Which do nurses sometimes do that increase their risk for injury when moving patients?

Chapter 3. Safe Patient Handling, Positioning, and Transfers

When patients are recovering from illness, they may require assistance to move around in bed, to transfer from bed to wheelchair, or to ambulate. Changing patient positions in bed and mobilization are also vital to prevent contractures from immobility, maintain muscle strength, prevent pressure ulcers, and help body systems function properly for optimal health and healing (Perry et al., 2014). The amount of assistance each patient will require depends on the patient’s previous health status, age, type of illness, and length of stay (Perry et al., 2014).

Types of Assistance

At times, patients are assessed and given a “level of assistance” required for transferring. This is most common in residential care settings. The level of assistance is based on the patient’s ability to transfer and stand. The terms describing different levels of assistance are used by health care providers to communicate with each other so everyone understands what type of assistance is required. The assistance needed is usually charted on the patient’s Kardex, above the head of the bed, and/or on the patient’s chart. Table 3.4 describes different types of assistance in the hospital and community setting.

Table 3.4 Level of Assistance

Level of Assistance	Description
Independent	The patient is able to transfer independently and safely.
Standby supervision	The patient requires no physical assistance but may require verbal reminder. This type of patient may also be learning to transfer independently using a wheelchair, walker, or cane.
Minimal assist	The patient is cooperative but needs minimal physical assistance with the transfer.
One-person standing pivot	The patient can bear weight on one or both legs and is cooperative and predictable. The patient also can sit with minimal support on the side of the bed.
Two-person standing pivot	The patient can assist with weight bearing, but may be inconsistent. The patient is cooperative and predictable.
One-person assist with transfer board	The patient is cooperative, follows directions, and has good trunk control. The patient can use their arms, but cannot bear weight on both legs.
Two-person assist with transfer board	The patient is cooperative and can follow directions. The patient can use their arms, but cannot bear weight on both legs. The patient does not have good trunk control. The patient’s wheelchair has removable arms.
Mechanical stand	The patient may have some ability to stand, but is unreliable. The patient may be unpredictable (due to cognitive changes, medications). The patient is a heavy two-person transfer and requires toileting or pericare. The patient does not have severe limb contractures or injuries where movement is medically contraindicated (e.g., spinal injury). Use of a mechanical lift.
Data source: Winnipeg Regional Health Authority (WRHA), 2008

Special considerations:

Assess the patient every time before a move as a patient’s condition may worsen or improve throughout the hospital stay.
Results of assessments should be properly documented according to agency policy to ensure safe transfers for all health care providers.
Any patient-handling injuries must be reported using the British Columbia Patient Safety and Learning System (BCPSLS), a web-based tool used to report and learn about safety events, near misses, and hazards in health care settings (BCPSLS, 2015).

If the patient is cooperative, able to bear weight, and has some balance to sit (see Checklist 24: Risk Assessment), the health care provider must decide how much assistance the patient needs. Table 3.5 provides guidelines to consider.

Table 3.5 Assistance Required for Transfer

Assess	Description
Minimal	One-person transfer with gait belt The patient is able to perform 75% of the required activity on their own.
Moderate	Two-person transfer with a gait belt, a stander, or a two-person transfer with a slide board and a gait belt The patient is able to perform 50% of the required activity on their own.
Maximum	Stander or a two-person transfer with a slide board and gait belt The patient is able to perform 25% of the required activity on their own.
Data source: WRHA, 2008

Special considerations:

The weight, height, and general physical, mental, or emotional condition of the patient all influence the potential for injury.
If the patient is uncooperative or unable to follow commands, there is an increased risk for injury. It is recommended that a mechanical lift or assistive device be used to prevent injury to the health care provider and patient.
If there is any question about the patient’s ability, always reassess.

A patient requires no assistance from the health care provider except for the occasional reminder to lift feet while walking. Is the patient’s level of assistance considered independent or a minimal assist?
A patient is assessed as a one-person pivot. As the health care provider begins the transfer, the patient suddenly becomes uncooperative. What should the health care provider do next?

All it takes is one bad lift to change a nurse’s life. Just one fast-paced decision has the potential to end a nursing career. That’s why the American Nurses Association (ANA) is committed to driving initiatives that prevent unnecessary injury and keep both patients and nurses safe.

Injuries and musculoskeletal disorders (MSD) are often caused by manually lifting patients, and nurses are at high risk every day. The consequences can be devastating: for health care professionals, MSDs are responsible for more lost work time, more long-term medical care needs, and more permanent disabilities than any other work-related injury.

Safe Patient Handling and Mobility programs and advocacy

Through Safe Patient Handling and Mobility (SPHM) programs and advocacy, ANA is working to establish a safe environment for nurses, with the complete elimination of manual patient handling as our goal.

Universal SPHM standards are required to protect nurses, across all health care settings. Without this concerted effort, nurses will continue to be needlessly injured. The use of technology, especially lifting devices, is critical to the success of these programs.

One major source of injury to healthcare workers is musculoskeletal disorders (MSDs). In 2017, nursing assistants had the second highest number of cases of MSDs. There were 18,090 days away from work cases, which equates to an incidence rate (IR) of 166.3 per 10,000 workers, more than five times the average for all industries. This compares to the all-worker days-away from work rate of 30.5 per 10,000 workers.

These injuries are due in large part to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures. Some examples of patient handling tasks that may be identified as high-risk include: transferring from toilet to chair, transferring from chair to bed, transferring from bathtub to chair, repositioning from side to side in bed, lifting a patient in bed, repositioning a patient in chair, or making a bed with a patient in it.

Sprains and strains are the most often reported nature of injuries, and the shoulders and low back are the most affected body parts. The problem of lifting patients is compounded by the increasing weight of patients to be lifted due to the obesity epidemic in the United States and the rapidly increasing number of older people who require assistance with the activities of daily living.

The consequences of work-related musculoskeletal injuries among nurses are substantial. Along with higher employer costs due to medical expenses, disability compensation, and litigation, nurse injuries also are costly in terms of chronic pain and functional disability, absenteeism, and turnover. As many as 20% of nurses who leave direct patient care positions do so because of risks associated with the work. Direct and indirect costs associated with only back injuries in the healthcare industry are estimated to be $20 billion annually. In addition, healthcare employees, who experience pain and fatigue, may be less productive, less attentive, more susceptible to further injury, and may be more likely to affect the health and safety of others.

Industries where patient handling tasks are performed include:

Long-Term Care (includes facilities that provide skilled or non-skilled nursing care);
Acute Care - (includes hospitals, out-patient surgical centers, and clinics);
Home Healthcare workers; and
Others - such as physical therapists, radiologists, sonographers, etc.

Some examples of areas of a facility that may be identified as high-risk include: bathing rooms, extended care wings, and diagnostic units (e.g., radiology, emergency department, spinal unit, orthopedics department).

Given the increasingly hazardous biomechanical demands on caregivers today, it is clear the healthcare industry must rely on technology to make patient handling and movement safe. Patient transfer and lifting devices are key components of an effective program to control the risk of injury to patients and staff associated with lifting, transferring, repositioning or movement of patients. Essential elements of such a program include management commitment to implement a safe patient handling program and to provide workers with appropriate measures to avoid manual handling; worker participation in the assessment and implementation processes and the evaluation and selection of patient handling devices; a thorough hazard assessment that addresses high risk units or areas; investment in equipment; care planning for patient handling and movement; training for staff; and program review and evaluation processes. The education and training of healthcare employees should be geared towards assessment of hazards in the healthcare work setting, selection and use of the appropriate patient lifting equipment and devices, and review of research-based practices of safe patient handling.

The use of assistive patient handling equipment and devices is beneficial not only for healthcare staff, but also for patients. Explaining planned lifting procedures to patients prior to lifting and enlisting their cooperation and engagement can increase patient safety and comfort, and enhance their sense of dignity.

Mechanical wheelchair helps patients from a sitting position to a standing position

Acute Care and Long Term Healthcare Workers

Safe Patient Handling Tools and Resources. OSHA has developed a series of online resources to help hospitals develop and implement safe patient handling assessments, policies, procedures, programs, training, and patient education.
Beyond Getting Started: A Resource Guide for Implementing a Safe Patient Handling Program in the Acute Care Setting. Association of Occupational Health Professionals in Healthcare (AOHP), (2014). This resource guide addresses patient handling with the goal of providing the necessary tools for occupational health professionals to implement a safe patient handling program.
Guidelines for Nursing Homes: Ergonomics for the Prevention of Musculoskeletal Disorders. OSHA, (Revised 2009). These guidelines provide recommendations for nursing home employers to help reduce the number and severity of work-related musculoskeletal disorders (MSDs) in their facilities.
Safe Lifting and Movement of Nursing Home Residents. U.S. Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication, No. 2006-117, (November 2006). This guide is intended for nursing home owners, administrators, nurse managers, safety and health professionals, and workers who are interested in establishing a safe resident lifting program. This guide also presents a business case to show that the investment in lifting equipment and training can be recovered through reduced workers' compensation expenses and costs associated with lost and restricted work days.

Home Healthcare Workers: How to Prevent Musculoskeletal Disorders. U.S. Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2012-120, (February 2012). This is one in a series of six fast fact cards developed to provide practical advice for home healthcare workers and is based on NIOSH Hazard Review: Occupational Hazards in Home Healthcare, NIOSH Pub No. 2010–125. Lifting and moving clients create a high risk for back injury and other musculoskeletal disorders for home healthcare workers.
NIOSH Hazard Review; Occupational Hazards in Home Healthcare; Department of Health and Human Services, Center for Disease Control and Prevention. National Institute for Occupational Safety and Health (NIOSH). The document aims to raise awareness and increase understanding of the safety and health risks involved in home healthcare and suggests prevention strategies to reduce the number of injuries, illnesses, and fatalities that too frequently occur among workers in this industry.

Physical Therapists

The Ergonomics Module of the OSHA Hospital e-Tool is relevant to safe patient handling concepts in the field of physical therapy.

Radiologists

The Radiology Module of the OSHA Hospital e-Tool is relevant to patient handling concepts in the field of radiology.

Sonographers

The Sonography module of the OSHA Hospital e-Tool is relevant to safe patient handling concepts in the field of sonography.
Preventing Work-Related Musculoskeletal Disorders in Sonography. U.S. Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication, No. 2006-148, (November 2006). NIOSH recommends appropriate engineering controls, work practices, hazard communication, and training to prevent these work-related musculoskeletal disorders in healthcare workers giving sonograms.

A-1136 safe patient handling legislation signed into law October 2011.

SB 879 safe patient handling legislation signed into law April 2007.

HB 712.2 safe patient handling legislation signed into law May 2007.

S-1758/A-3028 safe patient handling practice act signed into law January 2008.

Title 1-A of Article 29-D, added to the Public Health Law by Chapter 60 of the Laws of 2014, Part A, §20

House Bill 67 was signed into law on March 21, 2006, Section 4121.48. Repealed effective June 20, 2015.

House 7386 and Senate 2760 passed on July 7, 2006.

Senate Bill 1525 was signed into law on June 17, 2005.

House Bill 1672 was signed into law on March 22, 2006.

Through the Alliance between OSHA and the Association of Occupational Health Professionals (AOHP) (concluded 10/2012), AOHP and OSHA produced "Beyond Getting Started: A Resource Guide for Implementing a Safe Patient Handling Program in the Acute Care Setting."

The Alliance recognized that patient handling practices impact not only healthcare workers but also patients. Safe patient handling practices reduce the risk of the patient falling or experiencing other negative outcomes. In addition, implementing safe patient handling practices will reduce a healthcare facility's financial burden with regard to patient claims and workers' compensation claims.

Safe patient handling programs frequently are initiated by or become the responsibility of healthcare providers themselves. In some cases, this new responsibility may not include the additional resources to implement a program effectively and efficiently.

"Beyond Getting Started: A Resource Guide for Implementing a Safe Patient Handling Program in the Acute Care Setting":

Provides background information and reviews the differences between acute and long term care facilities;
Builds a foundation for a successful safe patient handling program;
Describes the process (assessment, planning, implementation and evaluation) of establishing a safe patient handling program;
Provides examples of forms, checklists, job descriptions, etc. which can be developed in support of a safe patient handling program; and
Lists additional references for more information.

This resource guide identifies the basic steps and processes necessary to implement a safe patient handling program in a comprehensive manner, including the need for adequate funding. Whereas this guide was initially focused upon occupational health care providers, much of the information holds true, is transferrable, and may be easily augmented to address safe patient handling programs in other healthcare fields as well.