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Abstract
Sort through the myths and facts to determine how you uphold best practices for patient lifting.
Despite the staffing shortage and concerns that nursing is a risky profession, progress has been slow in the United States to reduce work-related injuries associated with patient handling tasks. Between 1989 and 2001, the change in the number of U.S. lost-workday injury cases per 100 full-time nurses was minimal; in 1989 it was 4.0, compared with 3.8 in 2001.1 We're starting to see these numbers decrease, with 3.3 reported in 2004.2 In other countries where safe patient handling policies are supported by regulations, more significant declines in nursing musculoskeletal injuries are noted.3,4
Patient handling tasks are considered high-risk, due to the magnitude of weight lifted, awkwardness and unpredictable nature of the load lifted (patient), and sustained awkward positions used to provide nursing care, such as bending over beds or chairs while the back is flexed. Consider this: The cumulative weight lifted by a nurse providing direct patient care in a typical 8-hour workday is estimated to be 1.8 tons.5 Unfortunately, nurses accept back pain as part of their job, with 52% to 63% of nurses reporting musculoskeletal pain that lasts for more than 14 days; in 67% of cases pain was a problem for at least 6 months.6
Internationally, the newest approach to this serious occupational problem has been the use of safe patient handling policies-at the facility level, state level, or national level. There's significant confusion about what a safe patient handling policy is and whether it's practical to implement such a policy in the United States.
Countering the misconceptions
Let's examine this issue from an international perspective, addressing lessons learned from other countries.
Myth #1: The definition of a patient handling policy is clear, and all patient handling policies are essentially the same.
Fact: A safe patient handling policy (also referred to as "no-lift," "zero-lift," "minimal lift," "no-manual lift," or "lift-free") is one part of a comprehensive approach to preventing musculoskeletal injuries to healthcare workers.7 The wide variety of names has led to confusion about how healthcare providers interpret the intent of safe patient handling policies.
Some healthcare professionals believe this policy means that patients should never be physically lifted, while others believe this means that patients should never be manually lifted except in emergency or exceptional situations. Still others interpret a safe patient handling policy to mean that patients are to be moved with the assistance of appropriate equipement, when certain limits for manual handling are exceeded.
The purpose of a written safe patient handling policy is to provide a clear understanding of the elements of a safe patient handling and movement program, to define the roles and responsibilities for all affected staff (healthcare administrators, supervisors, frontline caregivers, therapy staff, maintenance personnel, and housekeeping staff), and to provide a reference for review when questions arise.7
Safe patient handling policies are undergoing an evolutionary process throughout the world, and include facility-based policies as well as state and national legislation efforts. The first safe patient handling policy in the United Kingdom stated that manual lifting of patients was to be eliminated in all but exceptional or life threatening situations.8 (Manual patient handling is defined as transporting or supporting of a patient by hand or bodily force, including pushing, pulling, carrying, holding, and supporting of the patient or a body part.) Over time the safe patient handling policy came to include the following key points, when adopted by Canada, Australia, and the Netherlands:
[white diamond suit] Patients should be encouraged to assist in their own transfers, and handling aids must be used whenever they can help to reduce risk, if this isn't contrary to a patient's needs.
[white diamond suit] Manual lifting may only be continued if it doesn't involve lifting most or all of a patient's weight, such as when a patient only needs minimal assistance. Many high-risk manual handling tasks have been banned, including the "Hook and Toss Method" commonly taught here in the United States.
[white diamond suit] A safe patient handling policydoesn't mean healthcare providers will never transfer or reposition a patient manually, but rather the determination of how a patient is to be transferred should be based on the patient's physical and cognitive status and medical condition.
[white diamond suit] Proper infrastructure must be in place before a safe patient handling policy can be enforced. Infrastructure is defined as management commitment and support, availability of equipment, equipment maintenance, employee training, resources for advanced training, and culture of safety.
[white diamond suit] The culture of safety approach includes the collective attitudes of employees and managers at all levels taking a shared responsibility for safety in the work environment and for providing a safe environment for themselves and the patients.
[white diamond suit] Ergonomic assessments should be conducted for high-risk tasks to determine the safest way to perform the task; the assessment and solution must be communicated to all staff.9-12
Safe patient handling policies were briefly recommended in the United Kingdom about 10 years ago.13 They actually implied a culture of safer lifting rather than no manual lifting, although some individual organizations (in particular social and home care services) interpreted these policies as no lifting under any circumstances. This caused problems for service provision, and, more recently, the interpretation has been explored legally. Many healthcare and social care employers in the United Kingdom are now reviewing their safe patient handling policies following a complex human rights legal case.
The judge found that a lifting policy that imposed a blanket proscription on all manual handling was likely to be unlawful. This position is reinforced by the Health and Safety Executive warning against no-lifting policies.14 The result of this case has emphasized the need for balanced decision making, based on risk and patient assessments. In the United Kingdom, good practice for routine lifting is likely to use equipment, but in an emergency caregivers would be expected to use manual lifting. It's particularly important to document the decision making in the risk and patient assessments to show how the decision has been reached, rather than just the final decision.15
Myth #2: A safe patient handling policy is intended as a punitive tool.
Fact: Safe patient handling policies are designed as a pledge from administrators to protect nursing staff. The purpose of the policy isn't punitive; it's a declaration of support from both staff and administration. This policy establishes expectations that staff will use the safest techniques to accomplish high-risk patient handling tasks, and that administrators will provide equipment and resources to support staff efforts.16
Myth #3: The United States is an international leader in implementing safe patient handling policies to protect nursing staff.
Fact: Several countries have implemented national safe patient handling policies. The United Kingdom initiated efforts to establish a safe patient handling policy on a national scale in 1992. In 1996, clinical guidelines were introduced by the Royal College of Nursing, credited with the first "lift-free hospital." In 1994, the Nordic Council (Denmark, Sweden, Norway, and Finland) developed force limits for patient handling, citing that the maximum patient weight to be lifted by a nurse is 54 pounds. Canada and Australia have followed with national and regional initiatives. The Netherlands issued national no-lift guidelines with a wide commitment from unions, employers, the Labour Inspectorate, and the two Ministries (Health and Social Affairs) in 2001.11 The guidelines are based on European legislation.
The movement toward safe patient handling policies is gaining momentum in the United States, becoming a focal point in safe patient handling programs through leadership efforts in the Veterans Health Administration (VHA) and American Nurses Association (ANA). The VHA identified evidence-based approaches and developed a multifac-eted program tested across severalhospitals.17
Building on the work at the VHA, in 2003, the U.S. Department of Labor, Occupational Safety and Health Administration released ergonomics guidelines for nursing homes to reduce the number and severity of work-related musculoskeletal disorders. These serve as advisory recommendations rather than an enforceable standard. Specific recommendations include:
[white diamond suit] Manual lifting of residents should be minimized in all cases and eliminated where feasible.
[white diamond suit] Employers should implement an effective ergonomics process that provides management support, involves employees, identifies problems, implements solutions, addresses reports of injuries, provides training, and evaluates ergonomics efforts.18
The ANA developed a program, "Handle with Care," that supports safe practices for patient handling.19 Although there's no national legislative or regulatory action in this area within the United States, one national bill is pending-HR 378"Nurse and Patient Safety and Protection Act of 2007."
Six states-Texas, Washington, Hawaii, Rhode Island, Ohio, and New York-have recently passed legislation related to safe patient handling. At least five other states-California, Massachusetts, New Jersey, Illinois, and Florida-have introduced legislation, though some bills have been defeated with potential plans by states to reintroduce. Several more states are drafting language for introduction of safe patient handling legislation.
Myth #4: Implementing a facility-based safe patient handling policy isn't feasible in the United States.
Fact: Many U.S. healthcare facilities have successfully implemented safe patient handling policies, resulting in significant reductions in injuries to caregivers and becoming an essential part of a comprehensive Safe Patient Handling and Movement program.16,20,21 The effectiveness of safe patient handling policies has been documented through research in diverse settings in private and government-owned hospitals and long-term care facilities. The U.S. Department of Veterans Affairs successfully implemented safe patient handling policies as an integral part of comprehensive Safe Patient Handling and Movement programs in acute care hospitals and long-term care facilities.16,22 Similar findings were obtained in studies conducted by the National Institute for Occupational Safety and Health and BJC Health Care in long-term care facilities.21
The safe patient handling policy is one part of a comprehensive approach to preventing musculoskeletal injuries to healthcare workers. Prior to implementing the policy, the hospital or nursing home should have the following elements in place:
[white diamond suit] a sufficient amount of mechanical lifting equipment and repositioning aids
[white diamond suit] adequate number of staff trained and competent in the use of the equipment in each high-risk unit and staff skilled in applying safe patient handling and movement algorithms
[white diamond suit] sufficient working space
[white diamond suit] administrators and supervisors who support the safe patient handling policy and safe patient handling and movement program.16
The policy communicates in writing the responsibilities of all medical, maintenance, and administrative staff with regard to the safe handling and movement of patients. The policy is nonpunitive and establishes methods to evaluate the transfer needs of patients, procedures to avoid hazardous patient handling and movement tasks, and delineates the responsibilities of frontline caregivers, nurse managers, therapists, maintenance personnel, supervisors, and administrators. In addition, a safe patient handling policy should include the following points:
[white diamond suit] program goals for reducing worker musculoskeletal injuries and improving care quality
[white diamond suit] review of injuries to staff and patients associated with patient handling and an assessment of the patient care environment to determine equipment requirements and potential workplace modifications
[white diamond suit] roles and responsibilities of the administrator, nurse managers, maintenance and housekeeping staff, and frontline caregivers who perform patient lifting
[white diamond suit] patient handling and movement algorithms to classify patients based on transferring needs, and the type of equipment required to safely move and transfer patients
[white diamond suit] definitions of content-specific training and education requirements for affected staff
[white diamond suit] training schedules during orientation and when there's a job, equipment, or process change, and annual refresher sessions
[white diamond suit] descriptions of methods to communicate the correct type of transfer to the frontline caregiver
[white diamond suit] resources available for lifting equipment, slings, batteries, repositioning aids, and bathing equipment that'll be required to establish a safe patient handling and movement program
[white diamond suit] infection control strategy
[white diamond suit] specific maintenance and inspection schedules for lifting equipment and repositioning aids, slings, batteries, and accessories, and tag out procedures for damaged equipment
[white diamond suit] procedures and equipment recommendations for handling bariatric and other special needs patients
[white diamond suit] procedures for evacuating patients in an emergency.7,16 (See "Sample safepatient handling policy for hospitals/nursing homes.")
Myth #5: Safe patient handling policies are too costly to implement properly.
Fact: Several studies have shown that the initial capital investment in a safe-lifting policy and the equipment required to establish a safe patient handling and movement program can be recovered in 2 to 3 years.21-23 Similarly, in the Netherlands the results reported in 2001 showed a break-even point after 2 years.24
The initial capital investment to purchase or lease equipment can be substantial depending on the needs of the healthcare organization and the extent and sophistication of equipment selected. Healthcare organizations can choose to phase-in equipment incrementally to work within limited budgets. Implementation of a safe patient handling and movement program in nursing units identified as high risk can provide proof of the program's success, which can facilitate replication of the program in other units.
Risk assessment is an important first step in establishing an effective prevention program. An overall assessment of the entire organization is required. A sound assessment will highlight problem areas and the reasons why the level of risk is high. It may be related to shortfalls in equipment, ergonomic and design implications, or handling procedures. Manual handling incidents in a particular ward may be due to the types of patients, inadequate equipment levels, or lack of training.
It's worthwhile to thoroughly assess the baseline facts to present a strong business case to management. Your goal is to convince managers that reducing musculoskeletal injuries will be beneficial as well as cost effective for the organization.25 It's useful when presenting the business case to be able to cite other organizations that have implemented a safe patient handling policy. Some interesting and successful case studies are available at http://www.hse.gov.uk .
Examining the cause for lost workdays and modified workdays can provide strong factual evidence to present a robust business case to managers and financial directors. Although there's a significant initial cost to implementing safe patient handling policies (mainly from developing the infrastructure and purchasing equipment such as patient hoists), the potential benefits that follow far outweigh the initial cost.
There's overwhelming evidence to show that manual handling incidents and employee lost workdays decrease after safe patient handling policies are implemented. In addition, these policies improve staff morale, increase staff efficiency for managers, yield cost savings for healthcare facilities, and most importantly, provide better care and a safer environment for patients.
Myth #6: Workers involved in moving or transferring patients will be protected from back injuries if they use "good body mechanics" or "manual lifting techniques."
Fact: There's no scientific evidence to support training in "body mechanics" or "manual lifting techniques" as an effective strategy to protect nurses against back and other musculoskeletal injuries.23 Although the first citation for the phrase "body mechanics" in nursing appeared in 1945, there was no scientific evidence to support this approach. However, lacking any evidence-based alternative, yet facing the need to teach students how to lift and move patients, schools of nursing have taught body mechanics and manual lifting techniques for the past 100 years and continue to teach these methods today.
Unfortunately, the "bent knee, straight back" method of lifting doesn't apply to lifting patients. When a patient is being lifted from a bed or chair, the placement of the patient requires awkward postures and excessive forward bending, while at the same time, a bed or chair can restrict the nurse's ability to bend his or her knees. Other factors that can contribute to the difficulty of lifting a patient are the size and weight of the patient, the patient's propensity to fall or lose balance, the bed height, patient resistance or combativeness, and the fact that 90% of the lifting and moving of physically dependent patients is performed by female nursing staff, who lack the body strength of men.26
A body of research knowledge has been developed that provides strong evidence that a comprehensive program can significantly reduce the risk of musculoskeletal injures in healthcare settings.17,21,22,27,28 Common elements of these successful programs are mechanical equipment to assist caregivers with resident lifting tasks, training in the use of the equipment, and a written safe patient handling policy.
Potential benefits of revised procedures
Reports show that safe patient handling policies, as part of a comprehensive program, resulted in significantly less risk for musculoskeletal injuries for nursing staff, particularly back pain.3,23,29-33 Lost workdays due to injury and light duty assignments among nursing staffs will also be reduced, preserving their ability to work as frontline patient care givers.34 Also, the career of a nurse is less likely threatened to be cut short as a result of injury. In addition, individuals may be more interested in pursuing a career as a frontline nurse if they're less worried about the risk of suffering a work-related injury. Further, a safe patient handling policy contributes to creating an overall culture of safety within the healthcare organization.
In addition to benefits to nursing staff, mechanical lifting equipment can reduce the risk of patient injury due to falls, and bruises or skin tears that may result from manual handling. Patients are subjected to less uncomfortable, awkward, or forceful handling when lifting, transferring, or repositioning is done with a mechanical lift.35 This can be especially important for patients with high-acuity conditions, with complex pain management, or those who are elderly or frail.
Additionally, patient dignity and privacy may be compromised during difficult manual handling tasks. Equipment can offer a more considerate way of handling patients that safeguards respect. Also, assistive patient handling equipment can be selected to match a patient's ability to assist in his or her own movement, thereby promoting patient autonomy.
Indirect cost savings can also be realized because healthcare organizations will replace fewer injured employees, train fewer new hires, have fewer nurses on restricted work duties, reduce the need to cover nursing shifts by paying overtime, spend less time and resources to investigate injury incidents, and reduce liability costs from patient injuries.
Healthcare administrators and staff members can work together to locate resources of information for vendors of mechanical lifting equipment and/or no-lift programs that suit their specific needs.
Sample safe patient handling policy for hospitals/nursing homes
(Facility name) safe patient/resident handling policy is one part of a comprehensive program to prevent musculoskeletal injuries to frontline caregivers, one of our most valuable resources. The policy recommends guidelines to ensure that the transferring needs of all patients/residents1 are assessed. All healthcare personnel responsible for transferring patients shall be aware and trained on the correct procedures for lifting and moving patients. Adherence to this policy ensures that patients/residents are being lifted and transferred safely while encouraging patient mobility and independence.
The administrator is responsible for:
- Supporting the implementation of this policy.
- Providing training opportunities for all staff affected by the safe-lifting policy.
- Furnishing sufficient lifting equipment and repositioning aids.
- Identifying acceptable storage locations for lifting equipment and repositioning aids.
- Providing resources for the medical management program and the evaluation of the safe-lifting program.
The unit/nurse manager, the physical and occupational therapy departments, and frontline caregivers are responsible for:
- Assessing the transferring needs of each patient and prescribing lifting and transferring method(s) that are consistent with the patient's care plan and rehabilitation goals and their ability to ambulate, bear weight, and follow verbal instructions. Patients should be reassessed if their condition changes.
Unit/nurse manager and supervisors are responsible for::
- Ensuring that all staff affected by the policy complete initial and annual training.
- Ensuring that the transferring needs of patients are assessed and all high-riskpatient-handling tasks are completed safely using mechanical lifting devices or other appropriate equipment or techniques.
- Ensuring that mechanical lifting devices, slings, and other equipment are available, maintained in proper working order, and stored conveniently and safely.
- Ensuring that patient transfers are being performed as prescribed.
- Maintaining training records.
Nursing staff and frontline caregivers are responsible for:
- Being knowledgeable of the procedures to follow when transferring patients.
- Using proper techniques, mechanical lifting devices, and other approved equipment/aids when performing high-risk patient handling tasks.
- Notifying supervisor if a change has occurred in a patient's condition.
- Notifying supervisor if you have a need for retraining in the use of mechanical lifting devices, other equipment/aids, and lifting/moving techniques.
- Notifying supervisor if mechanical devices, slings, or equipment/aids are damaged or need repair.
- Notifying supervisor of any injury sustained to staff or patients.
Maintenance personnel are responsible for:
- Inspecting the patient lifting equipment, slings, and batteries each month.
- Maintaining lifting devices and other equipment in good working order.
- Establishing procedures for removing damaged equipment from service.
The transferring needs of each patient should be assessed and the most appropriate lifting and transferring method(s) should be prescribed based on the patient's rehabilitation goals and ability to ambulate, bear weight, and follow verbal instructions. Patient algorithms should be used to assess a patient's transferring needs and to identify the most appropriate methods to lift and move the patient.
The patient care environment should be assessed to examine the layout of patient care rooms, bathrooms, and bathing areas to identify factors that might contribute to patient handling incidents, such as furniture that might interfere with transfers, the adjustability of bed height, the size of the bathrooms and bathing areas, and physical barriers such as thresholds that aren't level with the floor that might restrict the movement of lifting equipment.
Training should be provided to all staff affected by the safe patient lifting program; this should include administrators, nursing staff, physical and occupational therapists, maintenance staff, and housekeeping and laundry staff. All nursing staff and caregivers who lift and transfer patients should be trained and made competent in the use of patient lifting equipment and the procedures to follow while transferring patients. Training should be provided during employee orientation, and whenever there's a change in job assignment, equipment, or procedures. Refresher training should be conducted annually and upon the request of staff.
The employer will provide mechanical patient lifts, slings, batteries, and repositioning aids that are made of durable quality and intended for commercial use. The number of lifts required to ensure the safety of patients and caregivers depends on the level of physical dependency of the patients. As a general rule, one full-body lift should be provided for every 8-10 non-weight-bearing patients/residents, and one stand-up lift should be provided for every 8-10 partial-weight-bearing residents.
All patient lifting equipment, slings, and assistive devices should be cleaned and laundered to comply with infection control procedures and policies. If possible, disposable slings should be used on patients who pose an infection control risk. If reusable slings are used, the patients' name should be marked on the sling and the sling should be stored at their bedside. Patient lifting equipment should be cleaned on a regular basis and after each use on a patient who poses an infection control risk.
Full-body lifts are intended for patients who can't bear weight during any patient transferring task. If any caregiver is required to lift more than 35 lbs of a patient's weight or the patient is unpredictable or prone to lose balance, that patient should be considered fully dependent, and assistive devices should be used for the transfer. Full-body lifts can be equipped with a weighing scale.
Full-body lifts:
- should be able to lift patients from bed height as well as pick up a patient from the floor.
- should be stored with slings in a convenient location.
- should have charged batteries when the lift isn't in use.
Stand-assist lifts are intended for patients with partial-weight-bearing ability who require the caregiver to lift no more than 35 lbs of a patient's weight. The patient should require no more help than stand-by, cueing, or coaxing, and the patientshould have the mental capacity to follow simple commands when prompted. The stand-assist lift is useful for toileting residents and for bed to chair transfers.
Stand-assist lifts:
- should be stored in a convenient location with slings.
- should have charged batteries when the lift isn't in use.Slings that are used with mechanical lifts:
- should be available in a range of sizes.
- should be stored in a convenient location that's readily accessible to caregivers.
- should be washable or disposable.
- should be laundered on site if possible; laundering off site can result in lost slings; back-up slings should be available for use when slings are being laundered.
Repositioning aids should be available to assist with repositioning patients/residents in bed.
Surface friction-reducing devices, slide sheets, and lateral transferring devices:
- should be made of durable quality.
- should be capable of adjusting patients/residents in bed, regardless of patient size.
If an employee is injured on the job, employees should report the injury to their supervisor immediately. Every injury should be treated promptly and each incident should be investigated so that preventive measures can be implemented.
Training records shall be maintained by the training coordinator. All injury and illness records and incident investigations should be maintained and periodically examined to evaluate the effectiveness of the safe patient lifting program. Periodic analysis of these data will make it possible to identify and understand persistent injury problems and propose countermeasures.
More information about developing a safe patient handling policy can be found at: Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement, VA Hospital, Tampa, Fla., and Department of Defense, 2001. Revised August 31, 2005. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf .
Occupational Safety & Health Administration. Guidelines for Nursing Homes: Ergonomics for the Prevention of Musculoskeletal Disorders, OSHA 3182, 2003. Available at: http://www.osha.gov/ergonomics/guidelines/nursinghome/ .
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