.)

184 BAPTISTE

capacities (up to 2500 lb). The disadvantage ofusing such a device is that it may not fit into theelevator when attached to a bed, so careful

measurements and planning should be takenbefore purchase. The advantage of using a detach-able, powered device, however, is that it can be

attached to many items, such as linen carts,trolleys, or beds. The cost of these detachableunits is cheaper than the alternate type of powered

technology that is integrated into beds.The second type of transport technology is one

that is incorporated into beds and powers them byunplugging a bed, releasing the brakes, and

pressing two buttons. Use of powered transportdevices is beneficial especially when movingheavier patients, because there is minimal force

exerted to initiate movement of a bed.Another type of patient transport device is

a powered wheelchair mover. This device (Fig. 9)

is designed to be attached to a standard manualwheelchair via a securing hitch. Once connected,a caregiver is able to operate and steer the deviceby toggling a lever. This powered wheelchair

mover has two variable speeds and an emergencystop button.

Use of these powered transport devices is

becoming popular in health care facilities, asthey reduce the risk for caregiver injury. Todate, there is no literature found regarding the

use and benefit of patient transport technologies.Currently, a research team at the VISN 8 PatientSafety Center of Inquiry (James A. Haley Vet-

erans’ Hospital) is conducting a laboratory study

to quantify the push forces required when usingoccupied beds and wheelchairs manually on differ-ent surfaces. This evaluation is designed to com-

pare the biomechanical factors required toperform transport tasks manually versus usingpowered devices (described previously). Patient

Fig. 8. Powered bed mover. (Courtesy of Ergotech, Danbury, CT; with permission)

Fig. 9. Wheelchair mover. (Courtesy of Dane Industries,

Minneapolis, MN; with permission.)


transport can be made safer for caregiversthrough the proper use of powered patient trans-port technologies.

Summary

There are several high-risk nursing tasks in the

critical care environment discussed in this article.These tasks include lateral transfers, repositioningpatients up or side to side in bed, bed-to-chair

or -wheelchair transfers, pericare of bariatricpatients, toileting in bed, sustained limb holdingfor dressing wounds, and patient transport. Thereare, however, technological solutions available to

perform these tasks more safely. Evidence-basedresearch currently is in development to prove thatpatient handling technology works for suggested

high-risk tasks. Although there are few studiesthat currently provide objective data regardinguse of technology in reducing caregiver injuries,

the aforementioned patient handling equipment ispromising. There are reports of improved jobsatisfaction and employee morale among health

care staff when using these technologies. Usingthese technologies properly is the only true way torealize the benefits these devices provide. Techno-logical solutions are available and should be

implemented in critical care to promote the safetyof all involved in patient care.

References

[1] Bos E, Krol B, van der Star L, et al. Risk factors and

musculoskeletal complaints in on-specialized nurses,

IC nurses, operation room nurses and x-ray technol-

ogists. Int Arch Occup Environ Health 2007;80(3):

198–206 [E-published ahead of print, 2006 June 24].

[2] Baptiste A, Boda S, NelsonA, et al. Friction-reducing

devices for lateral patient transfers: a clinical evalua-

tion. AAOHN J 2006;54(4):173–80.

[3] Lloyd J, Baptiste A. Friction-reducing devices for lat-

eral patient transfers-a biomechanical evaluation.

AAOHN J 2006;54(4):113–9.

[4] Collins JW,Wolf L, Bell J, et al. An evaluation of best

practices musculoskeletal injury prevention program

in nursing homes. Inj Prev 2004;10:206–11.

[5] Department of Veterans Affairs (VHA). Technology

resource guide. Accessed August 31, 2006. Available

at: http://www.visn8.med.va.gov/patientsafetycenter/

resguide/TechnologyResourceGuide.doc#Reposition

ingDevices.

[6] McGill SM, Kavcic NS. Transfer of the horizontal

patient: the effect of a friction reducing assistive de-

vice on low back mechanics. Ergonomics 2006;48(8):

915–29.

186 BAPTISTE




Justification for a Minimal Lift Programin Critical Care

Arun Garg, PhD, CPEa,*, Suzanna Milholland, MS, OTRb,Gwen Deckow-Schaefer, MS, OTRb, Jay M. Kapellusch, MSbaCenter for Ergonomics Industrial & Manufacturing Engineering University of Wisconsin-Milwaukee,

P.O. Box 784, Milwaukee, WI 53211, USAbIndustrial & Manufacturing Engineering University of Wisconsin-Milwaukee,

P.O. Box 784, Milwaukee, WI 53211, USA

Back and shoulder injuries are a major and

serious problem for nursing personnel in all areasof patient care, including hospitals, long-termcare, and home health care. According to the

Bureau of Labor and Statistics [1,2] nursing assis-tants led all other occupations in overexertion in-juries in the United States in 1993. The rate of

overexertion injuries among nursing assistantswas four times higher than the average rate forall other private industries. This overexertionrate continued to be four times higher through

1995. In 1995, the Bureau of Labor and Statistics[3], reported home health care workers’ injuryrates that were double, and hospital health care

workers’ injury rates were nearly double that ofinjury rates in private industry. In 2000, the Bu-reau of Labor and Statistics [4] reported that the

injury incidence rate for nursing personnel wasthe second highest in the United States for nonfa-tal occupational injuries. Furthermore, these in-

juries were severe enough to require medicaltreatment or produce lost workdays. With thesehigh injury rates come significant costs. Directcosts including medical treatment, medications,

therapies or surgeries have been estimated torange between $9,000 and $30,000 per injury.One example can be cited by Dunn and De Peralta

[5]. They documented that 17 injuries occurred ona spinal cord unit in 2002 resulting in $162,815.53of direct costs. Meanwhile, the indirect costs

(ie, replacement personnel, training, insurance

premiums) of these injuries are estimated to befour to ten times greater still [5]. These injurieswere all attributed to patient-handling tasks. The

Bureau of Labor and Statistics [4,6], in 2001stated that among full-time hospital workers, in-juries were 8.8 per 100 full-time hours and 13.5

per 100 full-time hours among nursing homeworkers. This compared with all other industrywork injuries and illnesses including rates of 4.0per 100 full-time workers in mining, 7.9 per 100

full-time workers in construction, and 8.1 per100 full-time workers in manufacturing. Nursingaides and orderlies were surpassed only by truck

drivers and nonconstruction laborers when rank-ing lost day injuries [1]. These nursing personnelinjuries do not appear to be isolated to the United

States. The Health and Safety Executive [7] inLondon cited that approximately 70% of work-place injuries involved health care workers associ-

ated with patient-handling tasks [6]. Anotherstudy cited that nurses in Israel ranked first inlow back injury rates compared with most otheroccupations, including light and heavy industry

workers, farmers, bus drivers, and others [7]. InSweden, the National Board of OccupationalSafety and Health reported the highest frequency

of back injuries was among bath attendants andnursing aides [8]. Injuries among nurses arelargely unreported. French and colleagues [9]

sent a questionnaire to 47 nursing personnel inan acute care hospital. They reported that80.9% had back pain at some time during their


E-mail address: [email protected] (A. Garg).





career; however, more than 90% never reportedany back pain to their employer. In 1995 Vasilia-dou and colleagues [10] conducted the first ever

study on prevalence of back pain among Greeknursing personnel. They administered a question-naire to 407 nursing personnel in a tertiary carefacility in Athens. Of the participants, 63% re-

ported work-related low back pain within the pre-vious 2 weeks and 67% within the previous6 months. Prevalence was higher in conjunction

with heavier physical duties. Although it is diffi-cult to directly compare these studies in variouscountries, the statement can be made that all of

the nursing positions were classified as high-riskoccupations for low back injury.

Causes

Although the exact mechanism of injury is notclearly defined, many of the injuries to nursingpersonnel have been attributed to patient-

handling tasks. Overall, many studies cite patientlifting and transferring as the most common causeof back injuries [9–21]. Owen [22] stated that as

many as 89% of low back injury reports filed bynurses in a hospital setting indicated that a pa-tient-handling task was the precipitator of their

injury. Kumar [23] suggests that cumulative loadexposure predisposes the spine to pain or injury.Cumulative spinal loading can be defined in threeways: (1) accumulated demands on the spine dur-

ing a single patient-handling task, (2) additive ef-fects of lifting loads over a workday, or (3)accumulation of loads throughout the lifetime.

Others have added the risk factors of frequentbending, twisting, carrying, and pushing of bedsas contributors to musculoskeletal complaints

[24–26]. Still others have added that forward flex-ion, lateral bending, twisting of the spine, or an in-creased horizontal distance of the load from the

body during lifting further increases the chancesof low back injury [27–29]. A study performedin Hong Kong by French and colleagues [9] notonly cited transferring patients and lifting patients

as two major causes of back pain but also in-cluded the static posture of stooping during vari-ous patient care tasks as contributing to pain.

Others have cited bad work technique or lack oftraining as contributors [30,31]. Hignett and Ri-chardson [32] add that unpredictable patient fac-

tors such as shape and size, disability, andcapacity for compliance may interfere with theuse of safe handling techniques. Many also state

that any previous history of back pain has shownto be a risk for future episodes of back pain[33,34]. It has been noted that nurses perceive

that their low back symptoms were caused by orexacerbated by work [35].

Biomechanical evidence

Garg and colleagues [26,36,37] conducted lab-oratory studies to evaluate five different manualtechniques and three different mechanical hoists

for transferring patients to and from bed to wheel-chair, wheelchair to shower chair, and wheelchairto toilet. Static biomechanical evaluation showed

that estimated compressive forces ranged from1973 N to in excess of 5000 N and shear forcesranged from 442 N to more than 900 N. Thesestudies also reported that less than 40% of female

workers have sufficient muscle strength to per-form manual lifting and transferring tasks evenwhen using two nursing aides. The studies found

that estimated compressive forces exceeded theNational Institute Of Occupational Safety AndHealth (NIOSH) recommended acceptable limit

of 3400 N. The studies also found that use ofa walking belt in combination with a pulling tech-nique, rather than lifting, produced less biome-

chanical and perceived stresses on the nursingpersonnel, and the patients found it to be morecomfortable and secure than the manual lifting.Further, two of the older hoists were perceived

by the nurses to be more stressful than the useof walking belts with pulling technique. Also, pa-tients found the older hoists to be less comfortable

and less secure than the walking belt.Marras and colleagues [38] estimated compres-

sive and sheer forces on the low back using an

electromyograph-assisted biomechanical modelfor transferring a 50-kg, non-weight–bearing co-operative woman. They also studied the probabil-

ity of membership in the high-risk low-back group(LBD) by using a lumbar motion monitor. Thepatient transfer tasks studied were transfers be-tween bed and wheelchair and between toilet chair

and hospital chair. The estimated compressiveforces ranged from 4463 N to 6408 N, anterior-posterior shear force ranged from 913 N to 1116

N, and LBD risk ranged from 76.9% 93.8%, de-pending on patient transfer technique used andnumber of nursing personnel involved in the

transfer. The study concluded that patient han-dling is an extremely hazardous job. The task ofpatient handling has substantial risk of causing

188 GARG et al

a low back injury whether one or two nursing per-sonnel are used for patient handling.

Winkelmolen and colleagues [39] studied repo-sitioning patients in bed (moving upwards toward

the head of the bed). Passive patients between55 kg and 75 kg were used to study five differenttechniques (Australian lift, Orthodox lift, barrow

lift, through-arm lift, and under-arm lift). Usinga two-dimensional, static biomechanical model,the estimated compressive force on the low back

ranged from 3315 N to 4003 N for the 55-kg pa-tient and 3869 N to 4487 N for the 75-kg patient.The authors concluded that for almost all trans-

fers, the compressive forces exceeded the NIOSHacceptable limit of 3400 N.

Skotte and colleagues [40] studied low backloading for nine patient-handling tasks including

turning, lifting and repositioning a male strokepatient using a dynamic three-dimensional Biome-chanical model. The main compressive force

ranged from 1618 N to 4433 N, peak anterior-pos-terior shear force ranged from 106 N to 661 N,and ratings of perceived exertion on the Borg

CR-10 scale ranged from 0 to 8. The study con-cluded that the peak compression during twotasks involving lifting the patient was significantly

higher than all other tasks. The four tasks involv-ing repositioning the patient in bed had lowerpeak compression than the two tasks involvinglifting the patient. The task involving turning the

patient in the bed had the lowest compressiveforce. The study further concluded that, basedon peak compressive force or peak moment on

the low back, the patient-handling tasks can beclassified into three groups: (1) lifting tasks, (2)repositioning tasks, and (3) turning tasks.

Ulin and colleagues [41] studied six differentpatient transfer methods, three manual and threemechanical, to transfer two totally dependent pa-tients weighing 56 kg and 95 kg, respectively. The

study concluded that peak compressive forceswere greater than 10,000 N for manual transfermethods, exceeding the NIOSH maximum limit

of 6400 N. When mechanical lifts were used, theback compressive forces ranged from 437 N to719 N, well below the NIOSH recommended limit

of 3400 N. The study reinforced the need to usea mechanical lifting device when transferringtotally dependent patients.

A preliminary study by Lloyd and Baptiste[42], working to develop new patient transfer tech-nologies, reported that initial push and pull forcesrequired to manually transport an unoccupied

hospital bed over a smooth flat surface were

146 N and 134 N, respectively, whereas an occu-pied bed required push and pull forces of 189 Nand 196 N. The forces encountered over a thresh-old, such as the opening of an elevator, for an

empty bed were 151 N and for an occupied bedwere 198 N. Hospital beds found in medical-surgical units are typically heavier and require

more transport. Therefore, the investigators statethat forces required to transport these types ofbeds come close to or exceed strength capabilities

of most female workers.Zhuang and colleagues [43] conducted a biome-

chanical evaluation of nine battery-powered lifts,

a sliding board, a walking belt, and a manualmethod for transferring nursing home patientsfrom a bed to a chair. The study concluded thattransfer method and patient weight affect a nurs-

ing assistant’s low back loading. The use of me-chanical lifts (portable or overhead devices)reduced low back compressive forces by approxi-

mately two thirds compared with the baselinemanual lift method.

Daynard and colleagues [44] reported that use

of new assistive equipment resulted in higher com-pliance with interventions. This was particularlytrue when the perceived risk of injury during pa-

tient handling increased because of an increasein patient size or a reduction in patient physicalcapability. The study found that use of new assis-tive handling equipment reduced spinal loading in

several tasks.Several other studies have confirmed that

patient-handling tasks result in high compressive

forces on the low back [43,45–51]. Consideringthese and other biomechanical studies collectively,it appears that patient-handling tasks requiring

a vertical lift produce the highest compressiveforces on the low back, followed by patient-handling tasks that require repositioning patientsin a bed or lateral transfers; whereas, turning pa-

tients in bed produces the least amount of com-pressive force on the low back.

Nursing personnel perception

Insufficient staffing of nursing units can con-tribute to work overload, which, in several stud-

ies, has been reported to contribute to feelings ofstress among nursing personnel [52,53]. Cato andcolleagues [52] reported that 73% of nurses with

low back problems reported feeling overly stressedat work compared with those nurses without lowback problems. Ore [54] reported that 35% of

189JUSTIFICATION FOR A MINIMAL LIFT PROGRAM

nurses responding to a questionnaire consideredchanging jobs related to their idea that low staff-ing levels would contribute to a higher risk of in-

jury caused by patient-handling tasks. Along theselines, a study by Yassi and colleagues [51] foundthat overly stressed staff perceived the inabilityto obtain and use correct assistive lifting equip-

ment because of time constraints. Yet anotherstudy by Yassi and colleagues [19] found thatnursing personnel with low back injuries perceived

that the cause of their injuries was inadequatetraining in patient-handling techniques. Job satis-faction is another factor that may predict low

back health according to a prospective study byReady and colleagues [55].

Perceived stresses

Many studies have found that nurses ratedperceived stresses on the low back and shoulder ashigh during patient lifting and repositioning tasks

[56,57]. Winkelmolen and colleagues [39] studiedperceived stresses for repositioning patientsweighing 55 kg and 75 kg in bed. The perceived

stresses on the Borg scale (rating scale of 6-20)ranged from 13 (somewhat hard) to 19 (extremelyhard). The perceived comfort ratings ranged from

3.3 to 4.3 on a six-point scale (rating scale of 0-5).Studies addressing nurses’ perceived stresses werealso conducted by Owen and colleagues [57,58]and Garg and Owen [56]. In all studies, nursing

personnel using assistive devices reported de-creases in perceived physical exertion to the shoul-der and low back during performance of all

patient-handling tasks. Yet another study byGarg and colleagues [36] showed that perceivedstress ratings for the whole body, including shoul-

der and upper and lower back, were lower for pa-tient-handling techniques based on pullingmethods rather than lifting methods. Owen and

Fragala [59] found similar results of decreases inperceived exertion during a specific transfer taskthat involved a pulling rather than lifting motion.

Yassi and colleagues [51] conducted a study in-

volving nursing personnel on medical, surgical,and rehabilitation units. Each unit was assignedto one arm of the study. One unit served as the

control group and received instruction in bodymechanics and lifting only on request. The ‘‘safelifting’’ unit was supplied with transfer belts in

each room and one mechanical lift for the unit.The ‘‘no strenuous lifting’’ program unit receivednew assistive equipment for patient-handling

tasks. The equipment was supplied based on theneeds of the patient population on the unit.Both the ‘‘safe lifting’’ and ‘‘no strenuous lifting’’

units were also given education on back care andhandling techniques in addition to training in theuse of assistive devices. Perceptions improved inboth the ‘‘safe lifting’’ and ‘‘no strenuous lifting’’

units, including perceptions of work fatigue, backand shoulder pain, safety, and frequency and in-tensity of physical discomfort. However, the nurs-

ing personnel on the ‘‘no strenuous lifting’’ unitshowed greater improvement.

Education and training

Historically the approach to decreasing lowback injuries in nursing personnel has been toprovide education and training in body mechanics

and lifting or transferring techniques [33,51,60,61]. A few studies have shown a decrease incompressive force on the low back with the proper

use of training and correct body mechanics[44,62]. However, manual patient-handling tasksare intrinsically so hazardous that no amount of

training alone can make the job safe. Also thecompliance with use of proper body mechanicsand techniques is lower when relying on education

and training alone [44,63]. Pheasant and Stubbs[64] showed that there was an initial reduction inback injury occurrence immediately after propertraining in patient-handling techniques; however,

this effect only lasted 18 months before the injuryrate climbed back to the original level.

There has been evidence to suggest that edu-

cation and training alone, without work modifi-cations, does not decrease the number ofoccupational low back injuries [33,56,65–72]. La-

gerstrom and Hagberg [60] conducted an educa-tion program for nursing personnel includingtraining on transfer technique, physical fitness

and exercise, and stress management techniquesover a 3-year period in a Swedish hospital. Al-though most participants expected that participa-tion in this program would lead to a decrease in

injuries, the results did not show any decrease inneck, shoulder, or back symptoms. Videman andcolleagues [33] compared nurses that did and did

not participate in an extensive training programand their incidence of low back pain. Similarly,the investigators found no significant differences

in occurrence of low back injury between groups.In summary, ‘‘although instruction on manuallifting and transferring patients is widely believed

190 GARG et al

to have prophylactic value, there is no scientificevidence that it alone is effective in reducing thefrequency or severity of back pain, especially innursing practice’’ [56].

Intervention programs

The focus of education and training programs

has been to change the way nursing personnelperform the task instead of changing the task itself[57]. As previously discussed, although this ap-

proach has not been able to show a reduction of oc-currence in lowback injury, an ergonomic approachto patient handling has shown success [58,61,

73–75]. In an ergonomic approach to patient han-dling the physical demands of the job are assessedand then changed to decrease the risk factors thatmay contribute to low back or shoulder injuries.

The changes to decrease the risk of injury are metby developing alternate methods of performingtasks todecrease stresses to thebodyand thenapply-

ing them to the job through education and training.Owen and colleagues [57] conducted a 5-year

follow-up study on nursing personnel after train-

ing and incorporation of several assistive liftingdevices in one of two hospitals. The second hospi-tal served as a control and the personnel were

given only a 1-hour in-service on proper liftingtechniques. By introducing the assistive devices,in effect, the physical job demands were changed.This study also showed a postintervention de-

crease of back injuries of 40%. This study con-firmed results found earlier in a study by Gargand Owen [56] conducted in a long-term care facil-

ity. Compressive force on the low back andstrength requirements were significantly decreasedwith the introduction of lifting devices, making

the job of patient-handling tasks safe for 83% offemale workers versus only 41% before interven-tion. Furthermore, lost work days also decreased

significantly showing a decrease in severity ofinjury.

Silverstein [61] stated that, with a systematicand thorough approach to initiating zero lift pro-

grams in nursing homes, decreases in injuriescould be seen for nursing personnel and patientsalike. This is with the caveat of engaging manage-

ment commitment through the entire process.Klebenow and colleagues [74] also showed a de-crease in number and severity of injuries with

the institution of a minimal lift program in a hos-pital setting and long-term care facility. The au-thors also reported positive by-products of an

improved safety image to the public, an increasein productivity, and an increase in recruitmentand retention of nursing personnel.

Collins [76] reported on a long-term study in-

stituting a minimal lift program in six long-termcare facilities. Results showed that low back in-juries caused by patient lifting and transferring

decreased steadily after implementation of theprogram from 47 injuries immediately after inter-vention to 16 injuries after 5 years of the program.

Severity of injury was also reduced as the lostwork days decreased from 488 before interventionto 229 after intervention. Injuries caused by trans-

fers in and out of bed, and during toileting andpicking patients off the floor were reduced by50%. Injuries caused by turning or rolling resi-dents in bed were also reduced by 50%. A 35%

reduction was seen in injuries attributed torepositioning patients in bed. Worker’s Compen-sation costs were decreased by approximately

50% over the same follow-up period.Evanoff and colleagues [77] introduced me-

chanical lifts in acute care hospitals and long-

term care facilities. After training in proper useof the assistive devices, the follow-up period lastedapproximately 3 years. Within that time period,

the results showed a decrease in musculoskeletalinjuries and lost workdays caused by injury. In-jury reduction was greater in long-term care facil-ities compared with acute care hospitals. Also,

injury reduction was greater on nursing unitsthat reported more consistent use of the assistivelifting equipment. Another implementation of

a ‘‘no lifting’’ standard in England reiterated theprevious study findings in that there was reductionof injuries and lost work days after introduction

of assistive devices on the nursing wards [78].Others have suggested that the development of

a lift team responsible for all patient handlingwith proper mechanical assists reduces low back

injuries [72,79,80]. Donaldson [80] conducteda study in acute, subacute, and extended care unitsof a 296-bed hospital. Acute care consisted of

telemetry, medical-surgical, intensive care, andoncology units. Low back injuries and Workers’Compensation costs for nursing personnel showed

significant decreases over the 6.5 years after the in-stitution of the lift team. Similarly, Charney [79]found that during a 1-year follow-up to the lift

team program, although the team performed3,188 lifts, there was only one injury reportedwith no lost time for the team members. Twomodified duty days were reported for that specific

injury. This substantially decreased injury costs.


Critical care

Although there has been an abundance ofresearch in the area of physical stresses from

patient handling in hospitals and long-term carefacilities, there is virtually no published literaturedealing with stresses to nursing personnel incritical care settings. Based on informal discus-

sions with nurses and other operating roompersonnel, several observations were made. Theseare discussed below.

Patients require critical care in operatingrooms for preoperative preparation and duringperioperative and postoperative care. They re-

quire critical care in emergency rooms, intensivecare areas, cardiac care areas, and on many otherhospital units. Lifting and repositioning patientsto and from hospital bed, to and from an

operating room bed, on and off stretchers, andin and out of cardiac chairs, are frequent occur-rences. Patients are transferred from stretchers,

transport carts, and beds to operating room tablesand back to stretchers, transport carts, and beds,both before and after surgery. Patients may need

to be transported for medical imaging (eg, com-puted tomography scan, magnetic resonance im-aging, ultrasound scan, x-rays) or any number of

other diagnostic procedures. Nursing personnelface a serious risk of musculoskeletal injuries, inparticular back and shoulder injuries, when han-dling patients in these environments. Some of

these patients are completely dependent becauseof general anesthesia, stroke, or sedation. Theymay be unconscious or comatose and cannot help

during transfer tasks. Nursing personnel, alongwith perioperative team members, are often re-quired to manually lift patients or patients’

extremities.As stated earlier, manual lifting of a normal

patient is considered hazardous to health careworkers. Lifting and handling of patients requir-

ing critical care is an even greater hazard forseveral reasons: (1) these patients often are totallydependent, and their entire body weight must be

lifted; (2) depending on the patient’s injury andillness and type of surgery performed, it may benecessary to maintain a patient in a dependent

position (eg, hips cannot be moved because ofsurgery); and (3) there may be equipment attachedto the patient such as oxygen, intravenous line,

respirator, catheters, or casts. Some of thesepatients may be obese or bariatric, weighing inexcess of 400 to 500 pounds. For example,a hospital in Milwaukee, Wisconsin is purchasing

specialized beds to care for patients in excess of700 pounds. In addition to lifting the entirepatient weight, certain surgical procedures require

lifting or supporting a limb of the patient fora prolonged period. Depending on the weight ofthe patient and the body posture used, liftinga patient limb could be hazardous to nursing

personnel, producing large compressive forces onthe spine along with the possibility of producinglarge torques on the shoulders. Some limbs of

obese or bariatric patients’ may weigh in excess of50 pounds alone. The Revised NIOSH LiftingEquation [81] recommends a maximum weight of

51 pounds under ideal lifting conditions fora smooth, continuous lift. If a nurse has to reachhorizontally about 20 inches away from the anklesduring lifting, then the recommended weight

limit significantly decreases to approximately25 pounds. Certainly, when reaching for and lift-ing a limb of an obese or bariatric patient, it is

quite likely that the nursing personnel could ex-ceed the recommended weight limit from NIOSH.Further, the recommended weight limit does not

account for holding a limb of the patient for a pro-longed period, which often may be the case duringa surgical or diagnostic procedure. It is well estab-

lished that a person’s ability to hold or supporta weight decreases nonlinearly with an increasein holding time. For example, Garg and col-leagues [82] have shown that endurance time for

holding a weight of 10 pounds or less with onehand is less than 60 seconds. They also showeda significant accumulation of fatigue in the shoul-

der girdle during such a task.A few studies have recognized the high risk

associated with patient-handling tasks in preop-

erative patient-handling tasks. For example Owen[83] identified several high-risk perioperativetasks. Some of these included transferring patientson or off operating room beds, repositioning pa-

tients in operating room beds, lifting and holdingpatients’ extremities, and holding retractors forextended periods. Wicker [84], in the United

Kingdom, stated certain unique aspects of high-risk patient-handling tasks associated with preop-erative limb preparation, supporting limbs during

surgical procedures, and patient handling duringpostoperative recovery. Wicker stated that nurs-ing personnel have to raise a limb to prepare it

for surgery. The nursing personnel may have tohold a limb manually during the entire timeneeded for skin preparation. Wicker also raisedconcerns regarding fatigue and pain from static

posture during surgical procedures. In addition

192 GARG et al

to patient handling, there is also concern regard-ing pushing and pulling of heavy equipmentsuch as operating room tables, imaging machines,microscopes, beds, or instrument trays. Some of

the patient-handling tasks may require lateraltransfer of a patient lying in a supine or prone po-sition from stretcher to operating room bed and

vice versa. These tasks may require moving thepatient from a prone position to a supine positionor supine position to prone position. Some perio-

perative tasks may require positioning and reposi-tioning a patient on the operating room bed ina supine position. Other perioperative tasks may

require positioning and repositioning the patientsin a semi-Fowler’s position, lithotony position, orlateral position. Other tasks may require liftingand holding of a patient’s leg, arm, or head.

Unlike patient handling in long-term carefacilities that mostly requires vertical transfers(eg, from bed to wheelchair), most patient han-

dling in critical care requires lateral transfers (eg,supine position to supine position from stretcherto operating room bed) and lifting and holding

of a patient’s limbs such as leg, arm, or head.Therefore, ergonomists need to pay more atten-tion to patient transferring devices that would be

able to perform lateral transfers such as fromoperating room bed to stretcher for patients inneed of critical care. Also, ergonomists need topay attention to devices that would be able to lift

and support patients’ limbs. Creativity and in-genuity are needed to develop devices that willturn patients from one position to another posi-

tion such as from supine to prone and vice versa.Regarding lateral transfers, many patient

transferring devices are commercially available.

Some of these devices have been used successfullyby long-term care facilities and hospitals. It isrecognized that when dealing with patients re-quiring critical care, some of these devices may

need to be modified. Regarding lifting and sup-porting a patient’s limb, currently both ceilinghoists and portable hoists are designed to lift the

entire patient. With appropriately designed slingsor with some creativity, these mechanical devicescan be used to lift and support patient’s limbs

during perioperative care. Regarding reposition-ing of a patient in an operating room bed, such asfrom supine to supine position, semi-Fowler’s

position to semi-Fowler’s position, or lithotonyposition to lithotony position, it is quite possiblethat some of the devices that are commerciallyavailable for repositioning a patient in a supine

position in bed may be useful. Another option for

repositioning a patient in these positions would beto use battery-operated hoists with properly de-signed slings that are capable of lifting a patientwhile maintaining the desired position. The issue

of turning a patient from a supine to a proneposition or from a prone to a supine position aswell as supporting a patient in a semisupine

position is difficult, because currently, there isa lack of commercially available devices to ac-complish this. In this regard, principles of bio-

mechanics can be used to make the job easier. Forexample, working with biomechanical principles,it is often less stressful to the body to pull a patient

toward you rather than to lift a patient. Similarly,supportive wedges or pillows can be used to makethe job easier on the critical care worker and morecomfortable for the critical care patient. These

recommendations are consistent with Owen’s [83]observations. Owen [83] conducted her study inmedical-surgical units. She concluded that her

findings could be useful to perioperative nursesbecause the type of horizontal transfer performedin the operating room and medical-surgical units

are similar.It is clear from the above discussion that

patient handling in critical care settings is a serious

hazard. It is also clear that no amount of bodymechanics and training in safe lifting and patienttransferring techniques will make the job safe.Therefore, the only safe solution for patient

handling in critical care settings is with incorpo-ration of the use of patient handling and assistivedevices to eliminate or minimize lifting and

supporting of patient weights as much as possible.These programs have worked extremely well inlong-term care facilities as well as in hospitals, and

there is no reason to believe that they would notbe successful in reducing musculoskeletal disor-ders in critical care settings.

Summary

Numerous studies and statistics clearly showthat low back injuries are commonplace among

nursing personnel. The prevalence of work-relatedlow back pain is higher in this population thanalmost all other working groups. Shoulder pain is

also an issue for nursing personnel that is oftenoverlooked. The primary causes of injuries arethought to be patient-handling tasks, specifically

lifting and transferring of patients. Repositioningof patients is also reported to be as physicallystressful as lifting. Biomechanical studies show


that compressive and shear forces exceed accept-able levels of exposure. The strength requirementof the job also exceeds the physical capabilities of

most female workers. Therefore, patient-handlingtasks are inherently very hazardous and posea high risk for injury.

Training in bodymechanics and lifting technique

is not enough to reduce low back and shoulderinjuries. Several epidemiologic studies have shownthat ergonomic interventions are effective in re-

ducing the risk of injury and the severity of injury.Critical care poses a very challenging environ-

ment because patients are usually more debilitated

and unable to assist during transfers. Therefore,the needs of this population as a whole are greaterthan some other patient or resident populations.Also, the risk of injury is also greater to nursing

personnel caring for this population. The onlylong-term solution is to introduce assistive devicesinto this specialty area of nursing care. This may

require some ingenuity in using current commer-cially available devices as well as creativity todesign new and improved equipment.

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196 GARG et al

Sustaining Staff Nurse Support for a Patient CareErgonomics Program in Critical CareLinda L. Haney, RN, MPH, COHN-S, CSPa,*,

Laurette Wright, RN, MPH, COHN-SbaDiligent Services, ARJO, Inc., 711 North Tenth Street, Wausau, WI 54403, USAbDiligent Services, ARJO, Inc., 1200 Theodore Lane, Durham, NC 27713, USA

Approximately 70% of all change initiativesfail, according to Beer and Nohria [1] of the Har-vard Business School. Ergonomic change initia-tives, such as safe patient handling in critical care

units, certainly are not immune from this discour-aging fact. Managers have only to look at pastpurchases of patient equipment to find it languish-

ing in the back of a storage room. Moving to a safepatient handling environment, with the purchaseof appropriate equipment, in any setting requires

nothing less than a cultural change demonstratedas new and consistent use behaviors of nurses.From the beginning of their training nurses aretaught to lift and move patients using ‘‘body me-

chanics’’ with the implication that if a task simplyis done properly it is safe for patients and care-givers. This notion is reinforced through in-service

trainings and managers who give well-meaning re-inforcement. A significant body of literature dis-putes the safety of body mechanics alone as an

effective way to prevent injuries [2].As research becomes available, nurses have

supported and rallied around evidence-based

practice for patient care. Malloch and Porter-O’Grady [3] define evidence-based practice as theapplication of the best possible research with evi-dence from clinical expertise channeled toward the

needs of patients. Partly for complex historicaland sociologic reasons, nurses tend to be self-sac-rificing and slow to move to evidence-based

practice for themselves. The research is clearthat safe patient handling programs can achievesafety goals for caregivers, although there isa dearth of research on the issue of improved pa-

tient safety as a result of the programs [4]. The an-ecdotal evidence, however, strongly indicatesreduced patient falls and increased comfort during

patient lifts and transfers when a safe patient han-dling program is in place. Additionally, there isbeginning recognition among rehabilitation pro-

fessionals that safe patient handling equipmentcan be used to further rehabilitation goals [5].

In spite of training, education and research tothe contrary, caregivers in general do not appear

to view mobility, such as sitting on the edge ofa bed or transfer to a chair, as clinical issues.Positioning of patients relative to lung function

clearly is seen as a clinical issue in critical careunits, however [6]. The general belief regardingmobility is important especially in critical care

units where the major focus is on life-threateningconditions, not the sometimes devastating after-math of immobility. Physicians routinely write or-

ders for patients to be ‘‘out of bed,’’ althoughinformal discussions with critical care nurses vali-date the belief that these orders often are unrealis-tic given patients’ condition. As a result, they do

not carry the same criticality as most other orders.The average age of a nurse is expected to rise to

45.4 years by 2010, as compared with 41.9 in 2000

[7]. Older caregivers who now predominate in theworkforce remember earlier practice mandatinglengthy enforced bedrest after open-heart surgery.

It is now widely accepted that patients do consid-erably better when they are mobilized quicklyafter surgery, usually within several hours. The

This work was supported through funding by

ARJO, Inc.


E-mail address: [email protected] (L.L. Haney).





conclusion is that mobility is just as much a clinicalissue as correct medication, procedure, or diet.There are many reasons, therefore, why mobility

and transfer tasks should be made as safe aspossible.

Sustaining staff support for a safe patienthandling program implies that support was present

at one point or for some period of time. Exploringthe nature of change, how it happens, how peopleare motivated to accept it, what barriers prevent

it, and how it is sustained all are inextricablylinked. Society actively seeks quick fixes andengages in limited long-term planning. Cultural

change, expressed as new and different behaviors,occurs slowly. Consider only the initiative to usegloves to understand the difficulty. Wearing glovesconsistently and appropriately has taken nurses

more than 15 years even with the knowledge andevidence of an associated frightening disease(AIDS) and a federal law (Bloodborne Pathogens

Standard) [8]. Safe patient handling programs arenot associated with a frightening disease, althoughthe toll of musculoskeletal injuries may be far in

excess of AIDS, and there is no a federal regulationspecific to the problem, although several states arehave enacted safe patient handling laws, with more

expected to come. Thus, it is important to under-stand that the change to an environment of safepatient handling may take many years.

The natural question is why change initiatives

are so difficult to maintain and fail so frequently.Field discussions with managers and employeesattest to the fact that beginning a change initia-

tive, although sometimes difficult, can be donewith relative ease compared with sustaining orcementing a change. There is a significant amount

of literature that provides insight, particularly inthe business and management realm, on changemanagement. As Harrington states, ‘‘[Permanent]change is not a simple process. It requires a lot of

thought, a well-developed plan, a sophisticatedapproach, and unfaltering leadership’’[9].

Other articles elsewhere in this issue address

the rationale and assessment of need for a safe pa-tient handling program. The remainder of this ar-ticle focuses on some of the issues related to

change management and communicating andmaintaining a successful safe patient handlingprogram in critical care units.

Change process models

Change is about seeking new and improvedways of doing things. Weick and Quinn [10] de-scribe two slightly different models of change,

based on the classic work of Kurt Lewin. Episodicchange follows the sequence of ‘‘unfreeze, transi-tion, refreeze,’’ whereas continuous change is

framed as ‘‘unfreeze, rebalance, refreeze.’’ TheUnited States Army uses the PMOC model, devel-oped from the work of an early French engineer,Henry Faylol. It consists of planning (setting goals

and the process for achievement), motivating(providing incentives for a group to work towardthe goal), organizing (how best to group activities

and resources), and controlling (monitoring andcorrecting ongoing activities toward the goal) [11].

Experience shows that there are two basic

approaches. The first is a common onedheavyhanded, top down, and ‘‘holding people account-able’’ with concomitant strictly applied punitivemeasures for those who do not comply, particu-

larly if there is a written policy in place. Thesecond approach is one of a softer and morerelaxed approach of building trust and emotional

commitment through a planned approach ofcommunication. Proponents believe this is themore effective approach, although they acknowl-

edge that this approach does take more time. Beerand Nohria [1] make the case that the most effec-tive approach is a combination of the two basic

approaches that includes setting direction fromthe top and engaging people from below. Changeimposed only from the top down tends to result inminimal compliance if not outright evasion.

More recently, Kotter [12] developed an 8-stepprocess-of-change model. He emphasizes that therole of leadership is more important than that of

management, although increasing leadershipdoes not mean decreasing management:

1. Create urgency.2. Build the guiding team.3. Get the vision right.

4. Communicate for buy-in.5. Empower action.6. Create short-term wins.

7. Do not let up.8. Make change stick.

All change models require organizations andindividuals to move from one entrenched positionto another one. All typically encompass variationsof the following and are similar to the familiar

nursing process [13]:

1. Recognizing a problem or an opportunity Assess

2. Assessment of the current situation Assess

3. Development of possible

ideas to solve the problem Diagnose

198 HANEY & WRIGHT

Covey [14] includes the following as one of hisseven habits of highly effective people: ‘‘begin withthe end in mind.’’ This is true especially when be-ginning a program with the goal of behavioral

change. Kirkpatrick [15] provides a useful modelfor determining the effectiveness of training, usingfive tiered levels of evaluation. His work, adapted

to effectiveness of a change initiative, suggests thatbehavioral-change end goalsdcost-effective andconsistent use of devices to reduce injuries for

patients and staffdand the planned step-by-stepobjectives to achieve those goals are essential tosuccess.

Communication

Critical care nurses are familiar with the pro-cesses of assessment, diagnosis, and planning.

They may not be as familiar with the businessliterature on communication processes. How wellcommunication is planned and delivered through-out the change process has critical implications

for the successful implementation and mainte-nance of the new behaviors. Every change man-agement model includes or implies the importance

of effective planning and communication aboutthe proposed change. Duck [16] states that man-aging a successful change initiative means manag-

ing the communication between those who seekthe change, those who are expected to implementit, the context of the change within the organiza-

tion, and the emotions that go along with thechange. She goes on to say that because peopleneed time to hear the message, integrate it intotheir thinking, and believe it, change proponents

need to talk about the change over and over andover. She expresses it well: ‘‘When you are sosick of talking about something that you can

hardly stand it, your message is finally startingto get through. Until managers have listened,watched, and talked enough to know that the an-

swer to all of the following questions is yes, theyhaven’t communicated at all: did they hear it, dothey believe it, do they know what it means,

have they interpreted it for themselves and havethey internalized it?’’ [16].

Social marketing is a new concept that aids incommunication. It is defined by the Social Mar-

keting Institute as the planning and implementa-tion of programs designed to bring about socialchange using concepts from commercial market-

ing [17]. The goal of social marketing is to initiateand sustain a change in behavioral action in indi-viduals and society through application of mar-

keting principals of communication andpersuasion [18]. The Centers for Disease Controluses social marketing in their public health efforts

and participates in the Turning Point Social Mar-keting National Excellence Collaborative spon-sored by the Robert Wood Johnson Foundationand housed at the University of Washington

School of Public Health and Community Medi-cine. The collaborative provides resources forsocial marketing, collaborative leadership,

performance management, information technol-ogy, and public health law modernization to en-courage the use of social marketing at state and

local levels. A helpful resource is the TurningPoint CD-ROM Toolkit available at no charge.It includes a wide and extensive variety of innova-

tive tools, worksheets, and resources, including‘‘The Basics of Social Marketing,’’ ‘‘Guidebookfor Performance Measurement,’’ and ‘‘Manager’sGuide to Social Marketing’’ [19]. Change that is

preceded and supported by ongoing social mar-keting seems to have a better likelihood of aneffective outcome.

The act of communicating and persuadingpeople to move from one way of thinking andbehaving to the adoption of another way is

important in all social settings. It allows progressto be made and permits research to move to reality.Various means of changing behavior have been invogue since the industrial revolution. Classic

Theory X and Theory Y approaches, developedby McGregor, attempted to categorize manage-ment believed as either one of work being a nega-

tive (X) or a positive (Y) for workers [20]. Newerthinking and changing social demographics havemoved management science to a more collabora-

tive model, although the heavy-handed approachwith workers remains surprisingly common.Duck [21] states that the new management style

recognizes that change ultimately is about feelings.Emotions must be recognized and addressed iffacilities or units want employees to contributetheir heads and their hearts to their work. Fournies

[22] emphasizes the importance of explaining the

4. Selection of best approach Plan

5. Identification of barriers Plan

6. Communication, Implement

7. Implementation Implement

8. Monitoring results Evaluate

9. Maintenance

199NURSE SUPPORT FOR A PATIENT CARE ERGONOMICS PROGRAM

cause/effect relationship in detail between the in-tended actions and the expected results.

The Social Marketing Institute and Turn Point

literature, based on the work of Weinreich, statesthere are several key concepts associated with so-cial marketing, including action as the objective,focus on the target audience, understanding that

the exchange is critical, analyzing the competition(in this case, for time, but also possibly for budgetdollars), flexibility and monitoring (the change),

and use of the 4 Ps (Table 1) [23]:

Create an enticing product (ie, the package of

benefits associated with the desired action).Minimize the price the target audience believesit must pay in the exchange.

Make the exchange and its opportunities avail-able in places that reach the audience and fitits lifestyles.

Promote the exchange opportunity with crea-tivity and through channels and tactics thatmaximize desired responses.

Training

New behaviors require initial and ongoingtraining. Some object to the term, training,

although it is in widespread use, preferring theterm, facilitating learning. Educating caregiversshould not be a one-time exercise but a process,

particularly if the scope of the information isextensive. Nin writes, ‘‘There are very few humanbeings who receive the truth, complete andstaggering, by instant illumination. Most of

them acquire it fragment by fragment, on a smallscale, by successive developments, cellularly, like

a laborious mosaic’’ [24]. Education in isolationrarely achieves goals. Benner [25], in her classicbook, From Novice to Expert, expresses the same

beliefs when she states that nursing practices andskills develop through experiences and are con-veyed through experiences. She states that thelearning derived from those experiences are

learned most easily and safely when based ona good educational foundation. Too often, educa-tion is an isolated process with little follow-up,

little monitoring, and limited review [26]. Adher-ence to the generally recognized principles of adultlearning and Kirkpatrick’s model help to insure

that real learning takes place and achieves thestated goals rather than training merely for thepurpose of compliance.

The purpose of training is change and action,

but it is not sustainable without an analogouschange in the supporting management process,according to Harrington [8]. He states that man-

agers must direct action within the first week aftera class by applying the information presented tothem. If they cannot or will not apply the infor-

mation quickly, there is only a 20% chance thatthey ever will use the techniques or methods thatwere taught [8]. In short, behaviors change in

large measure because of what managers do ordo not do.

Motivation

Herzberg’s [27] classic article on change re-viewed the various factors that motivate em-

ployees. His research concludes that motivationoccurs when people are given interesting work,

Table 1

Applying social marketing to safe patient handling

Target population Product Price Promotion Place

Caregivers within

critical care

units

Slide sheets

to reduce friction when

moving patients

within a bed

Perceived barriers:

Too much time to apply

Requires two people

to use

Other perceived

benefits:

Task made

physically easier

Reduces total

fatigue for shift

Reduces potential

for back/shoulder

injuries

Evidence-based

literature

Staff meetings

Success stories

Naming of

campaign

Task force

Incentives

Symptom

reductions

Facility newsletter

Unit bulletin

board

Signs for location

of the sheets

Pay roll stuffers

200 HANEY & WRIGHT

challenges, and increasing responsibility. Coombs[28] suggests that the following factors are neces-sary for motivation for intensive care nurses:pay conditions, clinical requirements, organiza-

tional requirements, interaction, autonomy/re-sponsibility, and prestige/status. Controversiesexist about whether or not it is even possible for

one individual to motivate another, although theconsensus seems to be that a leader’s responsibil-ity is to create the conditions where individuals

‘‘own’’ their motivation. Three short case studies,although not all specific to critical care, serve toemphasize the key role of leadership:

Case study 1

After extensive review, a large university-based

system made the decision to create a safe patient

handling environment and selected a critical care

unit to pilot the project, because this nursing staff

had the best compliance with equipment use.

When looking at the salient factors, the following

was discovered: a unit manager was committed to

the change and took the time to take pictures of

her staff in the equipment; a poster placed in

a prominent location on the unit where staff and

patients could see it easily; a small weekly

newsletter for the staff with a regular column

on the safe patient handling initiative; and

a manager who stated regularly that her staff

were absolutely terrific and she was very proud of

them. The enthusiasm and compliance with the

program resulted in no staff or patient injuries

related to patient handling for more than a year.

When this manager subsequently left because of

personal health reasons, compliance went down

to the level of other units in the hospital.

Case study 2

In a critical care unit of one hospital, a single

personal care technician who had sustained a pre-

vious back injury readily saw the benefits for

herself and others on her unit of a safe patient

handling program. She became a peer leader,

defined as unit champion, and the driving force

for the use of slide sheets to transfer patients from

bed to stretcher.With the support of her manager,

she insisted that they be placed on all of the beds

and doggedly pursued the goal of compliance on

the unit. It was not long before she was called

‘‘Purple Sandy’’ because of her advocacy of the use

of the purple slide sheets. This individual played

a strong role in creating an acceptance for the

change in behaviors on the unit.

Case study 3

One hospital, part of a 200-bed health care

system, approached the change to a safe patient

handling environment in a different way. The

entire system put together a task force that

created a baseball theme for the change to

a safe patient handling program. The initiative

included baseball shirts for unit champions,

themed posters and newsletter inserts, game score

cards, and initially used incentives to capture the

excitement after the training. The task force

continues to keep the initiative alive and the

hospital has seen sustained dramatic reductions

in staff injuries over 2 years.

Bringing motivation factors to life requires anenthusiastic walk-the-talk attitude and the abilityto lead others to a better way. Modeling the

behavior is one important way for managers toexpress their commitment to the change by in-dicating graphically that they not only say that they

want a change but also are demonstrating theircommitment. Modeling may mean actually doingthe task, such as using a new ergonomic piece ofequipment, giving positive reinforcement when the

equipment is used, including the desired perfor-mance in performance evaluations, and even pro-moting those who exhibit the desired performance.

One of the best methods is for managers, ona weekly basis, to round the units and randomlyrequest various employees to put a manager in the

equipment and demonstrate its use. Another rec-ommendation is to discuss the status of individualcompliance periodically during informal coaching

sessions and formally at the time of performancereviews. Employees intuitively know that if an issuedoes not appear in their performance evaluations itis not important.Whenmanagerswalk the talk they

build predictability. Duck [16] states that predict-ability leads to trust, and trust and competenceare necessary to achieve change. Ifmanagers ignore

behavior that does not reflect the desired change,they have sent a powerful message that the changeis not important or a priority, and caregivers are

not expected to change their actions. And, if thisis the case, it is difficult for the initiative to succeed.

Incentives

Human behavior research, beginning withSkinner [29], asserts that people do things forwhich they are rewarded and do not do things

for which there is no reward. Performance thatis rewarded increases in frequency; the reward re-inforces the behavior. Behavior psychologists,


such as Daniels, are applying theories and practi-cal applications to the fields of safety, health, er-gonomics, and change management. Daniels’

work indicates that if a change within an organi-zation is to be successful, leaders need to rewardit in a way that causes people to increase their ef-forts, cooperation, and quality of their work [30].

Beer and Nohria caution that incentives should beused to reinforce change rather than drive it [1].

Using behavior analysis techniques to examine

the antecedent of the behavior (what comesbefore), the behavior, and the consequence(what happens after) is the cornerstone for be-

havioral change. According to Daniels, anteced-ents have limited control over behavior. Theirfunction is to get a behavior to occur once or atbest a few times. Positive consequences, alterna-

tively, are the key to getting a behavior to occuragain and again. Daniels [30] succinctly summa-rizes by saying, ‘‘If performance is not improving,

reinforcement is not occurring.’’ Fray [26] puts ita slightly different way: ‘‘In reality a continuousinput of motivation is required to keep the change

process moving. Personal experience has shownnonmonetary or low monetary incentives to bethe most effective. A simple smile, pat on the

back, or personal note can serve as powerfuland inexpensive incentives. Selecting the right in-centive to motivate behavior may be individual;it is determined best simply by asking the

employee, ‘What motivates you?’’’

Peer leaders/unit champions

Coaching implies an expertise in a specialized

area. It generally is acknowledged that unit-basedcoaches or peer leaders for safe patient handlingare useful, although the evidence-based literature

is sparse. Safe patient handling coaches havevarious names, such as transfer mobility coaches,back injury resource nurses, and ergocoaches

(Netherlands). Peer leaders are defined as staffcolleagues who work alongside new staff or thoselearning new skills to assist with the transfer ofknowledge (learned in a class) to skills (ability to

apply the knowledge) in the real world [31]. Withstrong management support, specialized trainingfor this these individuals serves to extend the

reach of managers on units as it relates to safe pa-tient handling behaviors. Unit champions can bea strong factor in changing behaviors in support

of the goals. Cook [32] states that effective coach-ing moves learners from thinking only of them-selves to thinking about what is best for units or

organizations. The ideal ratio of coaches, allowingcaregivers to have ready unit-based access toa coach at all times, is 1 to 2 per shift per unit.

Coaches for safe patient handling typicallyincorporate this role into their existing responsi-bilities on a unit. Training includes the followingbasic skills: ergonomics, introduction of equip-

ment to patients and families, problem solving,techniques for improving compliance on a unit,review of patient handling injuries that have

occurred, and thorough knowledge about theavailable equipment and coaching skills. Backedby regulatory reinforcements and national fund-

ing, the Netherlands has a long and successfulhistory of changing the culture of health careproviders to one of safe patient handling. Theirergocoaches are supported through national con-

ferences, specialized training, and their own Website. A large, 600-facility–based study soon will beunderway to examine the value of ergocoaches in

a systematic way [33].

Resistance to change

Change and resistance are linked closely. Plan-

ning needs to identify possible barriers to thechange initiative and determine a plan to reducethem. There may be many reasons why there is

resistance to a safe patient handling environment,including distraction as the result of too manyinitiatives happening simultaneously, the beliefthat the change is unnecessary, a feeling that the

initiative has been tried unsuccessfully before, anda lack of appropriate communication. Sometimesmanagers themselves are skeptical about projects

and do not participate in senior-level change di-alog. Their skepticism about the project can affecttheir team’s response. Dym [34] sees resistance as

an attempt by the organization to regain equilib-rium and as feedback about the disruptions.

Resistance may be observed in individual

behavior showing apathy, skepticism, denial,anger, helplessness, incompetence, or lack offollow through. It also can appear in a phrase,such as, ‘‘I don’t have time to use the equipment.’’

Examined more closely, the caregiver may besaying, ‘‘I don’t believe this is a priority in thetime that I have available.’’ Ultimately, change is

a highly personal endeavor because it requiresindividuals to think about their behavior, makea decision about whether or not they are going to

change, and then act differently [16].Resistance also may come as the result of

impatience. When projects, such as safe patient

202 HANEY & WRIGHT

handling, do not communicate realistic expecta-tions, people become impatient and conclude thatthe change is not a good one. Clear and practicaltimelines reiterated repeatedly and a strong com-

mitment to persistence are needed. Dym [34] pro-vides a 5-step approach to management ofresistance: (1) anticipate resistance; (2) explore

the problems for which resistance provides feed-back; (3) join and validate the resistance, thus em-powering those who resist; (4) form a partnership

to solve the problem addressed by the resistance;and (5) problem solve.

Combining plenty of communication, persis-

tence in the message, unwavering modeling of thebehavior, problem solving, and rewards for thedesired behavior are effective.

Summary

The ultimate goal of a safe patient handlingprogram actually is ‘‘no program,’’ and the pro-cess may take years. When safe patient handling

practices become so embedded in education andpractice that they no longer are considered ‘‘aprogram,’’ change has occurred and the culture is

one where patients and caregivers are safe duringlifts, transfers, and mobility activities. The changemay not occur solidly until the current generationof caregivers leaves the workforce and the new

generation provides the bulk of care. A safe patienthandling program with its associated benefits istoo important to be left to change or a ‘‘good

effort’’ only to see the initiative die. Sustainablepatient handling change requires a change inbeliefs about the value of mobility tasks and the

unswerving belief of the importance of protectingcaregivers and patients during those tasks.

The ability to see that a safe patient handling

environment makes sense and has advantagesrequires individual thought and strong leadership.Sustaining the change requires a thoughtful planfrom the beginning with input from those who are

affected, a realistic attitude about the time it willtake, repeated communication, positive reinforce-ment, and dogged persistence. Change and a com-

mitment to the sustaining the change do result ingoal achievement.

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Safe Patient Handling Program in Critical CareUsing Peer Leaders: Lessons Learned

in The NetherlandsHanneke J.J. Knibbe, MSc, RPTa,*, Nico E. Knibbe, MSca,

Annemarie J.W.M. Klaassen, RN, MScbaLOCOmotion, Research in Health Care, Brinkerpad 29, 6721 WJ Bennekom, The Netherlands

bProject ErgoCoaches, RegioPlus Foundation, Zoetermeer, The Netherlands

An ergonomic approach in acute care

In the Netherlands, the ergonomic approach is

advocated as the most effective way to preventmusculoskeletal disorders among health careworkers. In the literature, this is referred to as

a nonlifting or minimal lifting approach, and thereis evidence of the effect of such an approach and ofthe lack of effect of other approaches [1–3]. The

primary objective is to eliminate or substitute allpotentially harmful actions. For this purpose,guidelines were developed mainly based on the Na-

tional Institute of Occupational Safety and Health(NIOSH) guidelines for manual handling of loads[4]. Patients or objects in excess of these limitsshould not be lifted or transferred manually. This

approach has been enhanced over the past 4 yearsthrough working environment covenantsdsignedagreements ensuring commitment by a range of na-

tional parties. The initial drive for these covenantsoriginates from the European Union guidelines forpromoting safe work practices. In nearly all health

care sectors (acute and critical care, nursing homes,home care, psychiatric care, and care for the hand-icapped) employers, workers (unions), and govern-ment have, on the basis of these convenants,

worked together to decrease the exposure of nursesto physical overload. The focus of the convenantsis not restricted to a nonlifting approach, but all

major sources of physical overload (lifting andtransferring patients, pushing, pulling, postural

load, reaching, prolonged standing, and so forth)are taken into account.

This article briefly overviews the implications ofthis development for critical care in hospitals. In theNetherlands, this applies to a groupof 110hospitals

across the country, which has a total population ofapproximately 16 million people. For the purposeof this article, the group of eight academic teaching

hospitals has been excluded, which, as a group,have taken a slightly different approach.

This article provides insight into the develop-

ment of the guidelines, the implementation pro-cess, and preliminary results.

Analysis of the ergonomic situation in acute

and critical care

Thefirst stepwas toassess the exact nature of theergonomic problems encountered in critical care.For this purpose, research material from differentsources was collected and the conclusions were

combined. Methods used were surveys, observa-tions, and direct measurements of exposure.

Prevalence of musculoskeletal disorders

In a survey of 4129 nurses from a convenience

sample of 27 hospitals (average nurse responserate 68% [50%–100%] per hospital; hospitalsevenly distributed across the country), it was clear

that there are back pain problems but also thatthe back pain prevalence differs widely betweenhospital wards [5]. The average 12-month back

pain prevalence of all nurses responding was63%. This is high compared with the average for


E-mail address: [email protected] (H.J.J. Knibbe).





the Dutch general population (42%) but slightlylower than the Dutch average for home care inthat period (67%). Preventive action, therefore,

was considered relevant and necessary. It alsowas clear that there were large differences betweendifferent specialties in a hospital. Surgery, cardiaccritical care units, ICU, emergency departments,

cardiology in general, orthopedics, and neurologyreported a higher prevalence, the latter two rank-ing first and second. Alternatively, specialties,

such as gynecology, pediatrics, and internal med-icine, reported prevalence lower than the hospitalaverage. Acute and critical care were in the mid-

range: not as high, for example, as nurses workingon orthopedic units report but higher than the av-erage for the general population (50%–62% de-pending on the ward). It also seemed that for

acute and critical care, back pain was not theonly problem, with an elevated prevalence of mus-culoskeletal disorders. Nurses working in critical

care also reported a relatively high prevalence ofneck and shoulder problems. Over a third(35%–55%) of the critical care nurses in the 27

hospitals included in the survey reported havinghad neck or shoulder pain in the 3 months beforethe survey.

These data underline that for critical care, thereis sufficient reason to undertake preventive action.

Exposure to physical load

Registration by means of a self-administeredlog (the so-called ‘‘Lift Counter’’ or ‘‘Lift Ther-mometer’’1) [2] in 12 of the 27 hospital revealed

that lifting and transferring dependent patientsoccurred frequently. On average, 5.2 transferswere performed per patient per 24 hours. Nearly

half of these patients (46%) were almost or totallypassive.

For acute and critical care, this percentage was

higher, with an average of 64%. Either they werenot able or were not allowed to move themselvesor assist in the transfers. An additional 26% werelimited in their mobility level and the remaining

10% were able to assist substantially or to moveindependently or with only verbal guidance. Theweight of the patients (average 71 kg), their

dependency level, and the type of transfer per-formed indicated that these transfers provideda health risk for the nurses if these transfers were

performed manually. The criteria for ‘‘safe,’’ inthese cases, were derived from the revised NIOSHguidelines for the manual handling of loads. More

specific assessments of the actual load wereperformed with the 3 Dimensional Static StrengthPrediction Program (3D SSPP) software programfrom Chaffin [6], which also refers to the NIOSH

guidelines [4].It seemed that 39% of the patients were

transferred with the help of two nurses, implicat-

ing an occupational health risk for both nurses. Itdid not make much difference if these transferswere performed with one nurse or with two

nurses. In both cases, the resulting load still wasin excess of safe limits for manual handling set bythe NIOSH guidelines (3400 N) [4]. In spite of thefact that dividing the weight of the patients be-

tween the two nurses made the transfer lighter,a biomechanical analysis by means of the 3DSSPP program revealed that it did not make the

transfer safe. This is in line with other research in-dicating that manual transfers of dependent pa-tients should be avoided [1–3]. The conclusion,

therefore, was that lifting with two nurses wasnot a structural solution and the guidelines forpractice now state explicitly not only that one-

person manual lifts should be avoided but alsothat two-person lifts and transfers should beavoided.

Alternatively, the frequency with which nurses

in acute and critical care lift and transfer patientsis not as high as in other wards or in nursinghomes and homes for the elderly. There, the

frequency per patient can be more than 12 perpatient per 24 hours.

Also, the type of transfers was specific to acute

and critical care when compared with other spe-cialties or situations in nursing homes. It seemedthat more than half of the transfers were performedwithin a bed itself, which is higher than in nursing

homes, where they often are a third or less.Examples of these types of transfers are reposition-ing in bed, up the bed, or sideways; rolling over; and

so forth. This means that solutions, such as mobileor overhead ceiling lifters, are not sufficient to solvetransfer problems. A well-designed, high-low pow-

ered bed and the use of sliding sheets help to solvethese problems and, therefore, have become part ofthe guidelines for practice. Another 10% consisted

of horizontal transfers: froma supine position (bed,stretcher, and so forth) to another supine position(bed, examination table, stretcher, and so forth).This type of lateral transfer occurs in less than 5%

of the transfers in nursing homes.

1 This tool is a practical but validated assessment

tool that assesses exposure to physically demanding

tasks and compliance with the use of preventive

equipment.

206 KNIBBE et al

It also seemed that other causes of physicalload, besides transfers, added to the total expo-sure level of nurses and increased their risk ofdeveloping musculoskeletal disorders. The static

or postural load especially was high. This mayoccur during daily routines, such as tending topatients in bed or elsewhere (wound care, tending

to drains, removing or placing needles, changingintravenous lines, or medical checks) and duringperiods of assisting doctors or colleagues with

treatments or other types of interventions. Duringthose activities, prolonged stooping over patientsoccurs. Besides static load during the periods of

direct patient-nurse interaction, there is a consider-able amount of static load during other activities,such as reading out the data on monitors andother types of electronic displays (often not in

ergonomically ideal positions), keeping records,sorting out medication supplies, and cleaning anddisinfection routines. This static load often is

underestimated but may provide an (additional)explanation for increased levels of sick or personalleave. Jansen and colleagues [7] found, for exam-

ple, that longer exposure to static load (witha trunk flexion over 45�) was related (relaltiverisk, 3.18) especially to more serious, disabling

back pain among health care personnel.Finally, pushing andpulling also seemed to be in

excess of safe values. Pushing and pulling occurredduring maneuvering heavy objects, such as during

the transportation of beds or heavy (diagnostic)equipment. Special types of ICU beds or specialmattresses in particular resulted in loads in excess

of the safe values of 200 N considered safe.Nurses reported these problems (transfers,

static load, and pushing and pulling) not only in

the logs and direct measurements but also in thesurvey. They reported them subjectively as majorproblems they would like to have solved. Theconclusions of subjective data and objective

measurements converged, underlining the validityof the results. In addition, some nurses reportedthe frequent use of computer terminals and other

devices and electronic patient files as unfavorableergonomic conditions and stated that this addedto their risk profile for developing musculoskele-

tal disorders.

Observations and expert walk-through

Finally, observations (expert walk-through

on all wards in 12 hospitals) pointed to a widerange of small and large practical ergonomicproblems. Some were general problems, occurring

in practically all the hospitals, and some werespecific to some hospitals. Patient rooms, exami-nation rooms, and bathrooms generally seemed tohave insufficient space for maneuvering beds and

heavy equipment. Some locations did have suffi-cient space, but the space (eg, in ICUs) often wastaken up completely by diagnostic and control

devices. It was difficult for nurses to put themselvesin an ergonomically ideal body position duringtransfers or nursing activities. They often were

working in awkward positions. For example,some of the bags with body waste or treatmentfluids were placed in difficult places and were heavy

(when full) and difficult to detach without goodvision (sometimes hanging under a bed or bed rail).

There often was not enough equipment in place.In some cases, nurses would have to go looking for

the equipment and did not do so. They consideredthis as too time consuming and not efficient. Inother cases, the equipment was not maintained

properly or it was unclear if it was maintainedproperly at all (eg, no records kept). This resulted inwheels that were clean but no longer rotated easily.

No maintenance records were kept for slings fromlifting devices (either ceiling or mobile patientlifters) as a rule. This implied that it was unclear

when the last strength test was performed andwhether or not a sling was in good working order.From a patient and nurse safety perspective, thissituation needed improvement. At times, the type

of equipment was not optimal. In some hospitals,high-low beds were present but operated partiallyhydraulically instead of electrically. Apart from

other disadvantages, this meant that patients werenot able to operate their beds themselves, leading tounnecessary dependence and lack of mobility. In

addition, nurses had to move the headrests up anddown manually, an activity experienced as heavy,especially with dependent patients in the bed.Another problem occurring frequently was that

mobile lifters often were present but frequentlywere not used because of lack of space. Overheadceiling lifters rarely were in place. When they were

present, their reach often was limited to one roomand access to another room or the hall way waslimited or absent.

Guidelines for practice

After this first research phase, a national taskgroup was formed consisting mainly of nurses and

physical therapists. It was their task to developpractical guidelines as a response to the majorproblems the studies (described previously)

207LESSONS LEARNED IN THE NETHERLANDS

pointed out. They were supported in this byhuman movement scientists.

This task group developed the guidelines in

several stages during nearly 7 months. At eachstage, they consulted with their own hospitals andtheir direct colleagues there. The purpose was todevelop guidelines that would be simple, under-

standable, andpractical for use in critical care itself.Although this was a time-consuming process, it wasconsidered necessary to ensure commitment, prac-

ticality, and quality of the guidelines. This processmeant that from the beginning the nurses them-selves were empowered to develop and produce

guidelines and implement them.Once this national group of 15 representatives

had reached consensus, the final versionwasofferedto the national covenant committee, in which

unions, employers, the health and safety inspector-ate, the inspectorate of quality of care, and twogovernment departments (health and social affairs)

participated. These guidelines were signed by theseparties to become official. After this, it was agreedthat the guidelines for practicewould form the basis

for future inspections of the health and safetyexecutive. Nationally, as of summer 2006, the finalstage has been reached, in which the health and

safety is starting their inspection process.For the purpose of the article, an outline of the

guidelines is given. For details, the authors may becontacted. The guidelines for practice cover the

major sources of physical load identified in theresearch. For hospitals, this means they coveredfive groups. In summary the guidelines are as

follows.

Repositioning in beds, on stretchers, and so forth

For all patients who are partially or totally

passive and who need repositioning in bed, the useof a powered high-low bed in combination withthe use of sliding sheets is necessary (Fig. 1).

For patients who have the capacity to assist ormove themselves, the use of a powered high-lowbed and smaller aids (monkey pole, ladder, and soforth) may be relevant and may help them to

maintain or improve their independence.When diagnostic tests need to be performed

(for example, X-ray cassettes that need to be

placed under a patient), a double-layer slidingsheet needs to be used to avoid having to lifta patient. When patients need to be positioned

carefully for treatment or diagnostic reasons,special sets of sliding sheets must to be used(Fig. 2).

Lateral transfers (bed bed, bed stretcher,and so forth)

For all patients who are passive or nearly

passive and who need lateral transfers, a slidingboard, sliding sheets, or a lifter with a horizontalstretcher frame must be used in combination witha powered high-low bed (Fig. 3).

Transfers from bed, wheelchair, and so forth

bed or wheelchair

For all patients who are passive or nearlypassive, patient lifters or hoists have to be used,either passive lifters or active lifters (Fig. 4).

Static or postural load during patient care

and so forth

For any activities lasting longer than 1 minutethat require a back inclination or rotation of more

Fig. 1. Repositioning in bed. (Courtesy of Knibbe JJ,

Knibbe NE, Geuze L. Beter, Werkpakket Fysieke Be-

lasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,

Utrecht, 2003; with permission.)

Fig. 2. Positioning for treatment. (Courtesy ofKnibbe JJ,

Knibbe NE, Geuze L. Beter, Werkpakket Fysieke

Belasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,


208 KNIBBE et al

than 30�, additional equipment needs to be used(Fig. 5). This may include powered high-low de-

vices, sitting supports, or supports for patientlimbs (wound care). If this is not possible, pro-longed tasks (longer than 1 minute) need to be al-

ternated frequently among nurses, or more breaksor microbreaks need to be used. Nurses in thesecases must be informed about the risks they mayexperience and the options they have to prevent

musculoskeletal disorders.If patients use antiembolism stockings (AES),

special devices need to be used to avoid postural

stress and excessive pulling forces in fingers andarms.

Maneuvering with heavy material

If the force required to maneuver an objectexceeds 200 N, a powered pulling or pushing(transportation) device must be used (Fig. 6).

To encourage nurses to use optimal techniquesand develop their techniques with sometimes newmaterial and equipment, special educational ma-terial (step-by-step leaflets) was developed. This

information did not replace the information thatmanufacturers offer with their equipment. In-stead, it provided additional and practical sugges-

tions to use the equipment or aids safely for nursesand patients. This was considered necessary be-cause some manufacturers suggest that sliding

sheets could be used for transfers out of bed toa wheelchair. The task group considered this anunsafe procedure for patients and nurses, so this

technique was advised against.

Implementing change in acute and critical care

After this stage of guideline development, theimplementation process started. As this was

expected to be a complex process, a choice wasmade to train and install so-called ’’Ergo-Coaches.’’ On every ward, one or two nurses

needed to be appointed and trained to becomean ErgoCoach (also called peer leaders, liftingco-coordinators, back injury resource nurses[BIRNs], lifting specialists, mobility coaches, and

so forth) [1–3,8]. In short, this ErgoCoach–nurseis responsible for starting the ergonomic processand keeping it going. These ‘‘ergonomic ambassa-

dors’’ are available for questions, problem solv-ing, introduction training, updates on newequipment, and so forth. ErgoCoaches can iden-

tify problem areas, can perform assessments, areconsulted easily (they work on wards like anyother nurse), and are trained and specialized in er-

gonomics. Theoretic advantages are that they are

Fig. 3. Lateral transfer. (Courtesy of Knibbe JJ, Knibbe

NE, Geuze L. Beter, Werkpakket Fysieke Belasting Zie-

kenhuizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;

with permission.)

Fig. 4. Lifter. (Courtesy of Knibbe JJ, Knibbe NE,

Geuze L. Beter, Werkpakket Fysieke Belasting Zieken-

huizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;

with permission.)


nurses (‘‘one of us’’), they speak the same ‘‘lan-guage,’’ and they ‘‘know what it’s like,’’ butmost of all they interact frequently with their

colleagues.For acute and critical care, this is of vital

importance, as this highly specialized setting is

from time to time complex and, as the researchpoints out, the problems are diverse in nature. Itwas considered that anyone outside this setting

not present on the ward itself and not matchingthe expertise level never would be able to generatethe necessary impulse for a preventive policy. Inaddition, the presence of and dependence on

outside experts would make the process inefficientand expensive. This makes the ErgoCoach phe-nomenon an essential and potentially effective

drive behind the ergonomic message, especiallyin acute and critical care.

Preliminary results

Nationally, the percentage of nurses on sick

leave has decreased from 5.6% in 2002 to 4.7% in2005 (2003: 5.1%; 2004: 4.8%) [9]. Monitoring ofall the hospitals revealed that the implementationprocess demonstrated a typical implementation

pattern [10]. Early innovators were in the lead,followed by a mid range of hospitals underway.These hospitals had made some changes and

were planning for more but were not workingaccording to the guidelines at this stage. The rea-sons often were oriented financially. For example,

if a hospital had a collection of hydraulic high-low beds, there was an obvious need to re-investin new powered beds. Budgetary constraints

would have forced these hospitals to plan this

over a period of 5 years or more. Another majorreason for a slow implementation process wasa difference in priorities. The national approachmeant that the time frame of the whole process

was a national one. Local hospitals may havemade different plans already. There was, for ex-ample, one hospital that made the implemen-

tation of a policy aimed at protecting theirworkers against aggressive and sometimes violentpatients and their relatives as their first priority.

Finally, there also was a group of hospitals thathad not started at all yet. An approximate divi-sion can be made of 20%/60%/20% for thesethree groups. The latter group now is ‘‘gently

but firmly’’ pushed into taking action with some

Fig. 6. Transportation device. (Courtesy of Knibbe JJ,

Knibbe NE, Geuze L. Beter, Werkpakket Fysieke Be-

lasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,


Fig. 5. Wound care. (Courtesy of Knibbe JJ, Knibbe

NE, Geuze L. Beter, Werkpakket Fysieke Belasting Zie-

kenhuizen, Sectorfondsen Zorg enWelzijn, Utrecht, 2003;

with permission.)

210 KNIBBE et al

pressure from the Health and Safety Inspectorate.Among others, they look for the presence ofErgoCoaches. In 2005, monitoring revealed thatErgoCoaches were present in 56% of the hospi-

tals, whereas there were few (!10% of the hos-pitals) ErgoCoaches 4 years ago. Long-termmonitoring will have to demonstrate if a higher

national implementation degree will be in placeand be effective.

On a hospital level, especially in the acute care

situation, the hospitals that are in the leaddemonstrate a variety of changes: smaller ones(such as better wheels under some of the equip-

ment and having a longer line on the stethoscopesso that postural stress is avoided) and bigger ones(making a plan for investing in new beds thatcomply with the guidelines and the specific de-

mands of acute and critical care) [10].In conclusion, ergonomic changes in acute and

critical care are relevant. The general guidelines

also are relevant for this specific group of nursesand patients, but the diversity and medical com-plexity of this setting indicate that tailor-made

solutions often are necessary. Interventions aresuccessful but take up considerable time. A time-frame of more than 2 years is average. To

implement this, strong professional stakeholder-ship from nurses themselves is essential. Workingwith ErgoCoaches on these types of wards canfacilitate empowerment of the nurses themselves

in this implementation process and can ensure andstimulate commitment.

References

[1] Hignett S, Crumpton E, Ruszala S, et al. Evidence-

based patient handling. London: Routledge; 2003.

[2] Knibbe JJ, Friele D. The use of logs to assess expo-

sure to manual handling of patients illustrated in an

intervention study in home care nursing. Int J Ind

Ergon 1999;24:445–54.

[3] Nelson AL, editor. Safe patient handling and move-

ment. A practical guide for health care professionals.

New York: Springer Publishing Co., 2006.

[4] Waters TR, V Putz-Anderson. Scientific support

documentation for the Revised 1991 NIOSH Lifting

Equation. Cincinnati (OH): National Institute for

Occupational Safety and Health; 1991.

[5] Knibbe JJ,HooghiemstraF,KnibbeNE.Ergonomic

problems in hospitals [in Dutch]. In: Arboconvenant

Ziekenhuizen, Stand der Techniek, Eindrapport.

Doetinchem (The Netherlands): Elsevier; 2001. p.

1–95

[6] Chaffin DB. 3D SSPP (Static Strength Prediction

Program), version 5.04. Ann Arbor (MI): University

of Michigan; 2005.

[7] Jansen JP, Morgenstern H, Burdorf A. Dose-

response relations between occupational exposures

to physical and psychosocial factors and the risk of

low back pain. J Occup Environ Med 2004;972–9.

[8] Knibbe JJ, Knibbe NE, Geuze L. ErgoCoaches in

beeld [in Dutch: a view of ErgoCoaches]. Bennekom

(The Netherlands): LOCOmotion; 2005.

[9] Available at:www.vernet.nl.AccessedMarch30, 2007.

[10] Vree F van, Petersen A van, Knibbe NE. Monitor

Arboconvenant Ziekenhuizen, Eindmeting (Moni-

tor Follow Up), [in Dutch]. Leiden (The Nether-

lands): Research voor Beleid, LOCOmotion, 2005.


http://www.vernet.nl

Creating a Culture of Change ThroughImplementation of a Safe Patient Handling Program

Karen Stenger, RN, MA, CCRNa,Lou Ann Montgomery, PhD, RN-BCb,*,

Eric Briesemeister, MSc,1aDepartment of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, Intensive and Specialty

Services 5JPP, 200 Hawkins Drive, Iowa City, IA 52242, USAbDepartment of Nursing Services and Patient Care, CNO T100 GH, University of Iowa Hospitals & Clinics,

200 Hawkins Drive, Iowa City, IA 52242, USAcBT 1000 GH, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA

Nelson and Baptiste [1] stated in 2004, ‘‘Nurs-ing can no longer afford the ‘human sacrifice’ ap-

proach to patient handling defined as replacingthe steady stream of injured nurses with newly re-cruited nurses.’’ Clearly something more must be

done to protect bedside care providers and theirpatients.

Risks when handling patients manually

The statistics are telling. The OccupationalSafety and Health Administration (OSHA) has

calculated that nearly half of all health careworkers suffer at least one work-related musculo-skeletal injury during their career [2]. More than

half of all nurses (52%) complain of chronicpain and 38% of registered nurses (RNs) have suf-fered occupation-related back injuries severe

enough to require time away from work [3,4].Twelve percent of RNs consider leaving the pro-fession because of lower back pain [3] and in anAmerican Nurses Association (ANA) survey,

almost 60% of nurses list disabling back injuriesas one of the top three health safety issues [5].

In 2000, health care injuries caused time awayfrom work for nearly 11,000 RNs and nearly45,000 nursing assistants, orderlies, and atten-

dants who said that ‘‘re-exertion and overexertionin lifting’’ were the cause of the events [6].

The National Institute for Occupational Safety

and Health (NIOSH) is the federal agency re-sponsible for conducting research and makingrecommendations for the prevention of work-related injury and illness. For 90% of men and

75% of women, the maximum weight limit forlifting, under ideal conditions, is 51 lb [7]. Idealconditions include the presence of handles for

grasping, keeping the load close to the body,avoiding twisting of the trunk, and minimizingthe distance a load is carried. Clearly, patient han-

dling in clinical settings occurs in less than idealconditions. Zuidema and colleagues [8] reportedthat the maximum weight limit for lifting several

times throughout the day under less than idealconditions ranged from 22 to 33 lb for men and15 to 22 lb for women.

Health care workers may perform many man-

ual patient handling tasks daily or during theircareers that exceed these recommendations [9]. Anoverexertion injury may occur if the forces applied

to a nurse’s musculoskeletal system exceed its me-chanical strength [10]. For example, a nurse mayreposition a 200-lb patient in bed manually that

* Corresponding author. Department of Nursing

Services andPatientCare,University of IowaHospitals&

Clinics, Intensive and Specialty Services 5JPP, 200

Hawkins Drive, Iowa City, IA 52242.1 Previously held position of Safety Manager,

Department of Safety and Security, 2002–2006.

E-mail address: [email protected]

(L.A. Montgomery).





results in an overexertion back injury. By con-trast, overuse injury may result when the rate ofcumulative damage exceeds a structure’s capacity

for healing and repair [10]. The wear and tearthat occurs daily in lifting and working manuallyin a bent and twisted position cause cumulativedamage and increase the risk for musculoskeletal

injury [10]. For example, a nurse who has spent20 years lifting critically ill patients manuallyone day may suffer an injury when doing a routine

manual lift. This acute insult may be superim-posed on the long-term cumulative effects of over-use injuries.

To protect health care providers and patientsfrom injuries related to patient handling, ergo-nomics has been investigated and researched toreduce the incidence and severity of job-related

injuries related to patient handling tasks. TheUniversity of Iowa Hospitals and Clinics (UIHC)embarked on a safe patient handling program in

2001. The UIHC is a 725-bed comprehensivetertiary-care academic medical center. There aremore than 2500 staff in the Department of

Nursing Services and Patient Care, approximately1400 of whom are RNs. There are more than 100radiology technicians and 20 inpatient physical

therapists and physical therapy assistants.The purpose of this article is (1) to describe how

this institution created a culture of change throughimplementation of a safe patient handling pro-

gram, as guided by the Iowa Model of Evidence-Based Practice to Promote Quality Care (IowaModel) [11,12], in order to decrease lost workdays

and reduce workers’ compensation costs and (2)to share lessons learned in the process.

Iowa Model of Evidence-Based Practice

to Promote Quality Care: considering

a practice change

The Iowa Model [11,12] served as a guide touse evidence for improvement of patient care

(Fig. 1). Following is a detailed description ofthe key components used to translate the evidenceinto safe patient handling practice.

Problem- and knowledge-focused triggers

A change in practice is considered as a result ofassessing the impact of factors in an environment.In 2001, several factors, or triggers, served as

catalysts for motivating UIHC to question thepractice of handling patients manually and mov-ing toward safe patient handling. Problem-

focused triggers include clinical problems seenrepeatedly in practice. The end results of theseproblems often are seen in risk management data.

At UIHC, there were an average of 121 nursingincidents per year related to patient handling from1997 to 2000. These injuries involved mainly theback and shoulder. With this volume of exertion

injuries, the units were faced with the need to re-place staff in direct patient care activities ona more frequent basis and for longer periods of

time. An increasing number of nurses, often expe-rienced nurses, found themselves unable to givedirect patient care because of the patient handling

injuries they had suffered. Staff noticed that theirpeers were becoming injured and were concernedfor their welfare and their own possible potentialrisk for becoming injured.

In addition, several knowledge-based triggersor newly recognized information, such as stan-dards and practice guidelines available from

national agencies and organizations, becameavailable. In 1992, the United Kingdom publishedmanual handling operation regulations. These

regulations govern regulatory and compensatoryaspects of patient lifting and require a risk assess-ment to be made for handling tasks and risks to be

reduced to the lowest level reasonably practicablebefore patient lifts occur [13]. Although these reg-ulations were in existence for several years, UIHChad no knowledge of them until the year 2001.

In October 2001, the Web site, www.patientsafetycenter.com [14], became recognizedmore widely as a resource mecca for the work of

Dr. Nelson [15] from the Tampa, Florida, Vet-erans Administration Medical Center PatientSafety Center of Inquiry. The downloadable,

128-page, Patient Care Ergonomics ResourceGuide: Safe Patient Handling and Movement, be-came available to serve as a resource to those in-terested in reducing the incidence and severity of

job-related injuries.As UIHC continued to develop a safe patient

handling program, more knowledge-focused trig-

gers occurred. In 2002, the draft of the Ergonom-ics OSHA Guidelines for Nursing Homes [16,17]was published. These guidelines were designed

to help nursing homes reduce musculoskeletalinjuries but also are applicable to acute care hos-pitals. In June 2002, the ANA adopted a statement

called, ‘‘Elimination of Manual Patient Handlingto Prevent Work-related Musculoskeletal Disor-ders’’ [18]. This statement provided support foraction and policies that result in the elimination

of manual patient lifting. In November of that

214 STENGER et al

http://www.patientsafetycenter.com

http://www.patientsafetycenter.com

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

NoYes

Yes

Is ChangeAppropriate for

Adoption inPractice?

YesInstitute the Change in Practice

Is Therea SufficientResearchBase?

Monitor and Analyze Structure,

Process, and Outcome Data

2. National Agencies or OrganizationalStandards & Guidelines

3. Philosophies of Care4. Questions from Institutional Standards Committee5. Identification of Clinical Problem

1. Risk Management Data

Problem Focused Triggers Knowledge Focused Triggers

• Staff• Cost• Patient and Family

Pilot the Change in Practice

1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based

Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline

The Iowa Model of

Evidence-Based Practice to Promote Quality Care

2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data

1. New Research or Other Literature

ConsiderOther

Triggers

Is this Topica PriorityFor the

Organization?

No

Form a Team

Base Practice on Other Types of Evidence:

1. Case Reports2. Expert Opinion 3. Scientific Principles4. Theory

Conduct

Research

Continue to Evaluate Qualityof Care and New Knowledge

No

Disseminate Results• Environment

= a decision point

Fig. 1. The Iowa Model of Evidence-Based Practice to Promote Quality Care. (Reproduced with permission from Mar-

ita G. Titler, PhD, RN, FAAN, Iowa City, IA. For permission to use or reproduce the model, please contact Dr. Titler.)

215CREATING A CULTURE OF CHANGE

year, ANA released their ‘‘Handle with Care�’’initiative [19]. This campaign’s purpose was toseek profession-wide effort to prevent back and

other musculoskeletal injuries through greater ed-ucation and training and increased use of assistiveequipment and patient-handling devices.

Is the topic considered a priority

for the institution?

The next step in the Iowa Model is to decide ifthe topic is a priority for the organization [11,12].Safe patient handling was considered a priority

for UIHC, triggered especially by the 121 averagenumber of annual injuries to staff (discussed pre-viously). Hospital administration charged the

UIHC Environment of Care Subcommittee withforming an ergonomics task force to begin to ad-dress how to improve the process of lifting and

moving for staff to minimize their risk for injury.

Form a team

The ergonomics task force was a multidisciplin-ary team chaired by the institution’s safety man-ager with representation from nursing, physical

therapy, the health protection office, and theworkers’ compensation office. The goal of thegroup was twofold: (1) to reduce injuries to direct

caregivers while maintaining patient safety and (2)to minimize exertion injuries for staff in nondirectpatient care activities, such as food, nutrition, and

environmental services. The task force met ona monthly basis but it became apparent afterapproximately 1 year that there could be more

impact if the group was separated into directpatient care and nondirect patient care subgroups.Although injuries to workers in each group weresimilar, the processes and resolutions would differ.

Assemble, critique, and synthesize relevant

research and related literature

The Iowa Model’s next step is to gatherevidence from research-related literature to de-

termine if a change in practice is warranted[11,12]. The remainder of this article describesthe process and outcomes achieved by the direct

patient caregiver subgroup of the ergonomicstask force to improve patient handling activities.

The ergonomics task force investigated litera-

ture, research findings, and expert opinion onpatient handling. Studies show that ergonomicapproaches to safe patient handling reduce staff

injuries. Specifically, assessment of stressful tasksand development of alternatives methods todecrease the stress can reduce the number of over-

exertion injuries [15,20–22]. Also, emphasis on edu-cation and trainingwith a focus on bodymechanicsmay not be enough in controlling musculoskeletalproblems [15,23,24]. The research does not show

conclusively that proper body mechanics can bemaintained during lifting among activities. Othervariables, such as the characteristics of patients,

environment, and caregiver, interact and have animpact on an experience. It seemed that a differentapproach was needed to solve the problem.

Considering sufficiency of a research base

and the role of expert opinion

The research literature, therefore, offered animperfect solution. The Iowa Model suggests that

if there is not a sufficient base of evidence to adapta change for practice, then practice changesshould be based on other types of evidence

[11,12]. The ergonomics task force decided to so-licit expert opinion on which to base a change.

Some of the staff wanted to explore the use of

a lift team to assist in patient lifting and movingactivities. The opinion of a consultant was sought,who had published on lift teams. In this model,

assigned ‘‘lifters’’ are hired by an institution to liftand move patients on an as-needed basis. Thebenefits of a lift team can include (1) a possibleimprovement in direct caregiver satisfaction re-

lated to not having to participate in lifts, (2)reduction in number of mechanical devices neededto move patients, (3) the possible result of de-

veloping a care team of lifters with expertise inthis activity, and (4) decreased costs that wouldoccur if all staff were trained to move and lift

patients [21]. The solution would have been an at-tractive option if not for one factor: the hospitaloccupies 3 million square feet spread over half

a mile and five pavilion buildings. There was nofeasible way that a few lift teams could respondto staff calls for assistance adequately and eco-nomically 24 hours a day, 7 days a week.

In 2001, the task force invited another consul-tant, a nursing researcher, to visit UIHC, assessthe patient handling tasks, and present informa-

tion on ergonomics to the committee and nursingmanagement. She gave encouragement, support,and motivation to implement a change to protect

staff and patients. The task force became con-vinced of the need to move to a comprehensive safepatient handling program involving all units and

216 STENGER et al

staff on the front lines who would be trained to liftand move patients safely whenever a need oc-curred. Although this option would have higherinitial capital investment for equipment and train-

ing costs, they believed it was the best solution.

Pilot the change in practice

The Iowa Model [11,12] suggests that the next

step is to pilot the change in practice. The taskforce believed, however, that they had to educateand raise awareness of staff on the hazards of man-

ual lifting and needed to secure financial supportbefore instituting a change. The strategies and pro-cesses used are described in the following sections.

Collecting baseline data

Vendor fairIn 2001, one of the strategies to educate staff

and get feedback on safe patient handling was toorganize a vendor fair. This vendor fair was heldin a large open meeting room and available for

staff to visit between 8:00 AM and 5:00 PM. Theroom was separated into four major sections sothat equipment could be displayed in a meaningfulfashion: total assist devices, stand assist devices,

repositioning aids, and beds with self- propelledfeatures. At midday, there was a presentationfrom a physician from the Iowa Spine Research

Center. The physician provided hands-on demon-strations of the impact of a sudden load and repet-itive motion on the spine. This helped staff

understand the risks they were taking when mov-ing patients without mechanical assistance. Therealso were poster displays of the research con-

ducted at the VA Patient Safety Center of Inquiry(Tampa, Florida) on safe patient handling. Staffwere asked to evaluate the various pieces of equip-ment from the fair and provide input as to

whether or not they would be interested in cham-pioning safe patient handling in their areas.

Unit assessmentsAnother important strategy for implementing

safe patient handling was to assess the need for

assistive devices in various inpatient units andambulatory clinics. Members of the ergonomicstask force, with the help of a vendor of choice,

visited 23 units andmetwith the nursemanager andstaff on each unit, asking asked them to identifyhigh-risk patient handling tasks and gathering

baseline data on patient handling. There wereapproximately 100 patients who needed limitedassist (patient has upper body strength and can

bear weight but needs limited help to stand), 200who needed extensive assist (patient has minimalupper body strength and can bear at least 50% ofthe weight on one leg), and 150 who were deemed

total assist (patient totally dependent on others toperform movement activity).

Equipment trialsAfter unit clinical assessments, portable equip-

ment from three different vendors was trialed.These vendors were chosen from the feedbackreceived from staff who attended the vendor fair.These companies could meet the basic minimum

requirements of having enough equipment andclinical support to trial on several areas. As partof this process, vendors would bring equipment to

trial and provide education and clinical support.For example, staff would know which daysa particular vendor would be at UIHC. The

vendor of the day would be provided with a pager,and staff were instructed to page when theyneeded assistance with a patient lift. Evaluationtools were developed based on information in

Patient Care Ergonomics Resource Guide: SafePatient Handling and Movement [15]. Some ofthe important criteria used to evaluate the equip-

ment were staff and patient input on overall com-fort and ease of use, power source requirements(battery versus electrical), design and ease of use

of slings, weight capacity, and clinical supportavailable for implementation success.

Ceiling lift trials were more complicated.

Ceiling lifts from the same three vendors weretrialed. One particularly successful trial had ceil-ing lifts from two vendors installed in one clinicfor approximately 1 month. With this setup, the

clinic could compare the lifts side by side. Anunanticipated outcome from the trial was thatwhen the trial ended, the staff did not want the

ceiling lifts removed! They had grown accustomedto them and wanted them to stay for patient useand staff safety.

Securing financial supportIn the spring of 2002, the ergonomics task

force submitted a capital request to the capitalbudget team for a 3-year comprehensive ergo-nomics program. NIOSH recommendations,

OSHA guidelines, and key literature findings forsafe lifting were presented [7,15,16]. The relation-ship between the project and the institutional stra-

tegic plan was articulated. Lost workdays,number of injuries, and workers’ compensationcosts associated with patient exertion injuries in


the department of nursing were chosen as the out-come variables. An estimated projected cost of in-juries and a return on investment that could be

captured within 3 to 5 years were demonstrated.Institutional support was shown when the

capital request was funded 100%. The ergonomicproject was funded for $667,116. Some of the

units of nursing had unit money available topurchase two stand assist, three total assist, twoceiling motors and track, and lateral transfer

devices. This was a good pilot for use of theequipment by different vendors and the informa-tion that was obtained in their clinical application

was used in making the decisions for standardizedcapital purchased equipment. Just buying theequipment and offering education on how to usethe equipment was not enough for the health care

providers to choose to use the equipment. Therewere fears of using the equipment, lack ofconfidence that the equipment made a difference,

and lack of active support from peers or manage-ment for the health care provider to take the timeto use the equipment, especially if the equipment

was not located easily.

Designing practice guidelines and implementing

the practice change

Once a practice change is decided on, the IowaModel directs developing practice guidelines. Thenext step is implementing the change [11,12].

In late 2002, plans ramped up to adopt andintegrate safe patient handling program intopractice throughout the institution. This phase

included selecting the equipment, developing pol-icies and procedures, obtaining management sup-port, and educating staff in how to use the

equipment and to coach their peers to use theequipment. It continued with empowering keycoaches, who were all nurses and patient handlingprofessionals, improving the belief among staff

that moving patients with minimum lift tech-niques is best practice for staff and patients.

Selecting equipment

In October 2002, equipment was selected,

ordered, and allocated based on data from theunit and clinic assessments done in the spring.Originally, it was believed that equipment might

be shared between units and clinics but in thepilot, there was too much manual patient han-dling occurring to depend on sharing equipment.

The purchased equipment fell into five cate-gories: minimal stand assist; stand assist; totalassist; repositioning aids, including lateral transfer

devices; and ceiling lifts. The minimal assist deviceis used to assist patients who have upper bodystrength and the ability to bear weight but needassistance to get to the standing position. It also is

used to transport patients in a sitting positiona short distance. It requires no battery or electricalsource and has a 265-lb weight capacity. For

example, the labor and delivery unit in the hospitaluses these to assist new mothers recovering fromrecent epidurals or who have pain management

regimes. It also is useful for patients who needassistance getting to a bathroom quickly.

The stand assist device is used for patients whodo not have the strength in their upper body to

assist them stand but can bear at least 50% oftheir weight with at least one leg. A belt is appliedaround the waist and the machine helps support

the patient stand. It has a 420-lb weight capacity.The machine has a commode attachment so thatpatients can be raised and lowered on a commode.

This lift feature makes it easier for caregivers toprovide necessary hygiene after toileting. Patientsfind this device helpful. One patient, who had

been diagnosed with a recent stroke, requestedthis ‘‘purple pooping machine,’’ because it didnot require him to have to use a bedpan andgave him some privacy during bowel movements.

This machine also is used as a bridge to indepen-dence when patients need short-term assistance instanding up as strength is built up. Physical ther-

apists use the device for patients who are takingtheir first steps after a period of immobility.

Two kinds of portable total assist devices were

purchased. The device used most commonly hasa 440-lb weight capacity and can be used to movepatients from laying-down, sitting-up, and on-the-floor positions. Patients do not have to follow

instructions and can depend totally on the lift. Thetotal assist also has a scale that has proved helpful.

The other total assist device was developed to

assist patients getting out of a car. The emergencydepartment and guest services department havefound this device invaluable in getting patients out

of a car. A sling is placed behind a patient,wrapped around the patient’s legs, and thenattached to the machine, which moves the patient

out of the car. Patients note that using the machineto get them out of the car is less painful comparedwith manual movement. This portable dependentlift also is used in clinic areas, as it folds up and

requires less room to store. It can be used in the

218 STENGER et al

same situations as the other total assist lift exceptthat it has a lower weight capacity, at 308 lb.

Lateral transfer devices are used to repositionpatients in bed and transfer patients from one

horizontal surface to another, such as bed to cart.A lateral transfer kit was purchased that includedtwo 6-ft slippery sheets with handles and a small

orange tube. The sheets are placed under patientsto reduce friction when moving in bed. There aremany applications for these devices, including

sliding patients up in bed, turning them, pronatingthem, and transferring them from a cart to bed.

An air lateral transfer device is helpful when

moving patients of size up in bed or laterally toanother surface. An electrical motor supplies thepower to expand the attached mattress with air.The result is the creation of an air mattress that

reduces the friction greatly beneath patients dur-ing lateral transfer. There is no reduced frictionwhen the air is not in the mattress, so patients may

lay on them safely, when the head of a bed is up,without sliding down. This apparatus is usedfrequently under surgical patients of size for easier

transfer to and from perioperative surfaces.Ceiling lifts are total assist devices that can be

used with many patient handling tasks. Assisting

patients from a wheelchair to a cart was a difficult,high-risk manual patient handling task beforeceiling lifts were installed.

Developing policies and procedures

A policy guideline was developed addressinghow the program would run and how the equip-

ment would be used. The policy comes short ofmandating equipment use. We allow choice by thecaregiver, but do follow-up, counsel, and poten-tially address disciplinary actions if injury occurs

and equipment is not used.

Educating staff and obtaining management support

By December 2002, the initial order was placedfor equipment and the task of extensive educatingstaff begun. At the same time as the equipmentwas purchased, a 3-year contract for clinical

support was signed. The clinical consultant as-signed to the hospital by this vendor presented tothe hospital management staff and nursing leader-

ship to map out the proposed education imple-mentation process. She also offered a 2-hourmeeting at several different times and days for

nurse managers to attend to provide an overviewof the proposed safe patient handling programand outline the key role nurse managers would

play to change culture on their units. Nursemanagers were asked to identify staff that wouldserve as transfer and mobility coaches, or keycoaches. These key coaches would be instrumental

in implementation of the safe patient handlingprogram. They included managers, staff nurses,advanced practice nurses, nursing assistants, nurs-

ing units clerks, and physical therapists. What isimportant is that they have passion to create theculture of change and eventually role model safe

patient handling skills in their respective units.The institution chose to roll out the equipment

and educate on the equipment by divisions of

nursing (ie, adult intensive care and specialtyservices, medical and surgical services, women’sand children’s services, and behavioral health andperioperative nursing areas). Key coaches were

taught by the clinical consultant in an 8-hourtraining session the week before divisional stafftraining. Four 8-hour classes of key coach training

were offered. Ten to fifteen staff members servingas key coaches were trained each day on ergo-nomic and coaching principles. The clinical con-

sultant worked with the nursing education centerto develop competency-based orientation check-lists for staff to use. One of the first responsibilities

of key coaches was to sign off, with returndemonstration, the staff on their unit as havingtrained on all the equipment.

The rest of the staff, who were not key coaches,

attended a 2-hour training session added to theannual mandatory competency sessions. Thisstrategy was a convenient way to educate staff

on a day when they were not responsible for directpatient care. The clinical consultants taught the2-hour class with content on risks of manual lifting

and how to use the new equipment. To assurethe ability to train individuals adequately, up to6 rooms of classes were running simultaneously sothat no more than 15 staff members were in a room

at one time. By the end of March 2003, all nursingunits had key coaches and staff trained. Allequipment was distributed to the units.

Evaluating the outcomes

Once a practice change is infused, the Iowa

Model directs evaluating the process and outcomes[11,12]. The outcomes were selected to monitorthe number of injuries, lost workdays, and cost.

Staff outcomes

Anecdotally, the staff have been impressedfavorably. One staff member left a picture of the


stand assist device on the door of her unit nursemanager, reading, ‘‘Please hire 6 of these folks!’’Another nurse noted, ‘‘I was going to have to

leave this unit because of all of the lifting, nowwith the equipment, I can stay.’’ Another said,‘‘We had to pick a patient up off the floor. Wewent and got the (total assist). I think we saved

four back injuries.’’ Staff on one unit, who werecaring for a paraplegic patient, commented posi-tively on the ceiling lift. The staff previously

would try to lift the patient manually to see allof his wounds. This was a difficult and risky taskfor staff and embarrassing for the patient. With the

new ceiling lift available, they were able to use themachine to provide the necessary wound assess-ment while maintaining the patient’s dignity.

Specific indicators used to analyze the effec-

tiveness of this project included lost workdays,workers’ compensation costs, and the number ofOSHA recordable patient exertion injuries within

the Department of Nursing Services and PatientCare (Table 1). From 2002 to 2004, lost workdaysdecreased from 2881 to 529, a 76% reduction. In

addition, the cost of replacing an injured em-ployee in the workplace can be substantial. IfUIHC replaced every one of the 2352 lost work-

days with another employee, it would be equiva-lent to the hiring of nine full-time employees.The cost estimated for nine RN full-time em-ployees salaried conservatively at $66,000 per

year (including benefits) would be approximately$600,000. From 2002 to 2004, workers’ compensa-tion costs fell from $559,610 to $84,880, indicating

an 85% reduction. In 3 years, UIHC reducedworkers’ compensation costs by more than$475,000. UIHC also has seen a reduction in the

number of OSHA recordable patient exertions.From 2004 to 2006, recordable exertions de-creased by 18%, from 92 to 75. It seems that theinstitution recovered the initial investment and

noted a reduction in the number of claims.Although the OSHA recordable rates do not

continue to decline, there has been a decrease in

severity, something Dr. Nelson said likely wouldoccur (Audrey Nelson, RN, personal communi-cation, 2004). Building a culture of safety often

resolves the musculoskeletal injury underreport-ing problem that has plagued nurses for years.Effective programs are more likely to see a possibleincrease in injury rates but a significant decrease

in severity of injuries (fewer lost workdays andlower workers’ compensation costs). Most of thecurrent injuries seem related to moving patients

up in bed or moving and lifting obese patients. Inmany of these situations involving obese patients,proper technology and equipment do not exist or

are in early stages of consumer use.

Patient outcomes

Several patients have commented favorably

about the ergonomic equipment. Some of thecomments included, ‘‘Please use the machineinstead of lifting yourself’’ and ‘‘Since I have

had bone cancer, I haven’t been moved thispainlessly.’’ A patient had been in one of theadult ICUs for a long time before being trans-

ferred to an intermediate care unit. He weighed400 lb. He had not been out of bed, because thestaff could not move him. Physical therapy hadconvinced him to try the stand assist device. He

did so and eventually was able to progress to fullmobility. His story eventually was included in theUIHC annual report, because the patient wanted

to tell others that ‘‘I would have never got out ofbed if it wasn’t for that machine’’ [25].

Disseminating the results

The final step of the IowaModel [11,12] is to dis-seminate results. UIHC is dedicated to keeping asmany people as possible updated and aware of their

work. Injury data is shared on a monthly basis atthe UIHC’s Environment of Care Committee,which reports directly to the Hospital AdvisoryCouncil. On a quarterly basis, two of the authors

(Stenger and Montgomery) make rounds of thenursing shared governance committeesdincludingthe nursing administration council, advanced prac-

tice nurse council, and staff nurse councilsdtoshare injury data trends, training plans, equipmentissues, and previous and current challenges and

successes. Annually, the work was and continuesto be reported to hospital administration throughyearly reports or project summaries.

Table 1

Annual report of patient handling figures

Annual report 2002 2003 2004

Number of claims 92 83 75

Lost workdays 2881 1020 529

Workers’

compensation

costs

$559,610 $245,677 $84,088

Equipment

expenditures

d FY2003

$667,116

d

220 STENGER et al

Lessons learned

Some valuable lessons have been learned in thecourse of overseeing this project. It was essentialto partner with the Joint Office for Marketing and

Communication to get the word out throughflyers, broadcasts, and internal media to anydepartment affected even remotely by the project.

Secondly, it is important to partner with preferredvendors. They can be excellent sources to assistwith trouble shooting, maintenance and replace-

ment of equipment, and product growth. Third,key coaches are great change agents at the localunit level. They are truly the ones who affect

practice and change the cultural mindset of peersand patients. Monthly key coaches meetings areessential to keeping this group empowered andupdated regarding safe patient handling practice.

Units that have active key coaches have a highercompliance of using the ergonomic equipment.Fourth, it is important to know upfront that safe

patient handling skills take time to develop andpersistence to sustain. In this case, initial compe-tency activities and related documentation took

a year for 1500 employees. Fifth, as any newpractice, there is a need to constantly re-educatestaff and re-infuse the desired practice. Coordina-

tors have to keep this goal continually on every-one’s radar. Sixth, share the ‘‘numbers’’ andstories with shared governance councils and lead-ership. It is essential that managers in key units

know how the program is progressing so thatthey can role model necessary practice improve-ments for staff and keep the practice changes go-

ing. Seventh, be prepared to make adjustmentsin current equipment or any purchased in the fu-ture. The ergonomic equipment purchased must

interface safely with other hospital equipment.For example, one lift purchased did not fit undersome of the beds. The bed casters were too low tothe floor. These casters had to be changed out to

larger ones. Such findings were commonplace inremote areas of radiology, for example, so be pre-pared. Eighth, ‘‘think ergonomics’’ when planning

construction and renovation projects. It is easierto build with these needs considered upfront in-stead of trying to retrofit equipment into existing

plans, especially ceiling lifts. Step up and suggestthat ergonomics considerations be added to everyconstruction renovation plan in your institution.

Ninth, a consistent process for ongoing educationof new health care providers is vital. Return dem-onstration here assures check-off lists are com-plete. Content in annual competency sessions

also is important to portray the importance ofsafe patient handling and assist staff in feelingcomfortable and proficient in use of the equip-ment. Tenth, include other health care providers,

such as radiologists, on the task force. Theyhave many high-risk tasks that can be performedin a safe manner with the use of the equipment.

Finally, if the initial ordering were repeated,more portable and ceiling total assist lifts wouldhave been purchased. The need for these in this in-

stitution was grossly underestimated.

Are you moving patients safely?

Most back injuries are the result of physiologicillnesses that develop over a period of weeks,months, or years as a result of prolonged me-

chanical stressors imposed on the musculoskeletalsystem. Research indicates that lifting more than51 lb under ideal conditions is not recommended

[7]. Nurses, however, routinely believe 100 lb islightdbut it is not. All health professionals areasked to stop and consider this fact carefully be-

cause every one of us is too valuable to risk beinginjured as a result of not taking time to plan aheadand move patients safely using lifting and moving

equipment.

Acknowledgments

We would like to acknowledge the followingstaff for their assistance in developing this man-

uscript: Linda Q. Everett, RN, PhD, CNAA, BC,FAAN, Associate Director, University of IowaHospitals and Clinics and Chief Nursing Officer,

and Linda K. Chase, RN, MA, CNAA, SeniorAssistant Director–Nursing Administration, foradministrative support; Becky Hurt, Secretary III,Nursing Clinical Education Center, and Shellee

Laubersheimer, Secretary IV, Nursing Adminis-tration, for clerical support; and David Hack-barth, Safety Engineer, Health Protection Office,

for data analysis support.

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http://www.nursingworld.org/readroom/position/workplac/pathand.pdf

http://www.nursingworld.org/readroom/position/workplac/pathand.pdf

http://nursingworld.org/ojin/topics25/tpc25_2.html

http://nursingworld.org/ojin/topics25/tpc25_2.html






Handling of the Bariatric Patient in Critical Care:A Case Study of Lessons Learned

Marylou Muir, RN, COHNa,*,Gail Archer Heese, BEd, OTR, BMRa,

Daria McLean, RN, COHN(C)a, Sheila Bodnar, RN, BNb,Betty Lou Rock, RN, BNc

aWinnipeg Regional Health Authority (WRHA), Occupational and Environmental Safety & Health Unit,

Health Sciences Centre Site, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, CanadabMedical Intensive Care Unit and Coronary Care Unit, Health Sciences Centre,

820 Sherbrook Street, Winnipeg, MB, R3A 1R9, CanadacWRHA Critical Care, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada

Literature review

The World Health Organization [1] has identi-fied that the obesity epidemic is increasing atalarming rates across all developed nations. Seen

as one of the most significant worldwide healthproblems, it is estimated that more than 1 billionadults worldwide are overweight and 300 million

are obese [2,3]. In the United States (US) alone,the incidence of obesity has doubled in the pastdecade to 38 million, 9 million of whom are cate-gorized as severely obese. This increase is occurring

in both genders and across age groups, races, andeducational levels [4]. The obesity epidemic coststhe US health care system $70 billion per year [5].

The direct medical costs attributable to adultobesity in Canada were estimated at $1.8 billionin 1997 or 2.4% of total direct medical costs [6].

Bariatrics is the science of providing healthcare for the proportion of the obese populationconsidered to suffer from extreme obesity. Bari-

atric patients are described by the followingdefinitions: overweight by more than 100 to 200lb and body mass index (BMI) greater than 40, orbody weight greater than 300 lb [7].

The increased number of bariatric patientsrequiring hospitalization and critical care matches

the increase growth in the population at an

epidemic proportion [8]. The current trend oftreating these patients through bariatric surgicalinterventions has contributed to increased admis-

sions into critical care units because of postopera-tive complications [8]. One study identified that upto 24% of bariatric surgery patients required ad-

mission to a critical care unit [9]. Nonsurgical ad-missions of bariatric medical patients to criticalcare areas also is increasing. Unfortunately, thereis a high mortality rate for these patients because

of patient delay in accessing treatment. It is be-lieved that one reason patients delay access totreatment is the inability of communities to ac-

commodate patients with expanded capacityequipment needs in medical clinic settings [9]. Ofpatients currently who are admitted to critical

care units, the prevalence of (US) patients whohave extreme obesity ranges between 1.4% and7% [10–12]. The mortality of those who are obese

in ICUs has a reported odds ratio of 2:1 comparedwith patients within normal weight ranges [13].

Nurses are challenged when caring for bariat-ric patients, because tasks require increased time

and additional patient handling solutions andskills [14]. Inappropriate equipment or staffinglevels are identified as contributing factors that

lead to staff reluctance to provide care [7]. A sur-vey of the University Health System Consortiumreports that 39% of reported accidents or


E-mail address: [email protected] (M. Muir).





equipment-related problems are related to bariat-rics [15]. The same survey reports further that55% of nursing personnel report injury claims re-

lated to providing patient care. Patients them-selves also report claims, 18% of which arerelated to equipment inadequacies [15]. Overall,data addressing bariatric patients who are criti-

cally ill are scant and information on patient han-dling issues is even less available. There are toofew publications dealing specifically with patient

handling techniques and recommendations to as-sist with strategic management of these patients.

The emotional task of caring for these patients

also is affected by the high rates of morbidity andmortality in a young population. Several studieshave documented health care worker and physi-cian negative attitudes and stereotypes, including

fear of injury, disgust, or anger, which hasa negative impact on patient care [16,17].

Health Sciences Centre, Winnipeg, experience

TheHealth Sciences Centre (HSC) is a teaching,tertiary care facility in the core area of Winnipeg,Manitoba, Canada, which has a population of

600,000. The facility does not have a bariatric sur-gical program, yet receives an average of 30 to 40bariatric admissions per year. The definition used

to identify bariatric patients in this facility is weightover 350 lb. The most common weight range of ad-missions to the facility during the past 5 years wasin the 400- to 450-lb weight range (Fig. 1). During

a 5-year period (2001–2005), nurses requestedassistance consultations on patient handlingtechniques for 78 bariatric admissions (54 men

and 24 women). These patients were admitted formedical issues needing treatment, with approxi-mately 37% admitted to critical care units.

Bariatric patient handling resources

Over the past 10 years, the HSC has evolved inits provision of supports for bariatric admissions.

The facility has made provisions to assist nurseswith the necessary knowledge that is outside thenurses’ usual knowledge base. Equipment andpatient handling guidelines, access to patient

handling education, and corporate policies aresome of the ways HSC can ensure health carenursing personnel provide sensitive and dignified

patient care in a safe manner for themselves andpatients. Details of tools in place include

� Bariatric patient handling policy: identifiesadmission process, current list of and accessto equipment, team members, and methodof consulting (Fig. 2).

� Patient handling education: all new em-ployees receive a 3.5-hour class on minimal-lift patient handling. Nursing personnel are

asked to contact the trainers in the event ofbariatric admissions or transfers to assistwith specific bariatric patient handling tech-

niques and equipment needs.� Bariatric patient handling algorithms (Figs.3–7): each unit has access to a binder thathas algorithms for safe patient handling tech-

niques. These algorithms were adapted fromthe patient care and resource guide from theVeterans Affairs (VA) Patient Safety Center

of Inquiry in Tampa, Florida, directed by Au-drey Nelson. There are five algorithms specificto bariatric patient handling tasks. These

tools assist nursing personnel in identifyingthe safest methods for patient handling tasksbased on patient assessment and equipment

available.� Bariatric patient assessment tool: a tool usedto identify the equipment and procedure forproviding care to patients (Fig. 8).

� Bariatric safe patient handling work proce-dures: these are provided to nursing personnelin a written format. They describe the step-

by-step procedures for the associated patienthandling tasks when repositioning or transfer-ring bariatric patients using slider sheets.

� Bariatric equipment pool: the patient equip-ment services department provides expandedcapacity equipment to the units on request.Items available are lifts, slings, friction-reduc-

ing devices (sliders), beds, wheelchairs,stretcher chairs, footstools, commode chairs,and walkers.

051015202530

Nu

mb

er o

f

Patien

ts

300Lbs

350Lbs

400Lbs

450Lbs

500Lbs

550Lbs

600Lbs

650Lbs

700Lbs

750Lbs

With Weight Above

Fig. 1. Bariatric patients assessed on admission from

2001 to 2005. (Courtesy of the Health Sciences Centre

and the Winnipeg Regional Health Authority, Winni-

peg, Manitoba, Canada; with permission.)

224 MUIR et al

Fig. 2. Patient care policy and procedural manual of the Winnipeg Regional Health Authority. (Courtesy of the Health

Sciences Centre and the Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; with permission.)

225BARIATRIC PATIENT CARE: LESSONS LEARNED

Fig. 2 (continued)

226 MUIR et al

� Injury prevention training supports: resourcesare available for staff concerning any patienthandling or mobility difficulties from variousdisciplines. Allied health, including physio-

therapy, occupational therapy, and patienthandling trainers from the occupational andenvironmental safety and health unit are

available for consultation. Most commonly,staff request hands-on participation from thetrainers, especially during difficult patient

handling tasks. Most requests are made inthe early stages of admission or until theyfeel proficient to manage the techniquesindependently.

Process for the management of admission

When bariatric patients are admitted, corpo-rate patient care policy requires that a nurse

identify the equipment and training needs forthe unit and the health care needs of the patients.The nurse consults the patient handling manualon the unit that identifies available equipment

with its weight capacity, safe patient handlingalgorithms, safe work procedures, and a patientassessment tool template. Additionally, the nurse

determines if the space assigned is adequate forpatients’ care and their specific equipment needs.If patients require expanded capacity equipment,

the policy allows a two-patient bed space to beconverted to a one-bed space. The nurse alsodetermines the need to consult the appropriateresources for any assistance required. Team mem-

bers who may be consulted include, but are notlimited to, the following: physician, ergonomist,occupational health nurse, safety technician, phys-

iotherapist, occupational therapist, wound carespecialist, dietician, maintenance technician, andunit manager.

Fig. 2 (continued)


Fig. 2 (continued)

228 MUIR et al

Fig. 3. Bariatric patient handling algorithm #1. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-

source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department

of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)


http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf

Case study

History

Mr. B was a 42-year-old man. His admissionweight was 697 lb, height 6 ft 2 in, BMI 91. Until

his illness, he was employed part time, able to

ambulate one block with a cane before becomingfatigued, and independent with hygiene, meals,and laundry. He lived with his stepmother in

a bungalow. His father had passed away 3 weeks




230 MUIR et al





232 MUIR et al


before his admission. His medical history included

a diagnosis of rheumatoid arthritis, gout (mostlyaffecting his knees), and type 2 diabetes mellitus.Three days before his admission, he experiencedshortness of breath on minimal exertion. He called

an ambulance and on arrival at the emergencydepartment was unable to bear weight or maintaina sitting position. He was admitted because of

coffee ground emesis and abdominal pain, de-creased blood pressure, and decreased level of

consciousness. He was given blood products and

intubated for respiratory ventilation. He pro-gressed to develop bacteremia, acute renal failure,and elevated liver enzymes. Because of fluidretention, his weight elevated to 712 lb. He

remained in the ICU for 95 days.

AdmissionWhen Mr. B was admitted, the unit contacted

the patient handling team to assist in applying






techniques required to reposition, weigh, sit up,

and transfer the patient. Medical problems, suchas diabetes, cardiovascular disease, hypertension,stroke, certain types of cancer, and osteoarthritis,

commonly associated with bariatric patients, can

contribute to difficulties during patient handling

tasks [17,18]. The patient assessment of Mr. Bidentified several medical problems that requiredattention during patient care and handling

activities.

Patient: Weight: Height:

Ward: Room#

Assessed by: Date assessed:

Position of Assessor: Strong side: Right Left

Staff has reviewed Large Patient Handling Guidelines

Capabilities of Patient: Requires the Following Large Patient Equipment (Equipment Pool # 5031):

Ambulatory Total Body Mechanical Lift Ambulatory with assistance (large walker)

Wheelchair

Non weight-bearing Stretcher Can move in bed without assistance Commode Can move in bed with assistance Slider Board Cannot assist movement in bed at all Step Stool

Walker Armchair and footstool Reclining stretchair Bed Slider sheets

Is the bed on the ward appropriate for this patient? Yes No, large person bed has been requested

Patient Handling Requirements (Review Large Patient Handling Guidelines):

Task# of Staff Members

RequiredType of Equipment

Required

Bed Boost

Bed Turn

Side to Side Movement in Bed

Bed to Stretcher Transfer

Bed to Chair/Commode Transfer Transport Within the Hospital

Comments:

Fig. 8. Large patient assessment checklist (for nursing care plan). (Courtesy of the Health Sciences Centre and the

Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; with permission.)

234 MUIR et al

Respiratory status. The patient required intuba-tion, resulting in a tracheostomy and ventilation.Elevation of the head of the head of the bed wasrecommended to facilitate breathing compro-

mised by the weight of the chest wall, andimpingement of the thoracic cavity by the largeabdomen and fat deposits in the intercostals and

diaphragm [7,19]. Lowering of the head of the bedwas limited to short intervals during turns and re-positioning, as the patient could tolerate the flat

position for only 5 to 10 minutes.

Central nervous system. There were times whenthe patient was semicomatose and confused be-

cause of sepsis. At times he was not able to assist,follow directions, or assist with repositioning.

Gastrointestinal and genital urinary. The patient’snutritional needs were met with tube feeds formost of his admission in the ICU. His weight

reduced from 697 lb to 550 lb during 13.5 weeks ofhis stay in the ICU. Because of tube feeds, thepatient had frequent diarrhea. He was incontinent

of urine and spent time in renal failure. A Foleycatheter and Bardex rectal tube were in place toassist in monitoring output and assist in prevent-

ing further skin breakdown.

Immune system. Isolation was required because ofpoor immune response, partly from pancytopenia.

A private room was provided.

Musculoskeletal. The patient had severe weaknessand poor strength in arms and legs. He was ableto assist with upper body strength during turns

using the overhead trapeze bar when he wasconscious. His legs were weak and he was unableto move them independently or turn his body

from side to side.

Skin integrity. Skin integrity was compromised

from the excessive skin folds and poor nutritionalstatus, including diabetes. He had a pressure ulceron the coccyx and thigh and leg ulcers. A low air-

loss pressure reduction mattress and friction-reducing devices during turns, with close attentionto skin integrity, were required.

Psychosocial. The patient was grieving the recentdeath of his father. He had some family members

and co-workers visit during his admission butoften was too ill for social visits. Despite hissituation and isolation, he did not demonstratea depressed mood often. He always was thankful

for his care.

All of these medical conditions are not un-common for bariatric patients and are welldocumented in the bariatric literature [7,14,19].

The critical care unit

The critical care area in this case study islocated at the HSC. The unit is a 10-bed care unit

specializing in care for critically ill patients andalso houses a 6-bed unit for intensive coronarycare. Most nursing personnel follow a 12-hourshift rotation.

Annual training refresher courses and newemployee orientation are provided on patienthandling techniques to the medical ICU nursing

personnel. Friction-reducing devices (slider) use isencouraged for turning the patients on a bed,boosting patients up in bed, and during lateral

transfers. Mechanical patient lift devices are pro-vided for bed-to-chair transfers. In the case of thisbariatric admission, further assistance was re-

quired with hands-on teaching in the unit.

Patient handling equipment provided

The following equipment was provided for thepatient; some was available on site, and others

had to be rented:

� Bariatric bed with rated weight to 1000 lb and

a 48 inch sleep surface� Three double-width bariatric slide sheets (fric-tion-reducing devices)

� Mechanical lift with scale and capacity tomanage up to 1000 lb� Custom bariatric sling

� Wedge pillow, to maintain turning postures� Pressure-reduction, low-air-loss mattress� Stretcher chair

� Standing tilt table� Overhead repositioning trapeze bar� Step stool or bench for nursing personnel tostand on

Patient handling tasks

Table 1 reviews the patient handling tasks, thetechnique, equipment used, and the number ofpeople required. The desired outcomes from the

patient handling tasks included maintenance ofskin integrity to prevent further breakdown; facil-itating circulation to the heart, lungs, and extrem-

ities; monitoring the patient’s weight; meetinghygiene care needs; preventing infections; provid-ing a safe patient handling environment, thus


preventing injuries to health care nursing person-nel and to patients; maintaining or encouraging

patient strength in extremities; and providinga dignified respectful environment during allinteractions.

A daily patient handling care plan schedule forrepositioning was designed and posted. During therepositioning procedure, several other activities,

such as hygiene care, wound care, and pericare, alsowere provided. This included deflation and reinfla-tion of the Bardex tube, during each turn,

assessment and adjustment of the Foley catheter,treatment of skin excoriations in creases, and treat-

ment of any wounds. Most tasks required 6 to 8nursing personnel. Six nursing personnel were inposition to perform the maneuver using sliders;

the other two nurses provided the necessary treat-ments. Every other day, the procedure also in-cluded weighing the patient using a mechanical

lift. Changing of bed linens and insertion and re-moval of the bariatric sling were required at thistime. On two occasions, the patient was lifted

Table 1

Patient handling tasks

Patient handling task

Number of

nursing staff

Equipment

required Algorithm Technique

Repositioning in bed 8 Two double-width

sliders

Overhead trapeze

bar

#3 Slider insertion

with head-to-toe unraveling

Changing bed linens 8 Completed during

turns using sliders.

Also done when

up in lift

N/A

Weighing patient 6 Lift (Titan 1000 lb)

with

scale and sling

N/A Sling insertion

between two sliders

technique

Transferring patient

to stretcher chair

8 Three double-width

sliders

#2 Lateral transfer technique

Transferring patient

to alternate bed

8 Mechanical lift

(rated to 1000 lb)

with sling

#2 Sling application

using slider insertion

method

Lifting patient

with mechanical lift

device and suspending

in air while

bed switching occurs

Transfer patient

to standing tilt table

8 Three double-width

sliders

#2 Lateral transfer

with sliders

Chairing patient

in cardiac chair position

1 Bed with

cardiac chair

feature

N/A Using bed technology controls

Hygiene care

to abdominal groin Area

4 Long sheet

fan folded

#5 One nursing

personnel stands on each

side of bed facing

patient’s feet; the sheet

is fan folded,

placed against the abdomen,

and used to lift

the abdomen during

hygiene care

Accessing patient

(lines, tracheostomy,

and so forth)

1 Platform to stand

on to elevate

nurse to proper

height

N/A Teaching nurses

to not over

reach during care

236 MUIR et al

with the mechanical lift to facilitate a well-coordinated bed transfer (removal of one bed andprovision of another). When a lateral transfer wasperformed, six people performed the maneuver

while one observed the patient and another ob-served the patient lines (IV central lines, intubationequipment, Foley bags, and Bardex).

Lessons learned

The technology of bariatric equipment hasimproved greatly during the past 5 years withnew and emerging equipment designed that ac-

commodates these patients. Although equipmentmay be rated for increased weight, it often is notdesigned properly to accommodate the increased

size of patients (Table 2). The purchasing facilityshould put more emphasis on patient assessmentand equipment fit, instead of weight capacity.This applies to wheelchairs, commodes, stretchers,

walkers, and beds. Companies that manufactureequipment need to solicit more feedback relatedto equipment design needs from facilities’ front-

line health care nursing personnel.

Lift choices

A lift from another facility was borrowed, as

that in the HSC were weight rated to only 600 lb.A floor lift was used but found difficult to maneu-ver under the load during bed transfers. A ceiling

lift would have been easier to use under the cir-cumstances as the space and exertion require-ments would have been less.

Sling design

A sling should not bind or cut into a patient’sthighs nor should it constrict the shoulders. It

should provide good support and not be uncom-fortable. Currently, there is a limited choice inbariatric sling sizes. Regular lift slings are provided

in a range of six sizes for patients weighing from 35lb to 500 lb; however, it is common to find that onlyone sling is provided for patients spanning 500 lb to1000 lb. A patient’s individual body type, height,

and individual physical characteristics complicatea sling’s fit further. A custom sling needed to beordered for this patient at his initial 750-lb weight,

although the ones provided with the lift could beused when his weight decreased to 500 lb. In anideal situation, a facility should have a range of at

least four bariatric size slings tomeet different bodytypes. Additionally, extra slings are needed toenable the slings to be sent for frequent laundering.

Bed design

The bed manufacturers have improved selec-tion and the ability to accommodate bariatricpatients by providing beds that can expand and

adjust to several sizes. When fitting a bed toa patient, ensure that the bed is the right size. Asleep surface that is too small limits the patienthandling maneuver; conversely, too wide a bed

surface causes the health care nursing personnel toover-reach. Bariatric beds need to lower beyonda regular bed capacity. A patient’s body thickness,

increased air mattress thickness, and the need tohave the head of the bed elevated puts a patientout of reach of health care workers almost

constantly. The need to access a patient throughover-reaching resulted in a shoulder injury to oneof the nurses. Also, the authors have foundinstances when a patient could not reach the floor

to stand, as the bed was too high. The bed must beeasy to set up and transport in a quick and easyfashion, between units. A bed that can be reduced

to 39 inches will fit through most facility door-ways and then be expanded to the necessary widthto accommodate patient size once in the room is

optimal. The facility experienced many difficultieswhen transferring the patient’s bed betweenthe units. The patient could not be transported

in the bed because of a width of 48 inches. Thus,the patient had to be removed and the beddisassembled and reassembled manually at thedestination. Some newer bed designs have a power

transport feature, preventing worker exertion.Additionally, equipment tuggers to move thebeds are another option.

Bed mattress

The facility bed comes with a regular foam

mattress. In this case, it was not effective inpreventing skin breakdown to the patient. A lowair-loss mattress was rented rated for 1000 lb. The

mattress available for rent was only 39 in wide, sobolsters were placed on either side, to fill theremaining space. The bolsters were problematicwhen the patient was dangling, as they separated

from the mattress and needed extra reinforcementwith duct tape. Although the mattress did not fillthe entire bed space, it worked well to facilitate

skin integrity. The mattress did not inflate underload and the patient needed to be removed fromthe mattress to reinflate it. The variable pressure

oscillation on the mattress was a great feature. Itrotated pressure relief to varying parts of thebody using cyclical timed intervals.


Table 2

Problems and solutions associated with patient handling tasks

Problems Action taken Future recommendations

Recruiting enough nursing

personnel to assist with

repositioning, especially

scheduled turns.

Unit manager and director

arranged with other

managers to send staff

to assist at designated times

(every 3 hours).

Light refreshments were provided

as a gesture of appreciation for

those that attended.

Have a designated scheduled time, with

people identified to attend from other

units.

Provision of snacks as a goodwill

gesture of thanks.

Knowledge on techniques varied

between staff and shift changes.

Hands on and reinforcement of

techniques needed frequently.

Trainers consulted 2–3 times per

day initially. This decreased

to once daily and then on

request only.

Trainers needed to be available

to problem solve for

unexpected events. Otherwise

trainer’s attendance was

scheduled.

A draft manual with techniques,

protocols and algorithms

was provided as a resource

and kept on front of the chart.

Designated trainers in critical care units

need to be identified, trained, and

supported to problem solve and be

available more readily to their own

staff for when admissions occur.

Algorithms and safe work procedures

should be posted in room for easy

reference.

Transfer of knowledge and skills

when patient transferred to

another ward limited.

Critical care manager arranged

for critical care staff to attend

the unit on several occasions to

ensure transfer of knowledge.

Experienced unit needs to communicate

and visit receiving ward to pass on

information (unit transition

planning)

Bed needed repairs.

Patient had to be transferred

into a rented bed. The bed

available for rent was too

small for the patients needs.

Rush on bed repair ordered

Instruction booklet left at

bedside

Patient instructed in bed use

so he also could direct staff

Post instructions on bed use at bedside

to prevent further breakage

Sling fit inadequate and

compromised skin integrity

on thighs.

Custom sling ordered Several size bariatric slings should be

available.

Weight rating on tilt table in

question.

Call to company confirmed

that tilt table capacity

reduced from 600 to 500 lb.

Discontinued use of tilt table.

Other means of maintaining and exer-

cising of legs needs to be explored.

Purchase higher rated tilt table.

Stretcher chair worked poorly

under load and was inadequate

in size to fit patient size.

(Although rated for 800 lb,

it was a poor fit for patient

at 550 lb.)

Only used as stretcher for

transport as patient had to

remain side lying.

Recommend purchase of larger chair

with hydraulic capacity and electrical

functions for operation. Communi-

cation to company redesign is

recommended.

Difficulty maintaining patient

on side lying (to prevent

pressure sores and promote

circulation and so forth)

as he would crush positioning

pillows flat.

Wedge cushions to maintain

patient side lying were designed.

Patient found them

uncomfortable

Cushions need to be covered and

padded.

Repositioning mattress may be a useful

tool.

(continued on next page)

238 MUIR et al

Patient transport

Transporting a patient who weights 710 lb andhas a girth greater than 70 inches on a 39-inchstretcher is a difficult task. A patient of this sizedoes not fit on a 39-inch stretcher comfortably

even if it is rated for 1000 lb. The stretcher-chairwas found too narrow for the patient at 32 in,even when his weight was 550 lb. Also, bariatric

patients require the head of the bed to be elevated,and the head elevation feature worked poorlyunder load. One option is to have a patient to

remain side lying and if the girth hangs over thestretcher, then abdominal binding may berecommended.

Space planning

During this admission to the critical care unit,the space required was beyond a normal cubicalsize. Initially, this need was met by using a two-patient bed space for the one bariatric patient;

once he was admitted to an isolation room, thespace was adequate to accommodate all theequipment and nursing staff.

Diagnostic imaging

The CT scanner entrance was only 39 incheswide with a table rated at 350 lb. Therefore, noCT scan could be done. No facility could provide

imaging equipment, such as CT scanner or MRI,that would accommodate the size of this patient

Other facility issues

Identification of pathways and department

capabilities to accommodate bariatric patientsalso must be planned. Operating room tables,elevators, and morgues may pose problems.

Worker education

Training and written resource guidelines canprovide general information. The ability of nurs-ing personnel to become proficient in caring forthese patients can be affected by the frequency and

time intervals between admissions. Providing re-freshers and ready access to the resources forsupport and training are required under these

circumstances.

Emotional supports

Nursing personnel often have an emotionalreaction to this type of patient admission, includingfear of injury, disgust, or anger that can have

a negative impact on patient care. As discovered inthe case history literature reviewed, this is notuncommon. It is important that employers identify

and communicate, as part of training, the expecta-tions for appropriate conduct of workers. Thecritical care nursing personnel filed several injury

reports initially on receiving the patient. As thenursing personnel were able to feel confident intheir techniques and became aware of the patient asan individual, they became more sensitive to the

patient, and there were no further reports filed. TheICU staff needed other patient care programs inthe facility to provide manpower and consultation.

The provision of these supports assisted the staff infeeling supported.

Summary

Prevention of admissions to critical care unitsmight be mitigated by providing improved pri-mary health care access. Currently, bariatric

patients avoid accessing medical treatment untilthey are in a serious health crisis. Unfortunately,there is a high mortality rate for these patients

Table 2 (continued )

Problems Action taken Future recommendations

Mattress inadequate for

patient care.(Bed came with

regular mattress and patient

experienced significant skin

breakdown.)

A low air loss mattress was rented.

The size available was a bit small.

Bolsters were provided to assist in

fitting the mattress to the bed.

Recommend purchase of our

own low air loss mattress, to

ensure availability and immediate

use,

and to reduce costs

Worker injury reported due to over-

reaching. Bed height did not lower

adequately for safe worker

ergonomics.

Platform provided at the bedside to

enable shorter nursing personnel to

reach over patient.

Straps attached to sliders for lateral

transfers.

Future bed purchase criteria requires

that bed have ability to lower to a

minimum of 15 in or less from the

floor.


because of this delay in accessing treatment. Thismay help explain why critical care units receivea large proportion of the bariatric admissions.

This case study reviews the techniques, equip-ment, and difficulties associated with a bariatricadmission to a critical care unit as it relates to thepatient handling perspective. The techniques dis-

cussed are limited to patient handling, not toclinical nursing issues. The practices discussed arelimited to this unit and do not review the type of

equipment, techniques, struggles, and solutionsthat are experienced on a regular or rehabilitationunit.

As technology advances and the stream ofbariatric patient admissions increases, nurses needto communicate their experiences to their peers sothat others can learn from each other’s experiences.

References

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6876443 Critical Care Nursing Clinics of North America Safe Patient Handling 2007

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