1. Audrey Nelson, Ph.D., RN, FAAN audrey.nelson@.va.gov
Evidence-Based Safe Patient Handling to Promote Safer Work Environments
Audrey Nelson, Ph.D., RN, FAAN
Evidence-Based Safe Patient Handling to Promote Safer Work Environments
Audrey Nelson, PhD, RN, FAAN

2. Problem Statement
Musculoskeletal injuries associated with patient care have been a problem for decades.
Efforts to reduce patient handling injuries are often based on tradition and personal experience rather than scientific evidence.
Despite strong evidence, published internationally over three decades, most clinical settings have used significant resources to implement strategies that are not evidence-based.
There is a growing body of evidence to support interventions that are effective or show promise in reducing musculoskeletal pain and injuries in care providers.
Problem Statement
Musculoskeletal injuries associated with patient care have been a problem for decades.
Efforts to reduce patient handling injuries are often based on tradition and personal experience rather than scientific evidence.
Despite strong evidence, published internationally over three decades, most clinical settings have used significant resources to implement strategies that are not evidence-based.
There is a growing body of evidence to support interventions that are effective or show promise in reducing musculoskeletal pain and injuries in care providers.

3. Purpose
Provide a brief overview of the research related to nursing and musculoskeletal injuries-- pointing out what we know and common myths associated with risks.
Purpose
Provide a brief overview of the research related to nursing and musculoskeletal injuries-- pointing out what we know and common myths associated with risks.

4. The Ergonomic Challenge
The adult human form is an awkward burden to lift or carry. Weighing 200 pounds or more, it has no handles, it is not rigid, and it is susceptible to severe damage if mishandled or dropped. (circa 1950)
The Ergonomic Challenge
The adult human form is an awkward burden to lift or carry. Weighing 200 pounds or more, it has no handles, it is not rigid, and it is susceptible to severe damage if mishandled or dropped. (circa 1950)

5. No wonder nurses are injured!
In an eight hour shift, the cumulative weight that nurses lift equal to an average of 1.8 tons per day.
No Wonder Nurses Are Injured!
In an eight hour shift, the cumulative weight that nurses lift equal to an average of 1.8 tons per day.

6. 30+ years of experience shows us training alone is not effective.
Common Myths
“Classes in body mechanics and lifting techniques are effective in reducing injuries”.
30+ years of experience shows us training alone is not effective.
Common Myths
Classes in body mechanics and lifting techniques are effective in reducing injuries”.
30+ years of experience shows us training alone is not effective.

7. Show me the Evidence! Brown, 1972 Owen & Garg, 1991
Dehlin, et al, 1976
Anderson, 1980
Daws, 1981
Buckle, 1981
Stubbs, et al, 1983
St. Vincent & Teller, 1989
Owen & Garg, 1991
Harber, et al, 1994
Larese & Fiorito, 1994
Lagerstrom & Hagberg, 1997
Daltroy, et al, 1997
Show me the Evidence!
Brown, 1972
Dehlin, et al, 1976
Anderson, 1980
Daws, 1981
Buckle, 1981
Stubbs, et al, 1983
St. Vincent & Teller, 1989
Owen & Garg, 1991
Harber, et al, 1994
Larese & Fiorito, 1994
Lagerstrom & Hagberg, 1997
Daltroy, et al, 1997

8. Definition of Insanity
“Doing the same thing over and over and expecting different results”
Albert Einstein
Definition of Insanity
Doing the same thing over and over and expecting different results”
Albert Einstein

9. “Back belts are effective in reducing risks to caregivers”.
Common Myths
“Back belts are effective in reducing risks to caregivers”.
There is no evidence back belts are effective. It appears in some cases they predispose nurse to higher level of risk.
Common Myths
“Back belts are effective in reducing risks to caregivers”.
There is no evidence back belts are effective. It appears in some cases they predispose nurse to higher level of risk.

10. “Patient Handling Equipment is not affordable”.
Common Myths
“Patient Handling Equipment is not affordable”.
The long term benefits of proper equipment FAR outweigh costs related to nursing work-related injuries.
Common Myths
“Patient Handling Equipment is not affordable”.
The long term benefits of proper equipment FAR outweigh costs related to nursing work-related injuries.

11. Common Myths “If you buy it, staff will use it”
Reasons staff do not use equipment: time, availability, time, difficult to use, space constraints, and patient preferences.
Common Myths
“If you buy it, staff will use it”
Reasons staff do not use equipment: time, availability, time, difficult to use, space constraints, and patient preferences.

12. Common Myths
“If you institute a No-Lift Policy nurses will stop lifting”.
Before Zero Lift Policies are implemented, infrastructure needs to be in place-- technology and culture.
Common Myths
“If you institute a No-Lift Policy nurses will stop lifting”.
Before Zero Lift Policies are implemented, infrastructure needs to be in place-- technology and culture.

13. Common Myths “Various lifting devices are equally effective”.
Some lifting devices are as stressful as manual lifting. Equipment needs to be evaluated for ergonomics as well as user acceptance.
Common Myths
“Various lifting devices are equally effective”.
Some lifting devices are as stressful as manual lifting. Equipment needs to be evaluated for ergonomics as well as user acceptance.

14. Education & Training
Education & Training

15. Education and Training
Use of peer safety leaders shows promise
Introduce new technology or practices
Conduct ongoing hazard evaluation of unit
Assure competency of staff
Sustain the program
Back Injury Resource Nurses (BIRNs)
Ergo Rangers
Ergo Coaches
Education and Training
Use of peer safety leaders shows promise
Introduce new technology or practices
Conduct ongoing hazard evaluation of unit
Assure competency of staff
Sustain the program
Back Injury Resource Nurses (BIRNs)
Ergo Rangers
Ergo Coaches

16. Back Injury Resource Nurses (BIRNs)
New Education Model: Credible Peer Leader
Selected for each high risk unit
Provide ongoing hazard identification
Assure competency in use of equipment
Implement algorithms
Ergo Guide Book Free!
Back Injury Resource Nurses (BIRNs)
New Education Model: Credible Peer Leader
Selected for each high risk unit
Provide ongoing hazard identification
Assure competency in use of equipment
Implement algorithms
Ergo Guide Book Free!

17. Use of Technology
Use of Technology

18. Manual Lifting Techniques
Manual lifting techniques increase risk for injury. Many have been banned because they also pose risk and discomfort for patient:
Hook and Toss (aka Drag Lift)
Arm and leg lift (two person lift with caregiver arms under patient axilla and thigh)
Shoulder lift (aka Australian Lift)
Manual Lifting Techniques
Manual lifting techniques increase risk for injury. Many have been banned because they also pose risk and discomfort for patient:
Hook and Toss (aka Drag Lift)
Arm and leg lift (two person lift with caregiver arms under patient axilla and thigh)
Shoulder lift (aka Australian Lift)

19. NIOSH Weight Limits for Safe Lifting
Manual Materials Handling Maximum = 51 lbs.
Patient/Resident Handling Lifting Maximum = 35 lbs.
Tom Waters 2007 American Journal of Nursing
NIOSH Weight Limits for Safe Lifting
Manual Materials Handling Maximum = 51 lbs.
Patient/Resident Handling Lifting Maximum = 35 lbs.
Tom Waters 2007 American Journal of Nursing

20. New Curriculum Needed
Working with ANA and NIOSH to develop this curriculum
27 schools of nursing participating
USA is behind other countries in this area
New Curriculum Needed
Working with ANA and NIOSH to develop this curriculum
27 schools of nursing participating
USA is behind other countries in this area

21. Expected Speed of Implementation
It takes an average of 17 years for new knowledge generated by RCT to be incorporated into practice, and even then, the application is highly uneven.
Balas, EA and Boren, SA. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of medical informatics. Bethesda, MD: National Library of Medicine, pp
Expected Speed of Implementation
It takes an average of 17 years for new knowledge generated by RCT to be incorporated into practice, and even then, the application is highly uneven.
Balas, EA and Boren, SA. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of medical informatics. Bethesda, MD: National Library of Medicine, pp

22. Patient Handling Technology
Perceived by staff nurses as the #1 most effective solution for musculoskeletal discomfort.
Patient Handling Technology
Perceived by staff nurses as the #1 most effective solution for musculoskeletal discomfort.

23. Clinical Tools: Assessment & Decision Making

24. Practice Tools
Algorithms show promise in standardizing decisions related to type of equipment and number of people needed to perform a task safely.
Practice Tools
Algorithms show promise in standardizing decisions related to type of equipment and number of people needed to perform a task safely.

25. High Risk Tasks Vary by Setting
Nelson, AL, Menzel, N, and Motacki, K. (In development). Safe Patient Handling: An Illustrated Guide. New York, NY: Springer Publishing.
High Risk Tasks Vary by Setting
Nelson, AL, Menzel, N, and Motacki, K. (In development). Safe Patient Handling: An Illustrated Guide. New York, NY: Springer Publishing.

26. Algorithms AVAILABLE IN DEVELOPMENT SCI/Rehab Critical Care
LTC/Nursing Home
Orthopedic
Perioperative
Bariatric
IN DEVELOPMENT
Critical Care
Med/Surg
Home Care
Diagnostic/Radiology/Morgue ER
Algorithms
Available: SCI/Rehab, LTC/Nursing Home, Orthopedic, Perioperative, Bariatric
In Development: Critical Care, Med/Surg, Home Care, Diagnostic/Radiology/Morgue, ER

27. Unit Risk (Hazard) Assessments

28. Patient Care Ergonomic Assessments of Units
This approach is used to assess hazards:
High Risk Tasks unique to each clinical area
Root cause analysis of patient handling injuries (staff and patients)
Equipment inventory
Walk through of physical environment
Make Recommendations
Patient Care Ergonomic Assessments of Units
This approach is used to assess hazards:
High Risk Tasks unique to each clinical area
Root cause analysis of patient handling injuries (staff and patients)
Equipment inventory
Walk through of physical environment
Make Recommendations

29. “No Lift” Policies
“No Lift” Policies

30. Safe Patient Handling (No Lift) Policy
Several multi-site studies that addressed no lift policies, demonstrating they are effective. (Note: Multifaceted, with no-lift one aspect)
Need to integrate lessons learned from UK, Australia, and much of Europe into practices in USA.
Myths Associated with “No Lift”
Lessons Learned from UK (New)
Safe Patient Handling (No Lift) Policy
Several multi-site studies that addressed no lift policies, demonstrating they are effective. (Note: Multifaceted, with no-lift one aspect)
Need to integrate lessons learned from UK, Australia, and much of Europe into practices in USA.
Myths Associated with “No Lift”
Lessons Learned from UK (New)

31. Summary “Reader’s Digest Version”

32. Unfortunate Disconnect between Practice and Research
The most common patient handling approaches in the United States over the past decade include
manual patient lifting
classes in body mechanics
training in safe lifting techniques
back belts
There is strong evidence that each of these commonly used approaches is NOT effective in reducing caregiver injuries.
Unfortunate Disconnect between Practice and Research
The most common patient handling approaches in the United States over the past decade include
manual patient lifting
classes in body mechanics
training in safe lifting techniques
back belts
There is strong evidence that each of these commonly used approaches is NOT effective in reducing caregiver injuries.

33. Evidenced-Based Practices
patient handling equipment/devices
patient care ergonomic assessment protocols
no manual lifting policies
training on proper use of patient handling equipment/devices
patient lift teams (where equipment is used)
Evidence-Based Practices
patient handling equipment/devices
patient care ergonomic assessment protocols
no manual lifting policies
training on proper use of patient handling equipment/devices
patient lift teams (where equipment is used)

34. Emerging Evidence unit-based peer leaders
clinical tools, such as algorithms and patient assessment protocols
Emerging Evidence
unit-based peer leaders
clinical tools, such as algorithms and patient assessment protocols

35. Multifaceted Programs
Multifaceted programs are more likely to be effective than any single intervention.
Why?
Complexity of this high-risk, high volume, high-cost problem
Multifaceted Programs
Multifaceted programs are more likely to be effective than any single intervention.
Why?
Complexity of this high-risk, high volume, high-cost problem

36. Research/Practice Disconnect
It takes an average of 17 years for new knowledge generated by RCT to be incorporated into practice, and even then, the application is highly uneven.
Balas, EA and Boren, SA. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of medical informatics. Bethesda, MD: National Library of Medicine, pp
Research/Practice Disconnect
It takes an average of 17 years for new knowledge generated by RCT to be incorporated into practice, and even then, the application is highly uneven.
Balas, EA and Boren, SA. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of medical informatics. Bethesda, MD: National Library of Medicine, pp

37. Summary Article Reference
Nelson, AL and Baptiste, A. (2004). Evidence-Based Practices for Safe Patient Handling and Movement. Online Journal of Issues in Nursing, 19 (3) Manuscript 3. Available:
Summary Article Reference
Nelson, AL and Baptiste, A. (2004). Evidence-Based Practices for Safe Patient Handling and Movement. Online Journal of Issues in Nursing, 19 (3) Manuscript 3. Available:

38. Implementing and Sustaining Successful SPH Programs
New Challenge
New Challenge

39. State & National Policies for Safe Patient Handling