Work-related musculoskeletal disorders (MSDs) represent a significant occupational health challenge, particularly within the nursing profession. Among these, back injuries are the most prevalent and debilitating, impacting nurses’ well-being and career longevity. However, MSDs can affect various body parts including the neck, shoulders, wrists, and knees. Nurses consistently rank among the highest risk occupations for these disorders, highlighting a critical need for effective prevention strategies. Nursing aides, orderlies, and attendants are ranked second, and registered nurses are sixth in the list of at-risk occupations for strains and sprains, even surpassing professions like construction workers (seventh) and laborers (third) (United States Department of Labor [U.S. DOL], 2002). Statistics from 2000 further underscore this alarming trend, revealing that nursing homes reported an incidence rate of 181.6 back injuries per 10,000 full-time workers, and hospitals reported 90.1, significantly higher than rates for truck drivers (98.4), construction workers (70.0), miners (56.3), and agricultural workers (47.1) (U.S.DOL, 2000). In 2001, among registered nurses with cases involving days away from work (totaling 24,719), overexertion in lifting accounted for 4,547 cases, and sprains or strains for 14,832 (U.S. DOL, 2001).
Table 1. Ranking of Occupations at High Risk for Strains and Sprains in 2000, highlighting the elevated risk faced by nursing professionals compared to other physically demanding jobs.
The pervasive risk of musculoskeletal injury from manual patient handling affects all nursing specialties, placing every nurse at potential risk. This issue extends beyond individual nurses, leading to organizational challenges such as increased absenteeism, reduced productivity, burnout, difficulty in retaining experienced nurses, high turnover rates, and challenges in nurse recruitment. The high prevalence of MSDs within the U.S. nursing workforce is especially concerning given the existing nursing shortage, exacerbated by an aging workforce, declining retention and recruitment rates, and a perceived decrease in the social value of nursing.
The Institute of Medicine (IOM) in their report Keeping Patients Safe (IOM, 2003) emphasized the impact of aging on nurses’ physical capabilities, stating, “[t]he loss of strength and agility that often accompanies aging affects the ease with which nurses can perform patient care activities that require them to turn, lift, or provide weight-bearing support to patients” (p.71). Research further illustrates the connection between MSDs and the nursing shortage: studies indicated that 12% of nurses considered leaving the profession due to back pain (Stubbs, Buckle, Hudson, Rivers, & Baty, 1986), 20% transferred to different roles or units due to low back pain, with 12% contemplating leaving nursing altogether (Owen, 1989), and a significant 38% experienced occupationally-related back pain severe enough to necessitate time off work (Owen, 2000). Moreover, a notable percentage of Registered Nurses reported job changes due to neck (6%), shoulder (8%), and back problems (11%) (Trinkoff, Lipscomb, Geiger-Brown, Storr, & Brady, 2003).
Understanding the Causes of Musculoskeletal Disorders in Nursing
The demanding nature of patient care involves a complex interplay of factors that contribute to nurses’ elevated risk of injury. These factors can be broadly categorized as patient-related, nurse-related, and environment-related, all converging to create significant ergonomic hazards in healthcare settings. Identifying these factors is crucial for developing targeted prevention strategies.
Unsafe Patient Handling Practices
The demanding physical tasks associated with nursing, particularly manual patient handling, contribute significantly to the high rates of musculoskeletal disorders observed in this profession.
A primary source of MSDs among nurses is the cumulative effect of repeated manual patient handling activities, often involving excessive and unsafe loads (Smedley, Egger, Cooper, & Cogganon, 1995). Nursing care inherently involves numerous patient handling tasks, including lifting, transferring, and repositioning. The continuous repetition of these tasks over a nurse’s career can lead to the development or worsening of MSDs. Frequently, nurses perform these actions with outstretched arms or in bent, awkward postures, further increasing their injury risk (Nelson, 2003). Manual patient handling, defined as moving patients without assistive equipment, has historically been the standard practice. While nurses are often trained in “proper” body mechanics, the effectiveness and applicability of such training in preventing injuries in real-world nursing scenarios are increasingly questioned (Nelson, Fragala, & Menzel, 2003).
Traditional training in body mechanics has shown limited effectiveness in preventing injuries from manual patient handling in nursing, highlighting the need for alternative approaches like assistive equipment.
The National Institute for Occupational Safety and Health (NIOSH) has developed a “lifting equation” to determine safe lifting limits (Waters, Putz-Anderson, & Garg, 1994). NIOSH suggests that, under ideal and controlled conditions, the average worker should not lift more than 51 pounds. However, these conditions (e.g., lifting a stable box with handles from ground to waist level) are rarely applicable to the dynamic and unpredictable nature of patient handling in healthcare. While the 51-pound limit is often cited, it’s important to recognize the limitations of this guideline in nursing and the explicit recommendation by its developers to eliminate manual lifting whenever possible through technology and equipment.
Patient Characteristics as Risk Factors
Patient characteristics significantly influence the risk of injury associated with manual handling. Factors such as patient’s height, weight, body composition, and medical condition (e.g., contractures, spinal injuries, post-surgical status, presence of drains or IV lines) play a crucial role. Patients often have varying degrees of dependence and may offer minimal assistance with movement (Nelson, 2003). Cognitive impairments or pain can further complicate handling, leading to agitation or resistance. The evolving patient demographic, characterized by increased acuity, a growing elderly population, and rising rates of bariatric patients (Thomason, 2003), intensifies the challenges of safe patient handling.
Physical Environment of Patient Care
The physical environment where care is delivered can also introduce limitations and increase risks during patient handling and other nursing tasks. Whether in a standard hospital room, a skilled nursing facility, or a patient’s home, nurses must navigate confined spaces and environmental constraints while performing their duties, such as lifting patients or accessing equipment. Personal accounts, like one featured on the Handle With Care® website (ANA, 2003c), vividly illustrate how restrictive environments, such as intensive care units, can lead to awkward and injury-inducing postures. Limited workspace, hospital furniture, medical equipment, and the presence of other staff can create barriers that force nurses into compromising and potentially harmful positions.
The American Nurses Association’s Handle With Care® Program: A Proactive Solution
The ANA Handle With Care® program is a nationwide initiative dedicated to promoting safe patient handling practices and reducing musculoskeletal disorders among nurses through education, advocacy, and technological advancements.
Recognizing the urgent need to address MSDs in nursing, the American Nurses Association (ANA) launched the Handle With Care® program (ANA, 2003b) in September 2003. This national campaign is a proactive, multifaceted initiative designed to promote safe patient handling and prevent MSDs among nurses across the United States. Through various activities, the program aims to educate, advocate for policy changes, and facilitate a shift from traditional manual handling methods to technology-driven, safer approaches. The campaign’s core mission is to foster a healthcare industry-wide commitment to preventing back and other musculoskeletal injuries through:
- Building Partnerships and Coalitions: Collaborating with diverse stakeholders to amplify the message and impact of safe patient handling.
- Education and Training: Providing nurses and healthcare employers with essential knowledge and skills in safe patient handling techniques and the use of assistive technologies.
- Promoting Assistive Equipment and Devices: Advocating for the increased adoption and utilization of patient handling technologies in healthcare settings.
- Reshaping Nursing Education: Integrating safe patient handling principles and practices into nursing curricula to prepare future generations of nurses.
- Advocating for Ergonomics Policy: Pursuing federal and state policies that mandate or encourage the implementation of safe patient handling programs and technologies.
The primary objective of the Handle With Care® program is to drive industry-wide adoption of safe patient handling practices, thereby reducing nurse injuries and enhancing patient care quality.
The overarching goal of the ANA Handle With Care® program is to motivate the entire healthcare industry to actively reduce the incidence of MSDs among nurses while simultaneously enhancing the quality of patient care related to handling and movement.
Core Principles of the Handle With Care® Program
The ANA Handle With Care® campaign is grounded in a foundational position statement titled, “Elimination of Manual Patient Handling to Prevent Work-Related Musculoskeletal Disorders” (ANA, 2003a). This statement articulates ANA’s firm stance on manual patient handling, emphasizing the nursing profession’s vested interest in this issue. Key principles of this position include:
- Manual patient handling is inherently unsafe: It is a direct and primary cause of MSDs in nurses.
- Safe patient handling is achievable: Utilizing assistive equipment and devices makes patient handling significantly safer.
- Dual Benefit: Transitioning to technology-assisted handling not only reduces injury risk for nursing staff but also improves patient safety, comfort, and dignity.
This position statement serves as a call to action for the healthcare industry, urging the adoption of safe patient handling practices to protect nurses from MSDs and improve overall patient care. It also reinforces ANA’s commitment to the health and safety of its nursing members (ANA, 2003a).
The Role of Assistive Technology in Safe Patient Handling
Ergonomic programs incorporating assistive patient handling technologies are making manual patient handling obsolete, offering safer and more efficient alternatives for patient care.
The advancement of patient care ergonomics programs, particularly those incorporating assistive patient handling equipment and devices, has essentially rendered routine manual patient handling unnecessary. A growing array of technologies is available to address the diverse patient handling tasks nurses perform (see Table 2) (Nelson et al, 2003). While the quality, durability, availability, and suitability of equipment may vary, proper evaluation and selection processes involving frontline users are crucial to ensure effective implementation and consistent use.
Table 2. Examples of Safe Patient Handling Equipment and Devices, categorized by type and function, demonstrating the range of technology available to support safer patient handling practices.
Assistive patient handling equipment should be considered as engineering controls – methods that modify the work environment to minimize worker exposure to hazards (Plog, Niland, & Quinlan, 1996). In patient handling, the ergonomic hazard is the physical force and energy exerted by nurses during lifting, transferring, and repositioning. Assistive technologies effectively control this hazard by mechanically reducing or eliminating the physical demands on nurses. This approach aligns with ergonomic principles by adapting the job to the physical capabilities and limitations of the human body.
However, it’s crucial to recognize that equipment alone is not a complete solution. Assistive technology is most effective when integrated into a comprehensive safe patient handling or patient care ergonomics program. Essential components of such a program include:
- “No Manual Lift” Policy: A clearly defined, non-punitive policy demonstrating management’s commitment to eliminating manual patient handling and providing necessary resources.
- Ergonomic Hazard Assessment: Thorough evaluations to identify high-risk areas and tasks within healthcare facilities.
- Investment in Equipment: Adequate allocation of resources for the procurement and maintenance of appropriate patient handling technologies.
- Patient Handling Care Planning: Individualized plans for patient handling and movement, considering patient-specific needs and capabilities.
- Staff Training: Comprehensive training programs for all staff members on safe patient handling techniques and the use of assistive equipment.
- Program Review and Evaluation: Ongoing monitoring and assessment of the program’s effectiveness and areas for improvement.
The ANA recommends utilizing the Patient Care Ergonomics Resource Guide, developed by the Tampa VA Patient Safety Center (Patient Safety Center, 2001), as a model for implementing comprehensive safe patient handling programs.
Key Strategies of the Handle With Care® Program
The Handle With Care® program employs several key strategies to achieve its goals:
Building Strategic Partnerships
A cornerstone of the Handle With Care® campaign’s success is the development of strong partnerships. ANA collaborates with its related groups, state nurses associations, specialized nursing organizations, academic and research institutions, and healthcare systems. This collaborative approach facilitates information sharing and dissemination, creating a collective momentum for change. Building a network of organizations that endorse the campaign’s principles is vital for delivering a unified message to a broad audience. Partner organizations are actively contributing by adopting policy positions, creating resolutions, providing platforms for presentations, and leveraging their communication channels to reach members and other stakeholders.
A critical partner is the Tampa Veterans Health Administration Patient Safety Center of Inquiry (www.patientsafetycenter.com). Led by Dr. Audrey Nelson, a renowned expert in safe patient handling, this center is at the forefront of research in this field. The center has developed valuable resources to support the implementation of safe patient handling programs, including ergonomic hazard assessment tools, safe patient handling algorithms, equipment evaluation resources, and “No Lift” policy templates. These resources are freely available in the Patient Care Ergonomics Resource Guide (Patient Safety Center, 2001a; 2001b). Furthermore, ANA, the Tampa VA Patient Safety Center, and the University of South Florida jointly host the Annual Safe Patient Handling and Movement Conference, a leading event featuring national and international experts, healthcare organizations with successful programs, economists, policy leaders, equipment specialists, and vendors in the field.
Education and Training Initiatives
Education and training are central to the Handle With Care® program, targeting both frontline nurses and healthcare employers to promote understanding and adoption of safe patient handling practices.
Education and training are integral components of the Handle With Care® campaign, targeting both frontline nurses and healthcare employers (administrators, CEOs). Driving change towards valuing and implementing ergonomic approaches to patient handling requires knowledge and support from all levels of healthcare organizations. Training workshops designed for frontline nurses cover essential topics such as:
- Fundamentals of safe patient handling principles.
- The impact of back injuries on the nursing shortage.
- Debunking myths about “proper” body mechanics.
- Assessing ergonomic hazards in healthcare settings.
- Utilizing engineering controls (patient lifting equipment and devices).
Empowered with this knowledge, frontline staff can advocate for improvements in their workplaces through health and safety committees and collective bargaining.
Promoting the Use of Assistive Equipment
To engage healthcare administrators and executive leadership, the Handle With Care® campaign emphasizes the economic benefits of adopting safe patient handling programs. Addressing concerns about budget constraints and resource allocation, the campaign provides brochures and resources that demonstrate the cost-savings associated with preventing MSDs through the use of assistive technologies. While initial equipment purchases may seem costly, a programmatic approach that includes patient handling equipment leads to significant reductions in workers’ compensation claims, medical treatment expenses, and other indirect costs related to staff replacement, training, modified duty, and patient injuries. Presenting a compelling economic argument is crucial to convince healthcare administrators that investing in patient handling equipment is a sound financial decision that reduces injuries and related costs.
Reshaping Nursing Education for Future Practice
A critical dimension of the Handle With Care® campaign is to transform how patient handling is taught in nursing education. Traditional nursing education has historically emphasized “proper” body mechanics as a means to mitigate the physical stress of manual patient handling. However, this approach has proven inadequate and often ineffective in preventing injuries. Body mechanics training is often based on studies using static loads (e.g., boxes) and primarily focused on male subjects and lower back injuries, failing to address the complexities of patient handling and the range of vulnerable body parts involved.
Modern safe patient handling methods and technologies offer ergonomically sound alternatives to traditional manual techniques, which should be integrated into nursing education.
Overall, body mechanics training does not equip nurses to handle loads that frequently exceed recommended limits (Nelson et al., 2003). Traditional educational methods often perpetuate outdated manual techniques like “hook and drag” and multi-person lifts, contributing to the continued high incidence of MSDs among new nurses. Given advancements in scientific research, technological innovations, and successful implementations in real-world settings, safe and ergonomically sound patient handling methods are now available. The Handle With Care® campaign advocates for integrating these modern methods into nursing school curricula, aiming to fundamentally transform patient handling practices among future nurses. By influencing nursing students during their formative “learning stage,” the campaign seeks to instill a deep understanding and appreciation for ergonomic hazard recognition and prevention, empowering them to become champions of safe patient handling throughout their careers.
Advocating for National and State Policy Changes
The lack of federal ergonomics standards necessitates advocacy for state-level regulations and legislative changes to protect healthcare workers from musculoskeletal disorders.
Despite the clear need for ergonomics regulations to protect healthcare workers, efforts to establish national standards in the U.S. have faced significant challenges. In 2000, the Occupational Safety and Health Administration (OSHA) issued a final ergonomics rule (OSHA, 2000) aimed at protecting workers, including those in healthcare. However, opponents, citing concerns about the scientific basis of ergonomics and the potential financial burden on employers, successfully lobbied for the repeal of this rule through the Congressional Review Act (Boehner, 2001a; Bush signs, 2001; Boehner, 2001b). This repeal not only eliminated the ergonomics standard but also restricted OSHA from developing similar regulations without explicit Congressional authorization. While OSHA has published industry-specific ergonomic guidelines, including those for nursing homes (OSHA, 2004), these guidelines are not legally enforceable.
Table 3. A timeline of OSHA ergonomics regulation attempts, highlighting the challenges and setbacks in establishing national standards for workplace ergonomics in the US.
In the absence of federal regulations, the Handle With Care® campaign is pursuing state-level regulations and legislation to protect healthcare workers. This strategy recognizes that individual states may be more receptive to worker protection measures. Building momentum at the state level can create a groundswell of support for federal action. The successful passage of the federal Needlestick Safety and Prevention Act of 2000 (PL 106-430, U.S. Congress, 2000), following similar legislation in seventeen states (California State Legislature, n.d.), serves as a model for this approach (ANA, n.d.; ANA, 2002). The Handle With Care® campaign is actively supporting state nurses associations and coalitions in advocating for state-level safe patient handling/ergonomics regulations. This includes developing model legislative language and identifying states where such initiatives are most likely to succeed. ANA also provides direct support for state-level regulatory efforts, as demonstrated by its involvement in Washington State’s ergonomics rule (Washington State Department of Labor and Industries, 2000), and subsequent advocacy against its repeal (Queary, 2003; Washington State Department of Labor and Industries, 2003). The campaign continues to monitor and support state-level legislative efforts, such as California Assembly Bill 2532 (www.leginfo.ca.gov/bilinfo.html).
Global Recognition of Manual Patient Handling Risks
Globally, the nursing community recognizes manual patient handling as a significant occupational hazard, with many countries implementing regulations and guidelines to promote safer practices.
The international nursing community has long acknowledged manual patient handling as a significant occupational hazard. Many nursing associations worldwide have taken proactive steps, often in response to government regulations, to develop policies and guidelines addressing this issue. The United Kingdom and Australia are at the forefront of the global safe patient handling movement. The Royal College of Nursing (RCN) in the UK published its Code of Practice for Patient Handling in 1996, supporting the government’s “Manual Handling Regulations” (Royal College of Nursing, 2002). This code aims to eliminate manual handling except in emergencies and emphasizes the use of handling aids to minimize risk. Similarly, the Australian Nursing Federation (SA Branch) adopted a “No Lift, No Injury” policy in 1998, advocating for the elimination of manual handling and promoting training and resource networks for safe handling practices (Australian Nursing Federation, 2004).
Tangible Benefits of Safe Patient Handling Programs
Implementing safe patient handling programs and adopting technology-based solutions yields significant benefits across multiple domains:
Reduction in Nurse Injuries
Healthcare facilities that have implemented safe patient handling programs with technology integration have consistently reported substantial reductions in nurse injuries (Evanoff, Wolf, Aton, Canos, & Collins, 2003; Haiduven, 2003; Hefti et al, 2003; Hignett, 2001; Holliday, Fernie, & Plowman, 1994; Mutch, 2004; Owen, Keene, & Olson, 2002; Yassi et al, 2001). By fostering an ergonomic work environment and committing to the safest available methods, healthcare organizations can significantly decrease injury rates among nursing staff. Additional benefits for nurses include reduced fatigue, increased job satisfaction, elimination of work-related pain, and greater career sustainability.
Cost Savings for Employers
Investing in assistive patient handling technology proves to be cost-effective in the long run, significantly reducing expenses related to worker injuries and compensation claims.
The financial burden of occupational injuries is often underestimated. Reducing nurse injuries leads to substantial cost savings for employers, encompassing both direct and indirect expenses. Cost-benefit analyses have demonstrated that assistive patient handling technology effectively reduces workers’ compensation and medical treatment costs associated with MSDs (Collins & Bell, 2003; Garg, 2003; Nelson et al, 2003; Owen & Fragala, 1999). Savings are realized through reduced indirect costs such as investigation time, lost workdays, decreased productivity, modified duty, employee turnover, new hire training, liability risks, overtime pay, and other operational disruptions. Case studies have shown that employers can save tens to hundreds of thousands of dollars by implementing safe patient handling programs (Collins, Wolf, & Hsiao, 2002; Fragala, 1995; Nelson, Fragala, & Matz, in press).
Enhanced Quality of Patient Care
While primarily focused on nurse safety, safe patient handling technologies also significantly enhance the quality of patient care. Improved patient safety, comfort, and dignity are key benefits. Assistive equipment provides a more secure and controlled process for lifting, transferring, and repositioning, reducing the risk of patient injuries such as falls, skin tears, and shoulder dislocations. Patients experience less forceful and awkward handling compared to manual techniques. Furthermore, the use of mechanical equipment can alleviate patient anxiety associated with manual handling and enhance their confidence in the care process. Safe patient handling practices also promote patient dignity by minimizing potential compromises to patient self-esteem and privacy during difficult handling situations. Moreover, selecting equipment that aligns with a patient’s ability to participate in their movement can foster patient autonomy.
Conclusion: A Call to Action for Safe Patient Handling
In conclusion, the availability and success of safe patient handling programs demonstrate that manual lifting of patients by nurses is unnecessary and preventable, highlighting the need for widespread adoption of these programs.
Nurses should not be subjected to the risks of manual patient handling. Given the proven effectiveness and availability of safe patient handling programs utilizing mechanical equipment and devices, there is no justifiable reason for the continued prevalence of ergonomic hazards in patient handling within the American healthcare industry. The benefits of implementing safe patient handling programs for nurses, employers, and patients are undeniable and compelling. Continued education and advocacy are essential to ensure that all stakeholders in the healthcare industry are aware of the innovative programmatic and technological solutions available to effectively reduce nurse injuries and improve patient care. Through the ANA Handle With Care® program and its multifaceted strategies, the American Nurses Association is dedicated to transforming patient handling practices, raising awareness of ergonomic hazards, and fostering safer, healthier healthcare workplaces for nurses and improved care environments for patients.
Letter to the Editor from Dietrich Mackel .
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