1. Watters, Carol

Article Content

For years, hospitals have been buying safety equipment to use with little or no effect on workers' compensation costs or patients' comfort and safety. Nurses did not use safety equipment for several reasons, much of which involves the "time" it takes to get the equipment, set up the equipment, and move the patient. However, statistics from the Bureau of Labor clearly demonstrate that injuries to nurses are some of the highest in all industries. "While healthcare workers are the backbone of healthcare, nursing remains one of its highest risk occupations[horizontal ellipsis]. [the] American healthcare worker suffers a back injury every 30 minutes[horizontal ellipsis]. With nearly 55 percent of the U.S. population, or approximately 97 million adults, designated as overweight or obese, patient weight has become a contributing factor in these injuries, along with the accompanying cost[horizontal ellipsis]." (Bersch, 2003).


As orthopaedic nurses, we can relate to and understand the association of our occupation with musculoskeletal injuries, possibly having sustained an injury ourselves. Our NAON organization has been at the forefront of increasing the awareness of our members through education and Congress sessions about the effects of injuries and the need to be good role models for the concepts of safe patient handling. However, nurses continue to disregard the potential career-ending or life-hampering effects of not participating in safe patient-handling procedures. Resistance to the value of safe patient handling still exists. Let's revisit some of the reasons for making safe patient handling a priority in your work area.




Bersch, C. (April, 2003). Hospital gives patients a lift-What works. Healthcare deal Purchasing News, 1-4. Retrieved October 9, 2007, from http://findarticles.comp/articles/mi_mOBPC/is_4_27/ai_100484232. [Context Link]


deCastro, A. B., Hagan, P., & Nelson, A. (2006). Prioritizing safe patient handling: The American Nurses Association's handle with care campaign. Journal of Nursing Administration, 36(7/8), 363-369.


This article emphasizes that safe patient handling is imperative for the nursing profession with tremendous effect on the quality of patient care and the nursing shortage. Viewed within this context, several critical arguments for embracing the concepts of safe patient handling at the bedside and by nursing management are provided by the authors. Several points merit attention.


Patients who require assistance with mobility are typically physically dependent and may have only partial ability to understand instructions and cooperate with moving. Altered levels of cognition whether or not related to medications and language barriers may make the lift process even more difficult. Patient groups who experience increased weight, are elderly, have higher acuity, agitation, combative, or abusive behavior put the nurse at even greater risk of injury. The impact of all of these variables subject nursing personnel to greater hazards with mobility issues.


Injury to the musculoskeletal system is cumulative and "incremental" during the course of one's career. The first musculoskeletal damage (MSD) at a young age in nursing may not be recalled, but it can be the beginning of a long series of damaging events leading to inability to or restriction of physical activity for the rest of life, a career-ending possibility. Limited work duty is often part of the treatment plan for the MSD, restricting the work capacity of the individual and leading to dissatisfaction with one's nursing role. In light of the nursing shortage, musculoskeletal injuries become a burden on the workforce, with the necessity to restrict work capacity (light work) and cover for absenteeism or lost work time. Morale issues or transfer to other work areas may also become part of the outcomes from not using safe patient-handling measures.


As the nursing workforce ages, the risk of injuries to older nurses increases, both as the effects of cumu-lative injuries become evident and as nurses' ability to perform required strenuous activities, such as lifting and turning decreases. In turn, the loss of older nurses from injuries has a negative effect on the nursing shortage.


Retention of patient dignity is another point emphasized by these authors. Safe patient handling retains a patient's privacy from exposure, as opposed to one "tossing a patient" into a chair during a lift. Privacy issues of complete coverage during a transfer are managed more effectively with equipment that provides for protection of bodily areas during a lift.


These authors advocate the use of patient care ergonomics through the adoption of safe patient-handling interventions. Such programs use a formal educational process that encourages compliance with the best evidence to support use of the methods and equipment. The program is not "punitive" but solicits total management buy-in to avoid injuries and provides equipment for safe handling of patients, not an inexpensive venture. Patients are assessed on admission for their need of patient-handling equipment. The type of equipment needed is determined and assigned to the patient. Evaluation of compliance and patient outcomes is an ongoing need to demonstrate the cost savings associated with the program. The older methods of lifting promoted the "hook and toss" technique, where nurses "hooked" patients under the arm (axilla) and grasped the patient as they were "tossed" into the nearby chair. These static lifts used the lower back, which is a vulnerable portion of the body, for lifting. Most of the early studies of this method were based on lifting a box with handles from a lower position and used men as the study participants. Because women continue to be the primary participants in the nursing profession, the model of men lifting does not provide appropriate applicable evidence.


Success with the program is determined by the key stakeholders in the process, the bedside nurse user. Resistance to change is an expectation but can be overcome by recognition that evidence supports this approach to best patient care. Focus groups for nurse users may be a means to clarify misconceptions about safe patient handling by having them participate in the selection of equipment and change behavior resulting from increased knowledge about the injuries that can occur without using proper equipment. The American Nurses' Association and many other regulatory groups offer rationale for these types of programs. The role of the nurse administrator is to convince organizational stakeholders that the purchase of safe patient handling will reap benefits for organizational goals and be a financially sound investment that is based on evidence from practice, and outcomes will be evaluated to ensure compliance.


Waters, T. R. (2007). When is it safe to manually lift a patient? American Journal of Nursing, 107(8), 53-59.


The title of this article seems to be the opposite of the previous article. On closer examination, the author is discussing the revised equation developed by the National Institute for Occupational Safety and Health (NIOSH) in 1994-an ergonomics assessment tool that calculates the recommended weight for a safe two-handed manual lift task by healthy workers. Unfortunately, the NIOSH tool excluded assessment of patient-handling tasks from its tool, indicating that too many variables were associated with patient-handling conditions. Those types of limitations were that patients can be heavier than they appear, and patient movements during a lift can create unsafe situations. Waters, a research safety engineer in the Division of Applied Research and Technology at NIOSH, offers a revision of the NIOSH tool that can be used with limited patient situations, where the patient will not move suddenly during the move, the weight the caregiver can lift is estimated, the lift is smooth, and the patient is cooperative.


The unfortunate thing is that most nursing situations do not mirror the ideal conditions listed. Ideal lifting is no more than 35 pounds, not lifting with extended arms, not lifting near the floor, not lifting when sitting or kneeling, or lifting during a shift that lasts more than 8 hours. In addition, when two nurses lift an object (patient) together, it is hard to judge how much weight each person lifts. The usual is that one person may be stronger than the other, with the lift being disproportionate between to the two nurses. Therefore, a case of lifting more than 35 pounds would definitely occur.


The revised NIOSH lifting equation lists six variables that comprise any lifting situation. The maximum amount to be lifted under ideal conditions is 51 pounds. The following are the variables considered in the equation: LC (load constant), HM (horizontal multiplier), VM (vertical multiplier), DM (distance multiplier), AM (asymmetric multiplier), FM (frequency multiplier), CM (coupling multiplier); when multiplied together, they yield the recommended weight limit (RWL). In other working situations where a "static" weight can be calculated and used many times without variation, this formula would be appropriate. However, in nursing, where many situations (holding the leg of a 250-pound person while the patient is being prepared for surgery) require on-the-spot calculation of weight estimates, the formula would not provide an on-the-spot easy estimate of the weight limit for lifting.


The value of this article is that it highlights the combination of factors associated with lifting, which many nurses ignore or discount in a lifting situation. Why do they ignore these factors? Because many times the patient needs to be transferred from one situation to another in a hurry. Knowing that a 35-pound limit is recommended to prevent significant injuries, such as back strain, would caution the nurse to ask for assistance or a lift device to move a patient or object that weighs more than 35 pounds. The equation on its own is too complex to use for quick nursing decisions. However, as Waters illustrates, the Association of Perioperative Registered Nurses has used the equation to provide recommendations for the lifting of such objects as linen bags, lead aprons, sterile packages, and instrument trays (p. 57).


The take-away points from this article are that many factors comprise a safe patient and safe nurse lifting situation. The guide of a maximum of 35 pounds for an on-the-spot estimate of weight should caution any nurse to seek assistance with a lift of greater than 35 pounds. The formula could be used to provide evidence for static constant lift situations where administration needs to evaluate the potential harm of a repetitive lift on the health of a nurse over time.


Menzel, N. N., Hughes, N. L., Waters, T., Shores, L. S., & Nelson, A. (2007). Preventing musculoskeletal disorders in nurses: A safe patient handling curriculum module for nursing schools. Nurse Educator, 32(3), 130-135.


Evidence from practice is the foundation for implementing safe patient handling in clinical sites. However, one of the problems that may contribute to a lack of compliance with nurses' acceptance of safe patient handling is the gap between what is taught in the educational setting and what is practiced in the clinical area. This article, as is the case with the two previous articles, highlights that some educational institutions are not using current evidence about safe patient handling to frame curricula, thus contributing to musculoskeletal injuries in the workplace. Nursing textbooks and even the national examination for nursing licensure continue to discuss manual patient handling despite evidence that describes musculoskeletal injuries. For the past 10 years, other government and private professional organizations have supported the evidence-based practices of safe patient handling for the patient and the nurse. These organizations include the American Nurses Association (ANA) and the Veterans Administration (VA), who have published and researched extensively in this area, and the National Institute for Occupational Safety and Health (NIOSH). The authors believe the slow move to include the principles of safe patient handling in curricula was a result of limited educational materials dealing with the topic and the slow translation of research results to educators and questions for the national nursing examination. Therefore, many nurse educators continued to teach outdated techniques for patient handling, promoting a potential for nurse injuries in the workplace.


In 2004, the ANA, NIOSH, and the VA Patient Safety Center developed a new safe patient-handling curriculum for schools of nursing that would implement new ways of teaching about safe patient handling. The goals of the project were to focus on (1) student learning, (2) faculty development in effective teaching, and (3) assessment. Another area of emphasis was to connect the teaching to application in the clinical area. If you are an educator and interested in bringing this material to your setting, there is a slide show available on the following Web site:


Barriers to the implementation of the project and the curriculum were the lack of funding for equipment so schools could have the most recent technology for teaching purposes. Vendors did loan participating schools minimal required equipment to have demonstrations for practice laboratories. Other factors leading to acceptance were addressed with Lewin's theory of change as a model, as new areas were introduced in the existing curricula. In addition, the schools shared knowledge about the new equipment with hospitals and agencies that did not have the equipment, further spreading the word about safe patient handling.


Fitzgerald, D.C. (2007). Aging, experienced nurses: Their value and needs. Contemporary Nurse, 24(2), 237-242.


One unfortunate outcome of cumulative musculoskeletal injuries in older nurses is that they may have to leave the workforce or retire earlier than anticipated. This may be one of a series of contributing factors in the shortage of nurses.


It is estimated that the nursing shortage may extend beyond the year 2020. As a result, older nurses would be a valued commodity in the workplace, with fewer people seeking careers in nursing and the loss of older nurses' knowledge creating a deficit for the profession. However, are we valuing and replacing this lost capital? This article makes the case that older nurses have values that are at the "very heart of the organization's future and its sustainability" (p. 238) in a changing future. But older nurses report more job-related musculoskeletal injuries, rotating shifts are more difficult for them, and stressors of caring for older family members are a concern. The literature demonstrates that older nurses are seeking positions in places where the demands of nursing are not as great or intense and they are even leaving the profession for other work.


Fitzgerald makes the plea that we look at the needs of the older nurse and we also need to be vigilant for the orthopaedic nurse who faces challenges from a career of musculoskeletal injuries. She points out several areas of consideration. First, financial; salaries are often not commensurate with experience, where the new nurse, with such things as sign-on bonuses as recruitment strategies, makes more than the older nurse, negating experience as a factor for remuneration. Other employment packages related to retirement or healthcare are based on the final years of employment, where the increases for the older nurse have not kept pace with other industries. Second, she offers suggestions in the area of ergonomics to assist the older nurse in her physical work environment. She discusses things such as large computer screens to help with decreased visual acuity, improved flooring for comfort, adjustable lighting to increase brightness and prevent glare, electrical outlets at higher positions to prevent bending and stooping, and attention to wall coverings that think of acoustic problems. Third, the area of human resources is addressed specially to acknowledge the decreased stamina of older nurses and the use of their experiential knowledge. Wouldn't it be wonderful to have an older nurse mentor a younger nurse where he or she can impart experiential knowledge that would counter the effects of the "eat our young" syndrome? Flexible shifts of 4 or 6 hours could enhance a work area at high-volume times, such as patients needing feeding or dressing changes, but wouldn't increase the burden of long hours on arthritic legs. These are suggestions that all managers and administrators should give careful thought to. Fitzgerald does address the constant criticism of cost with such initiatives. Using an "out-of-the-box" approach, many of the suggested changes would be a minimal cost, but the value to the organization could be tremendous. Her concluding statement is one that should resonate with all nursing organizations, even if they don't care for the elderly. She contends that we have spent efforts to address the needs of the older patient but have failed to address the needs of the older worker. "The mission statements reflecting commitment to promoting health in the community lack wellness practice to support aging nurses" (p. 241).


Peterson, E. L. (2007). Fibromyalgia: Management of a misunderstood disorder. Journal of the American Academy of Nurse Practitioners, 19 (2007), 341-348.


Not a musculoskeletal disease, fibromyalgia could be a complaint nurses would see with coworkers and patients who have pain associated with orthopaedic problems. Fibromyalgia is the third most prevalent rheumatologic disorder in the United States (p. 341). The exact etiology of this disorder remains unknown, although a group of complaints, such as chronic musculoskeletal pain, persistent fatigue, nonrestorative sleep and generalized morning stiffness, are given by patients (Patkar, Bilal, & Masand, 2003). Peterson states that the disease is poorly understood, but current thinking gives prominence to abnormalities in neuroendocrine systems, such as the hypothalamic-pituitary-adrenal axis, alterations in levels of cerebrospinal fluid substance P and low levels of cortisol, growth hormones, norepinephrine and serotonin.


Since 1990, the American College of Rheumatology has recognized fibromyalgia as chronic pain involving a noninflammatory syndrome of the muscles not the joints, affecting both sides of the body. The patient is usually postmenopausal with proximal muscle pain in the neck, shoulders, or proximal thighs. These symptoms could also be associated with numerous orthopaedic injuries, so careful assessment of the patient over time may be the most important aspect of treatment. Stress seems to be a heralding factor for the onset of symptoms, with the comorbid conditions of depression, spastic colon, diarrhea, temporal mandibular joint syndrome, and thyroid problems being associated. Clearly, diagnosing this disease and separating it from other orthopaedic conditions can be a challenge. Treatment goals are to control severe pain (elimination is not usually possible), improve sleep to decrease fatigue, and improve functioning for daily activities.


Peterson recommends that the first line of treatment for these patients is attentive listening and acknowledgment that they are experiencing pain. Pharmacologic treatment in isolation is not effective. Current therapy recommends a combination of exercise, psychological treatment, and patient education for these patients. Nurses working with orthopaedic patients diagnosed with fibromyalgia need to remember that this disease may mimic many others syndromes and compound any existing orthopaedic problems. Remaining judgment free in listening is a key therapeutic intervention for the amelioration of symptoms that cannot be completely eliminated.




Patkar, A. A., Bilal, L., & Masand, P. S. (2003). Management of fibromyalgia. Current Psychiatry Reports, 5(3), 218-224. [Context Link]


Farley, F. A., & Weinstein, S. L. (2006). The case for patient-centered care in orthopaedics. Journal of the American Academy of Orthopaedic Surgeons, 14(8), 447-451.


This article gives the call for a patient-centered approach to orthopaedic care. Identified as a paradigm shift from the disease-centered or medical model of care, the Academy recommends that patient-centered care be defined as "The provision of safe, effective, and timely musculoskeletal care achieved through cooperation between the orthopaedic surgeon, an informed and respected patient [and family] and a coordinated health care team" (p. 447). The tenants of the model depict criteria orthopaedic nurses also value, namely safe care (avoid any harm), effective (care based on evidence), patient-centered (respects patient values and preferences), timely (reduce wait), efficient (avoid waste), and equitable (care that respects diversity in all areas-age, sex, and race). The Institute of Medicine (IOM), after the report of To Err is Human: Building a Safer Health System, promoted the patient safety movement. We have seen some of the parts of this system in effect when we take "time out" to be sure we have the right patient and the right surgical procedure.


The populous is demanding a place in his or her care. Nurses have been educated to view the patient from such a perspective for years. It is refreshing to see the emphasis placed on this model from the orthopaedic physicians. Nursing theorist Jean Watson and others have moved from a model of caring to "relationship-based care," a philosophy of care based on intentionally listening to the patient, setting goals of care with the patient, and evaluating care based on the patient's preferences. This philosophy also emphasizes the need for evidence-based practice, which clearly places the patient's preferences and needs as part of the process to consider when making decisions about care interventions and goals. No longer is decision making one-sided.


Orthopaedic nurses are a part of this team. We need to assist with the plans for patient-centered care and be seen as part of the team to provide the best possible care to patients. Here is an opportunity to collaborate with colleagues. Let's make the best of the challenges inherent in this new paradigm and be contributing members of the team.