Preventing Injuries Using an Ergonomic Approach

By Bernice D. Owen, from AORN Journal, December 2000

The saying "work can be dangerous to your health" is an important phrase in the nursing profession. In hospital settings, there are several dangers that especially affect nursing personnel. Although needle-stick injuries are the most frequently reported injury among hospital nurses, the most costly for health care facilities are overexertion injuries to workers' shoulders or backs. These problems have been studied, and progress has been made to decrease their prevalence. For example, the number of needle-stick injuries has decreased significantly in hospitals that use ergonomically designed syringes.

Ergonomics is the scientific study of human work. It involves matching the job to the worker, rather than attempting to fit the worker to the job. The goal in ergonomics is to identify aspects of the job that are particularly hazardous and redesign them to be safer. This can be accomplished by redesigning the task, product, work station, environment, or overall work organization. In the example of needle-stick injuries, the product (i.e., syringe) was redesigned so that the needle is shielded or retracted into the barrel immediately after the injection. In this way, nurses cannot self-inject themselves with a used needle, and the product now better fits the worker.

Many approaches to decreasing back and shoulder problems have been tried in general industry, as well as in health care settings. Emphasis primarily has been on education and training, with a definite focus on body mechanics. These approaches, however, have had little effect on the problem, as the aim has been to change the worker instead of the job or the task. Studies indicate that an ergonomic approach involving the assessment of stressful tasks and the development of alternative methods to decrease this stress can reduce the number of overexertion injuries. As a result, the assumption that reducing physical stress reduces injuries was true.

INJURIES INCREASE IN FREQUENCY
In 1984, nurses ranked fifth among workers in all occupations who claimed workers' compensation for back injuries; only heavy laborers (e.g., sanitary engineers, laborers, warehouse workers) ranked higher. The rate of overexertion injuries among hospital nurses is almost double that of workers in private industry. In 1990, the national goal was to decrease these injuries in nursing personnel from 12.7 injuries per 100 full-time nurses annually to nine. According to one source, however, the rate actually had increased to 17.8 injuries per 100 nurses by 1995.

NURSES CHANGE JOBS DUE TO BACK PAIN
Since the 1980s, many nurses have changed positions or actually left the nursing profession because of overexertion injuries. In one study, a questionnaire revealed that 38% of 503 nurse respondents had suffered occupation-related back pain severe enough to require leave from work. Twenty percent of those with back pain said they had made at least one employment transfer (e.g., from an intensive care to an obstetric unit; from the hospital inpatient setting to a school setting; from a staff nurse to a pharmaceutical representative) to decrease the amount of physical stress involved with lifting or moving patients. Twelve percent of respondents indicated they were considering making an employment transfer, and another 12% stated they were thinking about leaving the nursing profession because of occupation-related back pain. Another study in England found that 12% of all nurses intending to leave nursing permanently cited back pain as either a main or contributing factor.

TRIGGERS TO BACK PAIN AND INJURY
The lifting and transferring of patients has been found to be the most frequent precipitating trigger of back and shoulder overexertion problems in nurses. These studies, however, do not focus on the perceived triggers of overexertion problems for nurses in the OR. To address this lack of information, this author conducted an informal discussion with eight nursing staff members who worked in the OR of a large hospital. These nurses indicated that the following triggers affected back pain or injuries in their setting:
    * standing for long periods of time;
    * lifting and holding patients' extremities;
    * holding retractors for extended periods of time;
    * transferring patients on and off OR beds;
    * reaching, lifting, and moving equipment; and
    * repositioning patients on OR beds.

Although all of these tasks need to be studied to determine how to decrease their physical stressfulness, this author first focused on the task of transferring patients on and off OR beds by studying the perceived physical stressfulness of the similar task of transferring patients from beds to stretchers.

AN ERGONOMIC APPROACH TO TRANSFERRING PATIENTS
As part of this study, the author conducted a laboratory test to determine which assistive devices nurses perceived as being least stressful to use in transferring patients on and off stretchers. Eight nurses volunteered to perform transfers and act as patients to determine level of comfort in the transfers. The assistive devices studied included:
    * a roller board, which is commonly used in ORs;
    * a polyethylene slider board; and
    * a friction-reducing pad, which is made of two pieces of liquid-proof, surface-
       disinfectable material that are sealed at the edges and contain a silicone lubricant
       that continually coats the inside.

The method used with each of these devices involved turning the patient to the side, placing the assistive device under the draw sheet, placing the patient on his or her back, and using the draw sheet to pull the patient to the bed or stretcher.

Researchers found that the nurses perceived significantly less physical exertion (P [is less than] .01), and, as patients, the nurses were significantly more comfortable (P [is less than] .01) when the friction-reducing pad was used. By using this device, the nurses had to pull only lightly on the draw sheet because there was no friction impeding the process. As a result, the nurses chose the friction-reducing pad for use with actual patients.

The next step of the study took place in two hospitals, one as a control and one as an experimental site. At the control site, the nurses used their usual method of transferring patients from bed to stretcher and from stretcher to bed (i.e., at least two nurses used a draw sheet to lift and pull the patient). After completing each task, the nurses rated the physical stress caused to their backs and shoulders. The perceived exertion scale ranged from zero (i.e., no exertion) to 10 (i.e., extremely heavy, maximum exertion). In this test, actual patients rated their comfort during the transfer using a scale of zero, meaning very comfortable, to seven, meaning extremely uncomfortable.

At the experimental site, nurses used the friction-reducing pad to transfer patients from bed to stretcher and from stretcher to bed. In this setting, nurses again rated their perceived physical stress to the back and shoulders after each patient transfer, and patients rated their comfort.

Findings. Findings indicate that perceived physical stress can be decreased significantly by using a friction-reducing pad under the draw sheet. These findings are statistically significant (P [is less than] .01) in favor of the friction-reducing pad for transferring patients from bed to stretcher and from stretcher to bed. In addition, patient response is statistically significant; patients were more comfortable when they were transferred by nurses who used the friction-reducing pads under the draw sheet, as compared to when they were transferred by nurses who used only the draw sheet for transfer (P [is less than] .01).

Perioperative implications. These findings can be useful to perioperative nurses, as the type of horizontal transfers performed in the OR are similar to those performed on medical-surgical units. In fact, at the experimental site, the friction-reducing pads kept disappearing from the medical-surgical units where the study was conducted. Some detective work found that perioperative nurses were taking the assistive devices to use at their site for transferring patients on and off OR beds.

ERGONOMIC APPROACH TO REPOSITIONING PATIENTS
In the initial discussion, the perioperative nurses stated the task of repositioning patients on the OR bed also was stressful. Using a laboratory setting, researchers examined the task of repositioning patients in bed using the following techniques:
    * grasping the patient under the arms and lifting him or her up in bed,
    * grasping the patient under the thighs and shoulders and lifting him or her up in bed, and
     * using the draw sheet to lift the patient up in bed.

Researchers found all three of these tasks to be in the high-risk category for injuries; all of them surpassed the maximum safe level of compressive force to the [L.sub.5][S.sub.1] disk, as determined by the National Institute for Occupational Safety and Health. The amount of force produced by these tasks to the [L.sub.5][S.sub.1] disk ranged from 3,819 newtons (N) to 6,570 N; the maximum level for safety is 3,400 N.

In another laboratory study, researchers compared the use of the friction-reducing pad to the use of the draw sheet method for repositioning patients in bed. Again in this study, perceived physical stress to nurses' shoulders and backs was reduced significantly (P [is less than] .01) when using the friction-reducing pad, and patients rated their comfort significantly higher when the pad was used, compared to when the draw sheet was used (P [is less than] .01).

WHY ARE ASSISTIVE DEVICES NOT USED?
Nurses often have been reluctant to use assistive devices and have had negative attitudes toward their use. This remains true, even though today's devices are sturdier and more stable. The reasons most frequently given for not using devices include:
    * devices were not available,
    * they took too much time,
    * they were unstable,
    * they tipped over or were otherwise unsafe, and
    * patients did not like them.

Other studies, however, indicate that nurses use and have positive comments about the devices when the nurses
    * are trained in the use of the assistive devices,
    * have the appropriate number of devices on each unit,
    * are involved in the selection of devices that are less stressful and more comfortable, and
    * receive support from management for the use of these devices.

In the Netherlands, researchers found that nurses actually ranked assistive devices as their number one choice--over increased staffing, additional lifting and transferring courses, and sports or physical fitness classes--for the prevention of back and shoulder problems. Many assistive devices (e.g., transfer belts, stand-up mechanical lifts, full-body mechanical lifts) are available today for the majority of patient-handling tasks performed in health care settings.

WILL ERGONOMIC APPROACHES BE MANDATED?
In England, lawmakers have passed legislation to implement ergonomic programs in all health care settings to decrease the stressfulness of patient-handling tasks and, thus, the number of back and shoulder injuries to health care personnel. Such programs may become legislated in the United States, as well, because a draft of an ergonomic standard has been written by the Occupational Safety and Health Administration. Major components of the program include management leadership and employee participation, hazard information and reporting, job hazard analysis and control, training, medical management of injuries, and program evaluation. If the proposed standard becomes a reality, it is likely that health care settings will be mandated to establish ergonomic programs to prevent overexertion injuries.

SUMMARY
Back and shoulder injuries to nurses occur frequently. The precipitating trigger for these injuries seems to be the lifting and transferring of patients. Using an ergonomic approach can decrease the perceived physical stress and the injury rate; however, additional precipitating factors to this problem in the OR need to be studied.

Nurses must remember that the majority of overexertion injuries are the result of cumulative trauma. Nurses must develop and share an attitude of making workplaces as safe and healthy as possible for health care workers, as well as patients. It is important to determine which tasks are physically stressful and experiment with different approaches to decrease that stress. Nurses must be encouraged to solve problems and work with managers to make changes that could alleviate overexertion problems. All nurses should take responsibility to protect themselves from injury by implementing improved techniques for performing patient-handling tasks.

Bernice D. Owen, RN, PhD, is a professor at the University of Wisconsin-Madison School of Nursing, Madison, Wis.

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