6876443 critical care nursing clinics of north america safe patient handling 2007
TRANSCRIPT
Index
Note: Page numbers of article titles are in boldface type.
A
Air-assisted devices, for lateral transfers, 179
American Nurses Association, ‘‘Elimination ofManual Patient Handling,’’ 214, 216
Antiembolism stockings, devices for, 209risk for and prevention of musculoskeletal
injury with, 138–139
Association of periOperative Registered Nurses(AORN), ergonomic guidelines of,131–132
for lateral transfer, 134–135
B
Back injuries. See also Low back injury andproblems.incidence of, 213
Bariatric patient, education for care of, 239pericare of, technological solutions for,
183
Bariatric patient handling, 223–240admission process and, 227, 231case study, 230–235
admission, 231equipment provided, 237–239history, 230–231
systems status and care in, 231–235tasks and daily care plan, 237
emotional support for nursing personnel
and, 239equipment for, in case study, 237–239
patient assessment and equipment fit, 238resources for, 224–234
algorithms, 224, 229–233assessment tool, 234equipment pool, 224
injury prevention training support, 227policy and procedure manual,
224–228
work procedures, 224
tasks in, 235, 237
problems and solutions associated with,236–237
Bed design, for bariatric patient, 238
Bed making, musculoskeletal injury in,137–138
Bed mattress, for bariatric patient, 238
Bed space. See Space.
Bed-to-chair transfers, 181–182
Body mechanics, in manual handling, 197
C
Ceiling lifts. See also Lift(s).for bed-to-chair transfers, 181–182for lateral transfers, 177–178
for limb holding, 184for repositioning in bed, 181for toileting in bed, 183–184in University of Iowa Hospitals and Clinics
program, 217, 219
Change, behavior analysis techniques for, 202case studies of, 201
implementation of, in Netherlands program,209–210
incentives for, 201–202
leadership role in, 201models for, 198–200motivation for, 200–201
resistance to, 202–203training for, 200
Change process model(s), building trust andemotional commitment, 198
collaborative, 199communication in, 199–200
social marketing and, 199–200
comparison with nursing process, 198–199leadership top down, 198
Chronic pain, psychosocial factors in, 147–148
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Crit Care Nurs Clin N Am 19 (2007) 241–245
Coaches, for assistive equipment use, in
University of Iowa Hospitals and Clinicsprogram, 219, 221in safe handling program, Netherlands, 209,
211
Coaching, for safe patient handling, 202, 209, 211
Compressive forces, in patient handling,biomechanical evidence for, 188–189
reduction of, with lifting devices for patienthandling, 189, 191
Compressive forces, in patient handling, 188–189
Coping skills, musculoskeletal disorders pain anddisability and, 148
D
Disability and return to work, psychosocialfactors in, 147–148
E
Education, for bariatric patient care, 239for patient handling tasks, 190–191
Equipment, for bariatric patient, 238–239
ErgoCoaches, in safe patient handling program,in Netherlands, 209, 211
Ergonomic assessment of critical care unit,
155–165CCU background, 155–156CCU/ICU background, patient-focused
vs. health care worker protection,
156high-risk patient handling tasks, prioritization
of, 161
musculoskeletal disorders risks in vs. in nursinghomes, 163
presite visit unit profile, equipment inventory,
159patient population/staffing/equipment use,
158–160space/maintenance/storage, 158
recommendations, change from patient focusto nurse/patient safety dyad, 163dissemination of information on
musculoskeletal disorders incidence, 164education about need for assistive
equipment, 163
use of Lewin’s model of planned change,164
recommendations for, formulation of, 160, 162
risk analysis of, 160
study of medical ICU in Las Vegas hospital,
156study protocol, collection of baseline data, 157
identification of high-risk tasks, 157, 161
identification of high-risk units, 157presite visit data on high-risk units, 157–159
team site visit for ergonomic assessment, 160unit summary sheet, 160, 162
Ergonomics, in acute care, 204
Ergonomics program, sustaining staff nursesupport for, 197–204
change process models and, 198–199coaching in, 202communication in, 198–199
incentives for, 201–202motivation in, 200–201peer leaders/unit champions for, 202
social marketing for, 199–200training for, 200
F
Floor-based lifts, for bariatric patient pericare,
183for bed-to-chair transfers, 182
Friction-reducing sheets, for repositioning in bed,
180
H
High-risk tasks, musculoskeletal disorders from,131–143. See also Musculoskeletal disorders(MSD), tasks with high risk for.on CCU, identification of, 161
space reqirements for. See also Spacerequirements, for high-risk tasks.
space requirements for, 167–175technology solutions for, 177–186
in bed-to-chair transfers, 181–183in lateral transfers, 177–179
in limb holding, sustained, 184in patient transport, 184–185in repositioning, 179–181
in toileting in bed, 183–184
I
Injury(ies), incidence rate for, 187
low back, 188–189, 188–190overexertion, 187, 213–214overuse, 214unreported, 187–188
242 INDEX
Iowa model, for safe patient handling, 213–222baseline data collection for, 217–219dissemination of results, 220–221education of staff, 219
equipment selection in, 218–219equipment trials and evaluation, 217expert opinion and, 216–217lessons learned, 221
management support and, 219outcome evaluation, 219–220patient outcomes, 220
pilot the change, 217policies and procedures development in, 219practice guidelines and implementation of
change, 218priority of topic, 216research and related literature in, 216
securing financial support for, 217–218staff outcomes, 220team formation for, 216unit assessments, 217
vendor fair for equipment, 217knowledge-based triggers for, ANA
‘‘Elimination of Manual Patient Handling,’’
214, 216OSHA Ergonomics OSHA Guidelines for
Nursing Homes, 214VA Patient Care Ergonomic Resource Guide,
214of evidence-based practice for quality care,
214–215
problem-based and knowledge-based triggersfor, 214
J
Job satisfaction, in reduction of musculoskeletaldisorders, 148
Job strain, as musculoskeletal disorders risk
factor, 148–149, 189–190
L
Lateral transfer, 208–209. See also Transfers.air-assisted devices for, 179Association of periOperative Registered
Nurses� guidelines for, 134–135ceiling lifts for, 177–178friction-reducing devices for, 179
mechanical transfer devices for, 178physical demands of, 134–135safe performance of, 136space requirements for, 177–179
Lateral transfer devices, in University of IowaHospitals and Clinics program, 218–219
Lifters, for transfers, 208–209
Lifting, in critical care, 192weight limitations for, 213
Lifting/moving, heavy objects or equipment, risk
for and prevention of musculoskeletal injuryin, 139–141
Lift(s), ceiling. See Ceiling lifts.floor-based, 182–183
for bariatric patient, 238sit-to-stand, 182
Lift team, decrease in low back injuries with, 191
Limb support, ceiling lifts for, 184in critical care, 192–193
Low back, compressive and shear forces on, in
patient handling, 188–189perceived stresses on, during lifting and
repositioning, 190
Low back injury and problems, causes of,188–189nursing personnel perception of, 189–190work stress and, 189–190
MManeuvering heavy material, guidelines for,
transportation device for, 209
Manual handling, American Nurses Associationand elimination of, 214, 216of load, NIOSH guidelines for, 205–206
risks with, 213–214UK regulations for, 214
Manual patient handling, alternatives to, 142
internal loads in, 142musculoskeletal disorder risk in, 131
Minimal lift program, 187–196studies of, 191
Minimal stand assist device, in University of IowaHospitals and Clinics program, 218
Musculoskeletal disorders (MSDs), incidence of,
155pain in, cognitive-behavioral therapy for,
149–150
prevalence of, in Netherlands, 205–206psychosocial factors in, 145–153
as etiologic agents, 146case study of, 149–150
disability and return to work and,147–148
interventions to reduce, 148–149
243INDEX
Musculoskeletal (continued )reduction of, cognitive-behavioral therapy in,
149–150job satisfaction in, 148
risks for, job strain, 148–149, 189–190manual patient handling, 131
tasks with high risk for, 131–143applying antiembolism stockings, 138–139
lateral transfers, 134–136making occupied beds, 137–138moving heavy objects and equipment,
139–141pushing occupied beds, 132–134repositioning from side to side, 137
repositioning to head of bed, 136–137
N
National Institute for Occupational Safety and
Health (NIOSH), weight limits for lifting, 213
O
OSHA, Ergonomics OSHA Guidelines for NursingHomes, 214
Overexertion injury, 213–214costs of, 187
Overuse injury, 214
P
Patient handling, in critical care, 192shear and compressive forces in, biomechanical
evidence for, 188–189
Patient handling tasks, education and training for,190–191
intervention program for, assistive devices in,191
lift team for, 191minimal lift program for, mechanical lifts in,
191perioperative, 192–193
Patient transport, physical demands of, 132–133
powered technologies for, 184–186safety tips for, 133–134
Positioning. See also Repositioning.for treatment, 209
Psychosocial factors, definitions of, 145–146in musculoskeletal disorders, 145–153
case study, 149–150cognitive-behavioral therapy in reduction
of, 149–150
conceptual models of, 146–147
contribution of, research evidence lackingfor, 146
evidence for, as etiologic agents, 146
in disability and return to work, 147–148
R
Repositioning. See also Positioning.from side to side, 137guidelines for, in safe handling program, in
Netherlands, 208in bed, 189
devices for, 180–181manual, 179–180
in critical care, 192
nursing personnel perception of stresses in, 190on side, 181to head of bed, physical demands of, 136
tips for, 137
S
Safe handling program(s). See also Iowa Model.creating culture of change for, 213–222in Netherlands, analysis of ergonomic situation
and, 205–207implementing change for, 209–210observation of ergonomic problems in, 207
peer leaders in, 205–211physical load exposure and, 206–207practice guidelines for, 207–209
preliminary results, 210–211prevalence of musculoskeletal disorders
and, 205–206pushing and pulling and, 207
task force for, 207–208sustaining staff nurse support for, 197–198University of Iowa Hospitals and Clinics,
213–222
Shear forces, in patient handling, 188–189
Shoulder, perceived stresses on, during lifting and
repositioning, 190
Sit-to-stand lifts, for bed-to-chair transfers, 182
Sling design, for bariatric patient, 238
Social marketing, application to safe patienthandling, 200for change, 199–200
Space, in ICU, evidence-based practice in health
care architecture and, 168–169historical perspective, 167–168recommendations in USA and UK, 168
planning, for bariatric patient, 239
244 INDEX
Space requirements, for high-risk tasks, 167–175areas, 171functional space experiments, 169–170length, 171–173
link analyses for, 170resuscitation, 169–172transfer from bed to bed, 169–172washing and dressing patients, 169–172
width, 171, 173for lateral transfer, 177–179
Stand assist device, in University of Iowa
Hospitals and Clinics program, 218
Stresses, on low back and shoulder, nursesperceptions of, 190
T
Total assist devices, portable, in University ofIowa Hospitals and Clinics program, 218–219
Transfers, guidelines for, 208–209
in critical care, 192manual, in Netherlands, 206–207manual and mechanical, compressive and
shear forces in, 188–189
Transfer(s), lateral. See Lateral transfer.mechanical, 188–189
Transport, in critical care, 192
of bariatric patient, 238–239technological solutions for, 184–185
Transportation device, for heavy objects, 209–210
U
University of Iowa Hospitals and Clinics. See alsoIowa Model.safe patient handling program, 213–222
V
Veterans Administration, Patient Care ErgonomicResource Guide, 214
Veterans Administration Medical Center, Florida,
tasks with high risk for musculoskeletaldisorders, 131–143. See also Musculoskeletaldisorders (MSDs), tasks with high risk for.
W
Weight limits for lifting, 213
Workload, and patient safety, 121–129assessment of, systemic, 127
dimensions of, 121–124cognitive, 122–123emotional, 123physical, 121–122, 125
quantitative and qualitative, 123–124relations between, 124time pressure and, 123
variability of, 124impact of, on health, 125
on patient safety, 126
on quality of working life, 125–126systemic, 126–127
perception of, 125sources of, 124–125
static or postural, 206–207guidelines for, 208–209
Work-related musculoskeletal disorders
(WMSDs), 131. See also Musculoskeletaldisorders (MSDs).incidence rates for health care workers, 131
risk for, 131
Work stress, low back problems and, 189–190
245INDEX
Workload and Patient Safety Among CriticalCare Nurses
Pascale Carayon, PhDa,*, Carla J. Alvarado, PhD, CICb,Systems Engineering Initiative for Patient Safety
aCenter for Quality and Productivity Improvement and Department of Industrial and Systems Engineering,
University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USAbCenter for Quality and Productivity Improvement, University of Wisconsin-Madison, 610 Walnut Street,
575 WARF, Madison, WI 53726, USA
Workload is a major characteristic of the work
environment of critical care nurses [1]. It also isone of the most important job stressors amongICU nurses [2–6], which may have negative conse-
quences for nurses and the patients they care for.An analysis of the Australian Incident MonitoringStudy data for ICUs shows that a nursing staff
shortage may lead to compromised quality ofcare [7]. The main cause of nursing staff shortagewas inappropriate staffing for patient load (81%of the incidents). Insufficient nursing staff was
linked to problems with incorrect matching of pa-tient needs and staff experience, suboptimal stan-dard of nursing care and patient supervision,
inadequate supervision of inexperienced staff,and subsequent inadequate documentation. Thenursing shortage and the resulting understaffing
can create conditions of high workload for criticalcare nurses.
A lot of work has been done to developmeasures of workload in ICUs. These measures
often are focused on ICU patient needs, patientacuity, or severity of illness [1]. These patient-levelmeasures of workload include the Therapeutic In-
tervention Scoring System [8,9], Nursing Man-power Use Score [10], Nursing Activities Score[11], and Comprehensive Nursing Intervention
Score [12]. There is increasing recognition thatmeasures of nursing workload in ICUs at the pa-tient level are not sufficient and need to include
measures of organizational and system factors
[1,13]. Spence and colleagues [13] identified severalsystem factors that contribute to nursing work-load as measured by the Patient Dependency
Score (an estimate of the nursing hours requiredfor patient care at different levels of dependency).The most significant factors were related to the or-
ganization of work (ie, organization of managers,cooperation with doctors, cooperation with peernurses, use of relief staff, and planning of shiftschedules).
This article describes the various types ofworkload faced by critical care nurses, includingthe physical workload of patient handling. The
objective is to show that safe patient handling canbe achieved by examining the entire work systemof ICU nurses and the various types of workload
they experience. The links between workload andpatient safety also are described.
Dimensions of workload
Table 1 shows the various dimensions of work-load of critical care nurses and provides examples
of each of the dimensions.
Physical workload
Physical workload of ICU nurses not only is
related to nursing practice, including moving,lifting, and bathing patients, but also to disjointedsupply sources and missing and nonfunctioning
equipment [14]. Disjointed supply sources (sup-plies or equipment needed for a task located in
* Corresponding author.
E-mail address: [email protected] (P.Carayon).
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Crit Care Nurs Clin N Am 19 (2007) 121–129
another area of a unit or hospital) and missing ornonfunctioning equipment require repetitivetravel around units or even to distant locationsin the hospital, such as other patient care units
or the central equipment reprocessing area, add-ing miles of walking to nurses’ activities.
Almost all critical care nurses find their work
physically strenuous. The physical and ergonomiclayout of ICUs often is poor; the limited spacebetween patient beds and ICU equipment is
especially problematic. The causes of severestnurse physical workload distress are lifting, work-ing in awkward postures, and stooping [15]. With
an increase in bedside procedures and technolo-gies in ICUs, nurses often are required to moveheavy equipment in and out of patient areas.There is little or no acknowledgment that this
type of task requires heavy lifting and moving;nurses under task and time constraints often findit easier to move equipment alone than to wait
for additional help.Although most ICU nurses receive some nurs-
ing school education about ergonomics and body
mechanics contributing to musculoskeletal injury,few nurses are aware of the amount of lifting theywill do in ICUs and the safest ways to performthese tasks. The American Nursing Association
believes that the essential functions for mostnurses should depend on knowledge and carejudgment not physical strength [16]. In defining
the clinical role of critical care nursing practice,Brilli and colleagues [17] focus on nurses’ under-standing and support for technical medical care,
including diagnosis, treatment, care planning,and priority setting; no mention is made of theneed for physical lifting and moving equipment.
Trinkoff and colleagues [18] have examineda comprehensive array of nursing task physicaldemands, such as lifting and awkward postures.
Nurses practicing in hospital emergency, criticalcare, or operating room/post-anesthesia carespecialties stated the highest level of physical de-mands in their work. As the number of self-
reported physical demands increased so did thelikelihood of inadequate sleep, pain medicationuse, and absenteeism.
Cognitive workload
Cognitive workload is related to the need forICU nurses to process information, often in a shortperiod of time. For instance, code situations
require quick decision making and a lot of in-formation that needs to be processed quickly [19].
Critical care nurses do the majority of familycommunication, patient assessment, evaluation,
and care in ICUs. Through their cognitive skills,nurses readily recognize clinical changes thatprevent further deterioration in patients [17].
Nurses perform many cognitive adjustmentsacross patients throughout an assigned period ofcare. These adjustments are planned (eg, work
shift changes or morning reports for assigned pa-tients) and unplanned (eg, stable patients sud-denly changing status to an unstable condition)
[20]. This constant conscious shift in thinkingfrom one patient to another extends far beyondactual bedside care. Nurses often perform cogni-tive tasks while waiting on other systems or pro-
cesses (eg, delivery of medications, laboratoryresults, and retrieving necessary patient supplies).This cognitive and physical multitasking, al-
though common in ICUs with high patient acuity,often is overlooked in management decisions ad-dressing nurse staffing ratios.
Additionally, interruptions disrupt nurses’concentration and cognitive processing. Humanbeings find it difficult to stay attentive, vigilant,
Table 1
Dimensions of workload
Dimensions of workload Definitions and examples
Physical workload Amount of physical work, including patient handling
Cognitive workload Information overload
Time pressure Working under temporal constraints and tight deadlines
Emotional workload Dealing with emotional issues, such as patient death, end-of-life care,
and family demands
Quantitative workload Amount of work
Qualitative workload Difficulty of work
Workload variability Changes in workload: increase in workload (eg, code situation) and
decrease in workload (eg, night shift)
122 CARAYON & ALVARADO
and productive, particularly when they are inter-rupted, fatigued, or in a work overload situation[21]. Nurses whose attention constantly is shiftingfrom one item to another may not be able to for-
mulate a complete and coherent picture of tasks athand or complete assigned care activities [22].Some interruptions are necessary, such as point-
ing out critical monitor changes or emergentneeds of other patients assigned to a nurse’scare. Most interruptions are about communicat-
ing information or asking questions about pa-tients, however; for instance, asking aboutinformation and questions about patients who
are soon to be admitted to or discharged froma unit. The stream of constant interruptions dis-rupts nurses’ ability to identify and assess patientneeds, increasing the cognitive workload [20], even
potentially leading to patient error.Increased understanding of the work complex-
ity in ICU environments and nurses’ cognitive
workload are critical to successful patient safetyimprovement efforts and the recruitment andretention of critical care nurses [14].
Time pressure
Time pressure relates to the need to work fast,
under tight deadlines and temporal constraints.High time pressure is related to burnout experi-enced by ICU nurses [23]. Time pressure is related
to the number of tasks ICU nurses have to per-form under temporal constraints. ICU nursesperform a large variety of tasks, including assess-
ments, measurements, documentations, and thera-pies on a regular or frequent basis. Changes instandards of care for ICU patients sometimescan introduce additional tasks for ICU nurses,
therefore adding to the already high time pressure.One example is the introduction of glycemic con-trol, which involves insulin infusions and monitor-
ing of blood glucose levels. This requiresadditional work by ICU nurses, up to 2 hoursfor a single patient during a 24-hour period [24].
Emotional workload
Emotional workload is prevalent particularly
in critical care environments because of patientacuity and severity. Critical care nurses deal withvery sick patients and are the main interface with
the families of those patients. ICU nurses areeducated and trained to provide highly technicalexpert care and also need to deal with end-of-life
care [25]. Often, ICU nurses experience obstaclesto providing end-of-life care that can add to theiremotional workload. The following obstacles arereported by ICU nurses: continuing aggressive
treatment even when advanced directives exist,physicians too optimistic to a families, and deal-ing with angry families.
Critical care nurses report that dealing withfamily demands is related to increased workload[26]. Families play an important role in ICUs,
such as watching out for the patients or just ’’be-ing there.’’ Sometimes the perspectives of thenurses and the families are not aligned, however,
and conflicts or problems may arise [27]. For in-stance, nurses may experience time limitations intheir capacity to handle some of the family situa-tions or demands.
Verbal and physical assaults by patients andtheir families also can be a source of emotionalworkload [28]. A study by May and Grubbs [28]
examines reports of verbal and physical assaultsby a group of 86 emergency department, ICU,and general floor nurses. Approximately 85% of
the ICU nurses reported verbal assaults by pa-tients and family members and 78% reportedphysical assaults.
Quantitative and qualitative workload
Frankenhaeuser and Gardell [29] differentiatequantitative workload from qualitative workload:quantitative workload is defined as the amount of
work, and qualitative workload is defined as thedifficulty of the work. Quantitative workload ofcritical care nurses can be measured using the var-
ious patient-level measures of workload (discussedpreviously); these measures provide some measureof the amount of work critical care nurses have to
perform. Quantitative workload also is related towork hours: the amount of work performed in-creases with increasing work hours. Scott and col-
leagues [30] found that critical care nurses tend towork much longer than their scheduled workshift: in a study of 502 nurses who provideddata for 6017 work shifts, they found that in
86% of the shifts, nurses worked longer thanscheduled. Longer work duration was related toincreased risk for errors and difficulty in staying
awake. Fatigue also can contribute to musculo-skeletal injuries.
Qualitative workload of critical care nurses is
related to the rapid pace of knowledge in criticalcare medicine and nursing and implementation ofnew technologies and devices. Schaufeli and
123WORKLOAD AND PATIENT SAFETY
colleagues [31] found that intensive use of sophis-ticated technology was related to high burnoutamong ICU nurses. In addition, critical care
nurses need to carry out procedures accuratelyand react to urgent situations efficiently [19].This time pressure can add to the qualitativeworkload experienced by nurses.
Workload variability
Workload variability is the extent to which
workload continually changes during a period oftime [32]. Among critical care nurses, one cause ofworkload variability is related to shifts (eg, day
shift versus night shift). ICU nurses who workday shifts report higher levels of perceived work-load than ICU nurses who work during nightshifts [26]. The higher day shift workload may
be correlated directly with other patient care ser-vices availability. Many hospital departments areclosed or staffed only for emergency care during
night shifts. Night shift nurses often describe theshifts as more relaxed, with more time spentwith patients because there tend to be fewer inter-
ruptions and things are less hectic. Nurses reportexperiencing a greater sense of autonomy and in-dependence on night shifts as they have control of
their work and task time. Night shifts often leavethe nurses with sedentary tasks, however, such ascharting, organizing supplies, or monitoring sleep-ing patients. Many night shift nurses admit to de-
veloping bad eating patterns. They note thathospital cafeterias are closed at night, leavingthem with high-calorie vending machine snacks
or takeout pizza as typical meal options in addi-tion to lack of physical exercise in their worktasks. Geliebter and colleagues [33] observed night
shift nurses reported gaining more weight, exercis-ing less, and increasing food intake than the dayshift group since starting their jobs on their cur-
rent shift.Code situations are another example of work-
load variability. Workload suddenly increasesbecause health care providers need to concentrate
on the patients in danger, therefore reducing thenumber of staff available to care for otherpatients. Additionally, critical care nurses’ role
in the code may vary from finding and assessingpatients, initiating cardiopulmonary resuscita-tion before a code team’s arrival, to then re-
cording the events and interventions on the officialresuscitation record that documents all events andinterventions.
Relations between the dimensions of workload
The various dimensions of workload are notindependent of each other. For instance, quanti-tative workload, or the amount of work, is related
to physical workload: the more work criticalnurses have to perform, the more likely they areexposed to physical workload. The number ofpatients nurses care for and the nursing require-
ments of the patients also are related to physicalworkload.
Time pressure combined with physical work-
load may increase the risk for musculoskeletalinjuries significantly for critical care nurses. Inrushing to perform a task, nurses may not have
the time to use lifting devices. Moreover, a liftingdevice itself may add to nurses’ workload, as thedevice used must be decontaminated and madeready for the next patient in a physical environ-
ment not designed to facilitate optimal cleaningand disinfection. Nurses actually might choosenot to use a safety device as its cleaning or
decontamination seems too onerous a task giventhe physical environment and time pressure.
The cognitive workload associated with con-
sistent adherence to patient care guidelines mayincrease physical workload as nurses encounterproblems and barriers to guideline compliance in
an ICU. Critical care nurses often are the primarycare providers responsible for ensuring compli-ance with these guidelines. The Institute forHealthcare Improvement [34] is conducting a na-
tionwide effort to save lives by implementingstrategies to facilitate guideline compliance. A sig-nificant attribute of this program is nurses’ role in
monitoring care guideline compliance and takingcorrective action with ICU care teams. Althoughthe empowerment of nurses to ‘‘stop the proce-
dure’’ is critical to guideline compliance, it alsoadds to their cognitive, quantitative, and qualita-tive workloads.
Sources of workload
Understanding that the way work is organized
can contribute to workload is critical for de-veloping interventions aimed at reducing (ormanaging) workload and its impact on critical
care nurses. A range of patient care factors alsomay contribute to high workload in ICUs, such asthe number of postoperative events [35].
The authors propose that the work systemmodel of Carayon and Smith [36–38] can be usedto describe sources of workload and define the
124 CARAYON & ALVARADO
interrelationships between the dimensions ofworkload (Fig. 1). The work system comprisesfive elements [36,37]:
� Individual critical care nurses� Performance of various tasks (ie, direct care,
indirect care, and other tasks; patient carecharacteristics)� Use of various tools, equipment, devices, andtechnologies
� Physical environment (eg, the patient roomand the nursing station)� Specific organizational conditions (eg, shift
schedules, nursing management, teamwork,communication with physicians and otherhealth care providers, and interruptions)
Physical workload is related particularly to thetasks and their physical characteristics (eg, lifting
patients), the availability of equipment and de-vices, and the layout of patient rooms. Thesemicroergonomic factors also are related to the
macroergonomic characteristics of the work sys-tem, such as an organization’s management beingcommitted to providing the right equipment tonurses. Cognitive workload is affected by the
characteristics of the tasks of critical care nurses:those tasks, in particular operational tasks (eg,patient care and psychologic support of patients),
can be demanding and at the same time satisfying[39].
Improving the design of nurses’ work system
(eg, nurse-physician collaboration) is suggested asa strategy to reduce workload and deal with thenursing shortage crisis [40]. Laschinger and Fine-
gan [41] identified ‘‘empowerment’’ as a predictorof nurses’ perception of workload. Empowermentwas conceptualized as a characteristic of work en-vironments that provide nurses with access to
information, resources, and support necessaryfor accomplishing their work in a meaningfulmanner [42]. Organizational factors and other as-pects of the work environment of critical care
nurses can affect workload.
Impact of workload
Workload experienced by critical care nursescan lead to various outcomes: (1) impact on health
of the nurses, (2) quality of working life (eg, jobdissatisfaction, stress, burnout, and turnover in-tention), and (3) patient safety (see Fig. 1).
Impact on health
A major impact of working conditions on
health of critical care nurses is work-relatedmusculoskeletal disorders, such as back disorders.Physical workload is a working condition that is
a primary contributor to work-related musculo-skeletal disorders of critical care nurses [18]. Thepsychosocial aspects of work, however, such as
time pressure and emotional workload, also canbe contributors to work-related musculoskeletaldisorders [43]. Time pressure and emotional work-
load are job stressors that could lead to increasedrisk for work-related musculoskeletal disordersvia the following mechanisms [43]: (1) jobstressors that could lead to physiologic changes
(eg, increased muscle tension), which can makecritical care nurses more vulnerable to work-re-lated musculoskeletal disorders, (2) job stressors
that may heighten the impact of physical work-load, and (3) job stressors that may increasenurses’ sensitivity to pain and, therefore, increase
the likelihood that nurses experience and reportmusculoskeletal pain.
Fig. 1. Model of workload of critical care nurses.
125WORKLOAD AND PATIENT SAFETY
Impact on quality of working life
Workload also can affect the quality of work-ing life experienced by critical care nurses, such asjob satisfaction, stress, burnout, and attitudes,
such as turnover intention. In particular, burnoutis recognized as a problem among ICU nurses andis related to high workload [44]. Burnout may becontagious: ICU nurses who perceive that their
colleagues are experiencing burnout more likelyreport burnout, even after controlling for the im-pact of job stressors (eg, workload) [45].
Physical workload experienced by nurses canaffect not only physical health, such as musculo-skeletal disorders, but also turnover intention or
turnover. Fochsen and colleagues [46] conducteda longitudinal study to identify the predictors ofturnover among Swedish nurses. Nurses who re-ported musculoskeletal problems of the neck and
shoulder or knees and those who had limited useof transfer devices were more likely to leave theirjob. A multifaceted intervention aimed at reducing
physical workload of patient handling and work-related musculoskeletal disorders in nursing homecare units and spinal cord injury units was shown
effective (eg, decrease in musculoskeletal injuries)and to lead to increased job satisfaction [47].
Impact on patient safety
Medical errors are widespread in critical caresettings. A prospective observational study byBracco and colleagues [48] of consecutive patients
admitted during 1 year to an ICU examined 777critical incidents. The cause of the incidents wasclassified as equipment, patient, or human related.
The cause was classified as equipment relatedwhen the incident was attributed to a technicalequipment failure not associated with human mis-
use. The cause was classified as human relatedwhen actions did not go as intended or an in-tended action was not the appropriate one. In
all other cases, the incident was classified aspatient related. Thirty-one percent of the incidentswere human-related incidents, 2% equipment-related incidents, and 67% patient-related inci-
dents. A recent study by Rothschild and colleagues[49] examined a total of 391 patients admitted overa 1-year period in a medical ICU and a coronary
care unit. They found 120 adverse events among79 patients (20%). The most serious medicalerrors were found in the category of medication
ordering or execution of treatment.Several studies have examined specific types of
error in ICUs, such as medication errors. Cullen
and colleagues [50] compared the frequency of ad-verse drug events (ADEs) and potential ADEs inICUs and non-ICUs. Two medical and three sur-
gical ICUs and four medical and two surgicalgeneral care units participated in the study. Therate of preventable ADEs and potential ADEsin ICUs was 19 events per 1000 patient days,
nearly twice the rate in non-ICUs. When adjust-ing for the number of drugs used, however, nodifferences were found between ICUs and non-
ICUs.Several studies have linked medical errors and
patient safety to nursing workload. Giraud and
colleagues [51] conducted a prospective, observa-tional study to examine iatrogenic complications.A total of 382 patients for 400 consecutive admis-sions provided data. Thirty-one percent of the ad-
missions had iatrogenic complications. Humanerrors were involved in 67% of the major iatro-genic complications. The risk for ICU mortality
was approximately twofold higher for patientswho had iatrogenic complications. A major con-tributing factor was high or excessive nursing
workload. A study of medication administrationby Tissot and colleagues [52] detected 132 medica-tion errors in a total of 2009 observed events
(6.6%). The researchers attributed the errors notonly to deficiencies in the overall organization ofthe hospital medication track but also to the nurs-ing work overload.
Scott and colleagues [30] examined the effectsof critical care nurses’ work hours on their vigi-lance and risk for making an error. Longer shift
durations (in particular more than 12.5 consecu-tive hours) were associated with increased riskfor errors and near errors and with increased dif-
ficulty staying awake at work. This study did notfind an association between decreased vigilance(eg, difficulty staying awake at work) andincreased risk for errors. Longer shift durations
increase the exposure of critical care nurses tothe various dimensions of workload.
Systemic impact of workload
The impact of workload on various outcomesis systemic. According to the Systems EngineeringInitiative for Patient Safety (SEIPS) model of
work and patient safety [53], the various outcomesare affected by the characteristics of the work sys-tem and also are inter-related. Therefore, the var-
ious dimensions of workload likely affect morethan one outcome, and the outcomes are relatedto each other. Nurses who experience back pain
126 CARAYON & ALVARADO
because of physical workload may not be able todedicate their full attention to their tasks (cogni-tive workload) and, therefore, may be more likelyto commit an error (impact on patient safety).
Therefore, it is important to examine workloadof ICU nurses using a systemic approach.
A systemic approach to the assessment of
workload should fulfill the following objectives:
1. Evaluate the different dimensions of work-
load experienced by critical care nurses.2. Identify the work system factors contributing
to different facets of workload.
3. Understand the relationships between thedifferent dimensions of workload.
4. Assess the impact of workload on nurses’
and patient outcomes.
In the introduction, various measures of pa-
tient-related workload were described. This articleemphasizes the need to go beyond those measuresand include measures of workload that represent
the various dimensions of workload. The Na-tional Institute of Occupational Safety and Healthhas created a Web site where various measures ofworking conditions and job stressors are de-
scribed [54]. This is a resource for many measuresof workload, such as quantitative workload [32]and cognitive demands [55]. Gurses [26] has devel-
oped a questionnaire to assess performance obsta-cles experienced by critical care nurses; thisquestionnaire can be used to identify the various
sources of workload in the work system (ie, per-formance obstacles).
Summary
Interventions aimed at improving the safety ofcare provided by nurses to critical care patients
need to consider the work environment, inparticular the various types of workload. Sluiterand colleagues [56] implemented a multidisciplin-
ary structured process to evaluate work shifts toenhance team communication. Benefits of the in-tervention included increased satisfaction withteam communication and reduction in emotional
exhaustion. This multidisciplinary structured pro-cess was used to address the following issues:dealing with pressure of ICUs, teamwork, work
roles, and organizational aspects. Such a processcould be used to identify the work elements thatcontribute to different dimensions of workload,
to propose interventions to reduce workload,and to plan implementation of these interven-tions. According to the model of workload of
critical care nurses presented in Fig. 1, an inter-vention tackling workload should aim to under-stand the work system factors that contribute toworkload and the various outcomes resulting
from the different types of workload.
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129WORKLOAD AND PATIENT SAFETY
Patient Handling Tasks with High Riskfor Musculoskeletal Disorders in Critical Care
Thomas R. Waters, PhDa,*, Audrey Nelson, PhD, RN, FAANb,Caren Proctor, BSNc
aDivision of Applied Research and Technology, National Institute for Occupational Safety and Health,
4676 Columbia Parkway (MS-C24), Cincinnati, OH 45226, USAbPatient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL 33612, USA
cSurgical Intensive Care Unit, James A. Haley VAMC, Tampa, FL 33612, USA
Nursing remains one of the top 10 highest risk
occupations in the United States for work-relatedmusculoskeletal disorders (WMSDs) [1]. Com-pared with those in other occupations, nursing per-
sonnel are among the highest at risk.Nursing aides,orderlies, and attendants rank first and registerednurses sixth in a list of at-risk occupations for
strains and sprains that includes truck drivers(first), laborers (third), stock handlers and baggers(seventh), and construction workers (eighth) [2].Additional estimates for the year 2000 show that
the incidence rate for back injuries involving lostworkdays was 181.6 per 10,000 full-time workersin nursing homes and 90.1 per 10,000 full-time
workers in hospitals, whereas incidence rates were98.4 for truck drivers, 70.0 for constructionworkers, 56.3 for miners, and 47.1 for agriculture
workers [3]. In 2001, for cases involving daysaway from work among registered nurses, 4547were categorized as overexertion in lifting and14,832 were listed as sprains or strains [4].
Work-relatedmusculoskeletal disorders (WMSDs)in nursing persist as one of the leading and mostcostly occupational health problems in the United
States. Nurses suffer a disproportionate amount ofmusculoskeletal disorders attributed to overexer-tion from lifting unsafe loads and to the potential
cumulative effect of repeated patient handling
tasks [5]. A variety of patient handling tasks exist
within the context of providing nursing care,such as lifting, transferring, and repositioning pa-tients. Continuous, repeated performance of these
activities throughout a working lifetime withoutthe use of mechanical assistive equipment resultsin the development or exacerbation of musculo-
skeletal disorders. Because patient handling tasksconventionally are performed manually withoutthe use of assistive equipment, nurses are exposedto high levels of biomechanical loads on the spine.
Although nurses historically have been educatedand trained to use ‘‘proper’’ body mechanics andmanual techniques to prevent injury from lifting
and transferring patients, questions arise regard-ing the value of these methods and applicabilityto the practice of nursing [6,7].
The risk for development of WMSDs associ-ated with manual patient handling crosses allspecialty areas of nursing. No nurse effectively isfree from the risk for injury. The purpose of this
article is to describe high-risk patient handlingtasks performed frequently in critical care units,delineate the physical demands associated with
each task, identify technologic solutions, andoutline useful tips for making each task safer.
Background
The Association of periOperative RegisteredNurses (AORN) organized a task force that in-
cluded representatives from AORN, the NationalInstitute for Occupational Safety and Health(NIOSH), the Patient Safety Center of Inquiry at
the James A. Haley Veterans Administration
The findings and conclusions in this report are those
of the authors and do not necessarily represent the views
of the National Institute for Occupational Safety and
Health or the Veterans Health Administration.
* Corresponding author.
E-mail address: [email protected] (T.R. Waters).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.008 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 131–143
Medical Center (VAMC) in Tampa, and theAmerican Nurses Association to develop an ergo-nomic guideline for lifting and moving people and
objects in perioperative work environments. Thetask force formulated clinical tools and algorithmsfor high-risk tasks in perioperative settings thatincorporate current ergonomic safety concepts,
scientific evidence, and available technology, in-cluding safe patient handling equipment and de-vices [8]. This article expands on the work done by
the AORN for perioperative settings by applyingthe ergonomic principles proposed by AORN tonursing tasks in critical care settings.
Another ergonomic task force, ledby thePatientSafety Center of Inquiry at the James A. HaleyVAMC in Tampa, identified tasks associated withhigh risk for musculoskeletal disorders on five
critical care units (two surgical ICUs, two medicalICUs, and one cardiac ICU) at two large medicalcenters to identify tasks with high risk for muscu-
loskeletal disorders. The criteria used to identifypotential high risk for WMSDs for critical caretasks included (1) high force, (2) awkward postures,
or (3) repetitive loading. Data were collectedthrough direct observation of physical work envi-ronment, technology, and work practices; digital
photography; interviews with ICU nurses andnurse managers; and a 2-year review of WMSDsreported in ICUs. Based on this evaluation, sevenhigh-risk patient handling tasks in critical carewere
identified as having high risk for musculoskeletaldisorders. These include
1. Pushing occupied beds or stretchers2. Lateral patient transfers (eg, bed to stretcher)3. Moving patients to the head of a bed
4. Repositioning patients in bed (eg, side toside)
5. Making occupied beds
6. Applying antiembolism stockings7. Lifting or moving heavy equipment
For each of these high-risk critical care nursingtasks, a brief description of the task is provided,the physical demands discussed, solutions pro-
posed, and helpful tips for performing each tasksafely provided.
High-risk task #1: pushing occupied beds
or stretchers
Description of the task
Critical care nurses identified ‘‘road trips’’ asone of the most physically demanding tasks
performed. These trips involve pushing an occu-pied bed or stretcher off the unit for diagnostictesting, surgery, or other procedure. In addition to
the weight of patients and beds or stretchers, thesetasks are compounded by adding the weight ofmedical devices, such as intra-aortic balloonpumps, intravenous pumps, and portable ven-
tilators. In addition, nurses may be expectedto monitor patients while performing these tasksor manually ventilating patients while walking
or pushing. Typically, these tasks require two ormore persons for safety, and at least one personusually is walking backwards. The required force
to push or pull an object is the same, but pushingis preferred over pulling because pulling often isdone with one hand and with a twist of the trunk,resulting in unbalanced loads on the spine [9]. For
this reason, pulling force limits for these tasks arenot provided.
Physical demands
Factors that contribute to the physical demandof these tasks include distance traveled, weightbeing pushed, and uneven gradients (eg, slopes or
thresholds). The wheels of beds and equipment getstuck in elevator and door thresholds. The poten-tial physical risk factors associated with this task
include excessive pushing or pulling and liftingdemands. The likely result of excessive pushing,pulling, or lifting forces generated during thistask is high-resultant spinal anterior-posterior
shear and compression forces that likely exceedthe recommended spinal tissue load tolerancelimits. These limits are proposed as 3400 N (770
lb) for spinal disc compression force [10,11] and1000 N (225 lb) for spinal shear force [12]. Push-ing force requirements associated with four pa-
tient transport tasks proposed by the AORN arelisted in Table 1 [8]. Table 1 also provides a seriesof recommendations for the number of nurses and
equipment needed to perform a task safely. Theserecommendations are based on pushing forcelimits recommended by researchers at the LibertyMutual Insurance Research Institute for Safety
[13]. Additional information about pushing forcelimits is discussed later.
Another problem with transporting patients is
lifting occupied beds over small barriers, such asa door or elevator threshold. A basic biomechan-ical analysis (Fig. 1) shows that lifting an occupied
bed over a barrier or door threshold requiresa high amount of lifting force that easily couldexceed the recommended weight limit (RWL) for
132 WATERS et al
safe manual lifting, even when two nurses performthe lift under ideal lifting conditions.
The following example is provided to show
how a task easily could exceed the recommendedlifting limits: if W (ie, the weight of the bed plusthe weight of the patient) is 300 lb and the lift oc-curs at point B (the end of an occupied bed), then
according to static equilibrium (see Equation 1 inFig. 1), L is equal to 150 lb. This exceeds the RWLfor lifting, as defined by the NIOSH lifting equa-
tion (NLE), even with two nursing personnel lift-ing the end of the occupied bed over a barrierunder ideal conditions [10,11]
Proposed solutions
Two primary solutions are available for re-
ducing the physical demands associated withtransporting patients that exceed the recommen-ded push/pull force limits for one person. These
include the use of two or more persons to performa task or the use of a powered transport device. Ifthe required force exceeds the push/pull force
limits for two caregivers or a task is performedfrequently, then a powered transport device issuggested, although it is recognized these pieces of
equipment are not available for every type ofdevice that is transported with patients. If trans-porting patients requires lifting a bed or stretcherover a barrier, then a powered transport device
reduces the risk for musculoskeletal disordersignificantly for caregivers.
Safety tips
1. The height of a bed or stretcher should be po-sitioned so that the hands are at a middlepush point of 3 ft (0.92 m) from the floor.
For tasks where the push point is lowerthan 3 ft (0.92 m), maximum and sustainedpush forces should be decreased by approxi-
mately 15% [8,13].2. Manual patient transport tasks should not be
performed more frequently than once every
30 minutes. For transport tasks performedmore frequently than once every 30 minutes,a powered patient transport device is the best
solution [8].3. Pushing tasks are less physically demanding
than pulling tasks [9].4. If push force limits for one caregiver are ex-
ceeded (see Table 1), it is necessary to usetwo or more caregivers to complete the taskor use a powered transport device. In some
cases, even multiple caregivers may not beable to perform a task safely, especially ifa bed or stretcher must be lifted over
a door or elevator threshold [8].5. The wheels on beds or stretchers need to be
maintained properly to facilitate easier
Table 1
Physical demands and recommendations for safe patient transport
Transport task Pushing force lb/(kg) Max push distance ft/(m)
Ergonomic
recommendation
Pushing an occupied
stretcher
43.8 lb (19.9 kg) O200 ft (60 m) Task is acceptable
for one caregiver
Pushing an occupied bed 50.0 lb (22.7 kg) !200 ft (30 m) Minimum of two caregivers
required
Pushing an unoccupied
specialty surgical bed
69.7 lb (31.7 kg) !100 ft (30 m) Recommend use of a
powered
transport device
Pushing an occupied
specialty surgical bed
112.4 lb (51.1 kg) !25 ft (7.5 m)
Reprinted with permission fromAORN.AORNGuidance Statement: Safe Patient Handling andMovement in the Peri-
operative Setting. Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.
= L
(Eq. 1)
A BWeight of Occupied Bed + Patient (W)
Weight of Load Lifted (L) y
6 ft
3 ft
x
2
36
0)3()6(
WMomentz
WLMomentz
WLMomentz
Fig. 1. Simple biomechanical model of lifting occupied
bed over barrier.
133WMSD RISK IN CRITICAL CARE
transport. Wheels that are too small, castersthat do not face forward easily, or wheelsthat are maintained poorly increase the
amount of effort needed to complete the task.6. When possible, select a transport route that
has a minimum number of inclines, declines,or barriers, such as door or elevator thresh-
olds to traverse.7. Use bariatric equipment if patient weight
exceeds the acceptable weight capacity for
conventional patient handling equipment(the weight capacity usually is listed on theequipment). This may require special plan-
ning related to getting the equipment throughstandard-size doorframes and elevators.Bariatric equipment is designed speciallywith greater weight capacity than normal
lifting assist equipment.
High-risk task #2: lateral patient transfers
(eg, bed to stretcher)
Description of the task
Nurses in critical care units often engage inlateral patient transfers (eg, laterally movinga patient in a lying position from one surface to
another). This task often is completed with two ormore caregivers pushing or pulling a patientlaterally toward the destination position.
Physical demands
Both caregivers often must reach out with
extended arms, either at the start or end of thetask, to push or pull a patient from one surface(eg, a stretcher) to another surface (eg, a bed). The
potential risk factors for this task include exces-sive pushing or pulling forces and extendedreaches. These tasks may be more difficult when
the height of nurses working together is disparateor when a patient resists movement, such as whena patient is confused or may be guarding a surgicalwound. The likely result of excessive pulling or
lifting forces generated during this task is highresultant spinal shear and compression forces thatmay exceed the recommended spinal compression
or shear force load tolerance limits of the spinaltissues or excessive shoulder loading. The amountof pulling force required for this task is dependent
on patient weight and the coefficient of frictionbetween the sliding surfaces, which is a measure ofthe degree of slipperiness between a patient and
bed surface or between the sheet under a patientand a bed surface. As the slipperiness or smooth-ness between the surfaces increases, the required
pulling force decreases. Data for determining themaximum pulling force limit is published byresearchers at the Liberty Mutual Insurance Re-search Institute for Safety. According to these, the
maximum pulling force acceptable to 75% ofwomen is 51 lb (23 kg) for maximum initial pulls;the 51-lb maximum pulling force value is for one
caregiver. The actual required pulling force maybe difficult to determine. As a rule of thumb, with-out a friction-reducing device, the required pulling
force to move a patient is approximately 75% ofa patient’s body weight [14]. With newer slidingsheets, the required pulling force may be as lowas 25% of a patient’s body weight [14].
Based on published pulling strength data, theAORN published an ergonomic tool for assessinglateral transfers of patients between a stretcher
and an operating room bed. The ergonomic tool isshown in Fig. 2. According to the AORN re-commendation, the desirable approach for lateral
transfer of patients involves use of a lateral trans-fer device, such as friction-reducing sheets, sliderboards, or air-assisted transfer devices. If only
a draw sheet is used without a lateral transferdevice, care providers exert a pull force up to72.6% of patient weight [8]. The AORN recom-mendation assumes that one caregiver or anesthe-
sia care provider supports a patient’s head andneck to maintain the airway during lateral trans-fers. The remaining mass of the patient’s body
equals 91.6% of his or her total body mass [8].The rationale for the AORN recommendation isbased on research indicating that for a pulling
distance of 6.9 ft (2.1 m) or less, where the pullpoint (ie, starting point for the hands) is betweena caregiver’s waist and nipple line, and the taskis performed no more frequently than once every
30 minutes, the maximum initial force requiredequals 57 lb (26 kg), and the maximum sustainedforce needed equals 35 lb (16 kg) [8]. According
to the AORN recommendation, each caregiversafely can contribute a pull force required totransfer up to 48 lb, equal to 35 lb/0.726 (dis-
cussed previously). For one caregiver plus ananesthesia care provider, the maximum patientweight that safely can be transferred manually is
52.6 lb, equal to 48 lb/0.916 (described previ-ously). For two caregivers plus an anesthesiacare provider, a patient safely can be transferredmanually weighing up to 104.8 lb, equal to
(48 lb � 2)/0.916 (described previously). If there
134 WATERS et al
are three caregivers plus an anesthesia care pro-vider, then a patient safely can be transferred
manually weighing up to 157.2 lb, equal to (48lb � 3)/0.916 (described previously). If a patientweighs more than 157 lb, then the tool suggests
that either a mechanical lifting device, mech-anical lift with supine sling, mechanical lateral
transfer device, or air-assisted lateral transfer de-vice and a minimum of three to four caregiversbe used.
* The rationale for this tool is provided in the AORN Guidance document [8].
Start
Canpatient
transfer withoutassistance?
Caregiver assistance notrequired. Stand by for safety
as needed.
* One of the caregivers may be the anesthesia providerThe number of personnel to safely transfer the patient should be adequate to maintain the patient's body alignment,support extremities, and maintain patient's airway.For lateral transfers it is important to use a lateral transfer device that extends the length of the patient.Current technologies for supine to prone include: Jackson Frame, Spine Table, etc.Destination surface should be slightly lower for all lateral patient moves.A separate algorithm for prone to jackknife is not included as this is assumed to be a function of the table.If patient's condition will not tolerate a lateral transfer, consider the use of a mechanical lift with a supine sling.During any patient transferring task, if any caregiver is required to lift more than 35 lbs of a patient'sweight, assistive devices should be used for the transfer.While some facilities may attempt to perform a lateral transfer simultaneously with positioning the patientin a lateral position (ie, side-lying), this is not recommended until new technology is available.The assumption is that the patient will leave the operating room in the supine position.
No
Yes
What is thestarting
position?Prone
Use 2-3caregivers*
Use assistive technology(min. 3-4 caregivers)*
A mechanical device is preferable
for this task. Additional
technologies are needed
for turning a patient from supine to
prone and from prone to supine.
Is weight > 73 lbs?
Yes
No
Is weight>157 lbs?
Supine
Yes
Will patientstay supine?
Yes
No
Use one of the following:mechanical lift with supine sling,
mechanical lateral transferdevice or air-assisted lateral
transfer device(min. 3-4 caregivers)*
Use lateraltransfer device
(min. 4caregivers)*
No
Note: < means less than; > means greater than
See Rationale* See Rationale*
Fig. 2. AORN ergonomic tool for assessing lateral transfer between stretcher and operating room bed. (Reprinted with
permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting.
Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.)
135WMSD RISK IN CRITICAL CARE
Proposed solution
The best solution for a lateral transfer thatexceeds the acceptable pulling force limits for oneperson is to add one or more nurses to do the job,
use a friction-reducing device to reduce the pullingforce, or use a powered lateral transfer device.
Tips for performing lateral patient transfer
tasks safely
1. Previous research shows that there is no safe
way to lift a patient manually from a bed toanother bed, even with two nurses and ideallifting conditions [12]. Therefore, this task
should not be performed as a manual lift.2. Historically, nurses have completed this task
using a standard draw sheet or creatively in-serting a plastic trash bag under the draw
sheet to reduce friction. These strategies,however, do not reduce the risk sufficiently.Forces associated with excessive reaching
and lumbar hyperflexion are reduced by48% when a friction-reducing device is usedcompared with a draw sheet or trash bag.
Subjective evaluations by nurses demonstratethat they preferred the use of a friction-re-ducing device to a standard draw sheet as
a way to minimize musculoskeletal discom-fort [15,16].
3. A friction-reducing device reduced effort sig-nificantly, by 25% for the spine and 33% for
the shoulders [14].4. Observations of nurses using these devices re-
vealed the friction-reducing device was not
intuitive in its use, and, despite training,nurses did not use it to its full capacity.Nurses should be required to demonstrate
proficiency in the use of friction-reducing de-vices to assure appropriate use at onset andover time to fully use this type of patientcare equipment [16].
5. Friction-reducing devices with long handlesor straps reduce reach and associated forceson the back, shoulders, and arms signifi-
cantly and are preferable to friction-reducingdevices without long handles or straps [15].
High-risk task #3: moving patients
to the head of a bed
Description of the task
Patients who are physically dependent and inbed need to be repositioned frequently to prevent
pressure ulcers and other adverse events associ-ated with immobility. Despite careful reposition-ing, over time, patients tend to shift downward in
the bed and need to be pulled back to the head ofthe bed for comfort and safety.
Physical demands
This task is similar to the lateral transfer task(described previously), where a caregiver is stand-ing at the side of a patient’s bed. Because of theline of action of pulling a patient to the head of
the bed, however, hand forces are parallel to thebody rather than in-line with the front of thebody, creating large lateral shear and torque
forces on the spinal tissues. Additionally, toaccomplish the task, caregivers often have towork with their arms extended fully, increasing
the loads on the muscles, ligaments, and joints ofthe shoulder. When the arms are extended, themechanical moment for the task is increased. An
increase in the moment arm results in larger tor-que forces on the spine and shoulder. No limitsfor maximum acceptable torque forces on thespine are proposed, but studies show that axial ro-
tation during lifting can increase the risk for lowback pain in some workers [12]. Examination ofthe required muscle forces at the shoulder reveal
that the maximum recommended force that an av-erage woman is able to pull laterally across thebody with arms extended fully is 22 lb (10 kg) or
11 lb (5 kg) per hand [8]. It is likely that the shoul-der strength is exceeded before the lateral shearforce limit is reached for most repositioning tasks,
such as this. In addition, only approximately 44%of women have the torso strength capacity to dothis task. The 44% value was determined usinga 3-D strength prediction program developed by
researchers at the University of Michigan [17].
Proposed solutions
There are only a few solutions available for thistask. The best overall solution is to use a floor-based or ceiling-mounted patient lift that elimi-nates the need to pull or lift patients manually.
Using a floor-based lift, however, is time consum-ing and may not be accepted readily by nurses.Use of a ceiling lift with a ‘‘disposable’’ reposi-
tioning sling that can stay under a patient im-proves the acceptance of such lift use. Skinintegrity always is a concern when leaving slings
under patients and must be considered. An alter-native is to use a friction-reducing device and ad-ditional caregivers. This approach may reduce the
136 WATERS et al
maximum required forces, but it does not solvethe problem of pulling across the body.
Tips for moving patients to the head of a bed safely
1. This task requires two or more caregivers. It
is unsafe to move an occupied bed away froma wall and attempt to lift a patient unassisted.
2. The task should be performed with caregiverspositioned at the sides of a bed.
3. Pulling patients up in bed is made easier bylowering the head of the bed and raising thepatient’s knees [16].
A. The forces on the shoulder can be de-creased by 40% by raising the bed to anappropriate working height and angling
the head of the bed downward to facilitatethis repositioning task [16].
B. The amount of musculoskeletal discomfortin performing this task also can be de-
creased by nearly 31% by angling thebed surface and raising a patient’s kneesbefore sliding them [16].
4. Additional research is needed to design tech-nologic solutions for the high-risk, high-vol-ume patient handling task of repositioning
patients to the head of a bed.
High-risk task #4: repositioning patients
in bed (eg, rolling from side to side)
Description of the task
Patients who are physically dependent and inbed need to be repositioned frequently to preventpressure ulcers and other adverse events associ-
ated with immobility. Typically, this task isperformed at least once every 2 hours, alternatingbetween prone, right-side lying, supine, and left-
side lying, as tolerated by patients. Thus, this taskrequires rolling patients from side to side.
Physical demands
This task is similar to the lateral transfer task
described in task #2 and can be completed eitherby sliding patients to the center of a bed or liftingand moving patients to the center of a bed. For
this task, however, it is likely that the arms aremore extended for the maneuver than for a trans-fer from bed to bed. The same risk factors are
involved and the same limitations apply as for thelateral transfer task. As with the transfer task, therequired pulling force is dependent on patient
weight and the coefficient of friction betweena patient, or sheet under a patient, and bedsurface. If the task is performed with armsextended directly in front of the body, then the
shoulder strength or anterior-posterior shear onthe spine likely is the limiting factor for this task.If, alternatively, the task is performed laterally by
pulling across the body, then the limiting factorlikely is shoulder strength or lateral shear (dis-cussed previously).
Proposed solutions
There are few solutions available to reduce thephysical demands associated with rolling patientsfrom side to side in a bed. It may be possible to
use a ceiling-mounted lift to assist in rollingpatients from side to side, but use of a ceilinglift typically requires a manual rolling activity to
place a sling under a patient. Alternately, twocaregivers may be able to roll a patient manuallywithout exceeding recommended pushing andpulling force limits, but the best technique is to
use a lift with a repositioning sheet or strap to rollpatients from side to side. Friction-reducing de-vices may be helpful with larger, heavier patients.
Tips for repositioning a patient in bed safely
1. Performing this task manually may requiretwo or more caregivers, depending on patientweight.
2. A friction-reducing device or a mechanical
lifting device should be used for bariatric pa-tients or for patients whose pain or discom-fort does not allow them to tolerate manual
performance of the task.3. One caregiver safely can reposition a patient
laterally with the aid of a friction-reducing
device or a ceiling-mounted lift.
Additional research, however, is needed to
develop efficient, safe, user-friendly devices forassisting in rolling patients from side to side,especially as the average weight of patients
continues to increase.
High-risk task #5: making occupied beds
Description of the task
Patients who are physically dependent and incritical care often are unable to get out of bedbecause of illness, pain, fatigue, or medical
contraindications. Regardless, linens need to bechanged regularly, particularly if patients areincontinent, bleeding, or perspiring. The task of
137WMSD RISK IN CRITICAL CARE
making an occupied bed can be challenging,particularly when patients are obese, hooked tomultiple lines, or combative or uncooperative.
This task often requires that caregivers rollpatients from side to side to make a bed.
Physical demands
To perform this task, nurses usually approachpatients from the side of a bed, roll patients onto
their side, slide a sheet under patients, then moveto the other side of the bed to roll patients backonto the sheet and then onto their other side, then
pull the sheet out from under the patients, finallyrolling patients onto their back to finish makingthe bed. The potential risk factors for this task areexcessive pushing and pulling forces, excessive
reach, and twisting. The other problem is thatnurses often have to hold patients up with onehand while using the other hand to arrange the
sheet. The pushing/pulling forces required toperform this task are dependent on the individualand how much assistance can be provided by
patients. Again, the task likely is performed witharms in a fully extended position. The pushing orpulling force limit for this task likely is determined
by shoulder strength limits for most women ratherthan the spinal shear force. Also, the task mayneed to be performed with one arm, because theother arm may be needed to hold patients on their
side while inserting or removing a sheet under thepatient.
Proposed solutions
There are few solutions available to reduce the
physical demands associated with making anoccupied bed. It is possible to use a ceiling-mounted lift to lift the patient off the bed,
allowing for a hands-free approach to makinga bed. As discussed previously, one of the moststressful elements of this task is rolling patientsonto one side to get the sheet under them and then
holding them in place. As discussed previously forthe patient rolling task, two caregivers may beable to roll patients manually without exceeding
recommended pushing and pulling force limits.Reaching and pulling patients, however, shouldbe avoided when feasible.
Tips for making occupied beds safely
1. Raise the bed to an acceptable comfortable
working height (about the level of the elbow)[15]. When two or more nurses are complet-ing this task and they are of disparate
heights, the acceptable bed height should beset approximately at the average elbowheight of the two nurses.
2. Further, avoid twisting and excessive reachwhile performing this task. Nurses whomove back and forth along the side of thebed, rather than twist in place, reduce muscu-
loskeletal strain by 58% (60% back and 57%shoulders) [16].
3. This task is more difficult with some air mat-
tresses or overlays, which can cause increasedexternal forces when rolling patients towardand away from a caregiver, as required dur-
ing the execution of this task [16].
High-risk task #6: applying antiembolism
stockings
Description of the task
Many patients in critical care units are at riskfor developing a deep vein thrombosis. One
strategy used to prevent deep vein thromboses isthe use of antiembolism stockings. In critical care,this task nearly always is performed while patients
are supine.
Physical demands
The physical demands of this task are associ-ated with (1) lifting and holding a leg for anextended period, (2) the awkwardness of perform-
ing a task that takes two hands (sliding thestockings up the leg) while holding a leg in place,(3) resistance of extending tight elastic stockingsopen to fit a leg inside, and (4) long duration of
the task. The risk factor for this task is lifting andholding the weight of a leg for an extended periodof time and the excessive force needed to apply
stockings that intentionally are tight fitting.Guidelines for lifting a leg have been developedbased on acceptable muscle strength and muscle
fatigue guidelines for women. The limits areshown on Table 2 [8].
As can be seen in Table 2, the only acceptable
manual lift of a leg is a two-handed lift for pa-tients weighing less than 54 kg (120 lb) and fora holding duration of 1 minute or less. Performinga two-handed lift and applying the antiembolism
stockings are not recommended for one caregiver.
Proposed solutions
One solution for lifting and holding a leg isa mechanized lift with a strap or sling designed for
138 WATERS et al
lifting body parts. For applying antiembolismstockings, there are commercially available prod-ucts; one device works like a shoehorn, making
the task easier, whereas another is simply a plasticsleeve placed over the foot before application toreduce friction.
Tips for applying antiembolism stockings safely
1. Applying antiembolism stockings from thebottom of the bed with a pushing movementsignificantly reduces muscle activity by 25%
compared with applying stockings from theside, where a combination of lifting and pull-ing is required [16].
2. Applying lotion to the legs, before manualapplication of the stockings, is found to re-duce the force needed to apply the stockingsslightly, although this may be contraindi-
cated if there are wounds or other skin condi-tions on or near the legs.
High-risk task #7: lifting or moving heavy objects
and equipment
Description of the task
Patient care often includes use of equipment,
devices, and supplies that need to be brought toa bedside. Often, these items are heavy or awk-ward to carry or push and the distance can besignificant.
Physical demands
Critical care nurses often are required to lift
and move various heavy objects and equipmentmanually, often in awkward body postures. Therisk factor for this task is potential excessive
spinal compression force or shear force. As theweight of an object or the horizontal distance ofthe load relative to a worker increases or as the
posture becomes more awkward, the compressionforce increases and the acceptable amount ofweight that can be lifted safely decreases. Therevised NIOSH lifting equation (NLE) is an
assessment tool used to evaluate the physicaldemands resulting from specified two-handedmanual lifting tasks [10,11]. To use the NLE, spe-
cific information is needed, such as the weight ofthe object, the horizontal reach distance, the verti-cal height from which the object will be lifted, and
other factors described in the NLE applicationsmanual [10,11]. The principal products of theNLE are the recommended weight limit (RWL)
and the lifting index (LI) for a specified lift. TheRWL is defined for a specified lift as the weightof load that nearly all healthy workers can per-form for that task over a substantial period of
time (eg, up to 8 hours) without an increasedrisk for developing lifting-related low back pain.The LI value is a term that provides a relative es-
timate of the level of physical stress associatedwith a particular manual lifting task and is definedas the weight of load to be lifted (L) divided by
the RWL (ie, LI ¼ L/RWL). According toNIOSH, it is likely that lifting tasks with an LIgreater than 1.0 pose an increased risk for lift-ing-related low back pain for a fraction of the
population and that many workers are at risk ifthe LI value exceeds 3.0.
As with several other tasks (discussed pre-
viously), the AORN developed a series of recom-mendations for a set of lifting tasks performedoften in operating rooms [8]. These recommenda-
tions are based on the LI values calculated forthese tasks (Table 3). The NLE can be used to
Table 2
Recommended limits for lifting legs
Reprinted with permission fromAORN.AORNGuidance Statement: Safe Patient Handling andMovement in the Peri-
operative Setting. Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.
139WMSD RISK IN CRITICAL CARE
calculate the RWL and LI for other two-handedmanual lifting tasks performed by critical carenurses not listed in Table 3, such as lifting intrave-nous pumps to attach to a bed for patient trans-
port; moving chairs to accommodate visitors;lifting equipment to the end a bed; transportingmonitors; moving heavy bottled gas tanks; and
lifting beds and carts over electric cords or cablesin patient rooms. Those interested in more detailsof the NLE should refer to the NIOSH applica-
tions manual [10,11].Nurses also often have to push or pull wheeled
equipment or carts. These tasks have risk factorsas described for pushing an occupied operating
room bed (discussed previously). The amount offorce required to push or pull these items deter-mines whether or not they can be done safely.
The AORN presented a recommendation forpushing and pulling wheeled items in an operatingroom work environment (listed in Table 4). For
items not listed in Table 4, the guide in Table 5can be used to assess the acceptability of a specificpushing task. If the required pushing force ex-
ceeds the value in Table 5 for the selected distance,then the task should not be performed by onecaregiver. Pushing force limits for multiple
caregivers can be calculated by multiplying thevalues in Table 5 by the number of caregivers. Itis not recommended, however, that more thantwo caregivers push equipment. As noted in Table
4, the appropriate solution is to use a powered as-sist device.
Proposed solutions
The best approach for lifting loose objects and
equipment is to have two persons perform the liftor use lifting assist equipment (see Table 3). Thedeterminant of whether or not to use a single
lifter, multiple lifters, or assistive equipment isthe weight of the load to be lifted, the frequencyof lifting, and the accessibility to reach and lift
the equipment. As a rule of thumb, for lifts thatare performed often or every day, assistive liftingtechnology likely is the best choice.
Tips for lifting or moving heavy equipment safely
1. Pushing tasks ergonomically are preferred
over pulling tasks.2. Ensure that push handles are at a correct
push height of approximately 3 ft (0.92 m).
Table 3
National Institute for Occupational Safety and Health lifting index value for typical lifting tasks performed in operating
rooms
Reprinted with permission fromAORN.AORNGuidance Statement: Safe Patient Handling andMovement in the Peri-
operative Setting. Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.
140 WATERS et al
3. For tasks where the vertical height of thepush point is less than 3 ft (0.92 m) abovethe floor, maximum and sustained push
forces are decreased by approximately 15%.4. For tasks performed more frequently than
once every 30 minutes, maximum and sus-
tained push forces are decreased by approxi-mately 6%.
5. If push force limits are exceeded, it is neces-
sary to reduce the weight of the load, usetwo or more caregivers to complete the tasktogether, or use a powered transport device.
Powered transport devices are built intosome beds and stretchers; additionally, thereare devices available commercially to moveequipment [18].
6. Equipment or casters need to be maintainedproperly to assist in moving equipmentmore easily.
7. These recommendations are based on the Lib-erty Mutual psychophysical limits for pushforces, where hands are positioned at a middle
push point of 3 ft (0.92 m) from the floor orabove and tasks are performed no more fre-quently than once every 30 minutes [13].
Discussion
Many manual handling tasks performed bycritical care nursing staff (eg, handling andmoving patients, beds, and equipment) require
high levels of physical effort, resulting in signifi-cantly high internal loads on muscles, ligaments,and joints of the body, especially the shoulder and
low back. These high internal loads significantlyincrease the potential for development of WMSDsfor these workers.
Table 4
Association of periOperative Registered Nurses recommendations for pushing wheeled equipment
Reprinted with permission fromAORN.AORNGuidance Statement: Safe Patient Handling andMovement in the Peri-
operative Setting. Copyright � 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.
141WMSD RISK IN CRITICAL CARE
Fortunately, there are alternatives to unsafemanual handling tasks, such as use of floor-basedand ceiling lifts, lateral transfer devices, slip sheets,
antiembolism stocking applicators, and poweredtransport devices [19]. In addition, new technolo-gies rapidly are being developed for a wide range
of health care settings. As discussed in this article,solutions for many of the high-risk tasks found incritical care nursing currently are available.
Critical care nurses often are asked to performcomplex tasks that are time sensitive and requirea rapid response. There may not always be time tolook for the proper equipment to perform a task
unless the assistive equipment is in close proximityto workers. Therefore, it is important that ade-quate equipment is available and that the most
appropriate equipment is selected for the task.For example, for transferring tasks requiringa full-body lift, a ceiling lift might be preferred
over a floor-based lifting device, because theceiling lift always is in close proximity to thework area, and nurses do not have to go looking
for the lift. In addition, the problem of storage offloor-based lifts is eliminated by the use of ceilinglifts, which are stored on an overhead track anddo not take up any floor space. It is important
that the culture of the work environment incritical care settings be changed so that caregiversand management make a significant effort to
provide adequate equipment and training neces-sary to prevent the equipment from simply beingstored in a back room.
In this article, tasks with high risk for muscu-loskeletal disorders in critical care settings areidentified clearly and appropriate solutions pre-
sented. Previous studies have shown that imple-mentation of a safe patient handling andmovement program that incorporates the use ofthis new technology can pay for itself in a short
period of time and provide a long-term benefit forhealth care facilities and the nursing staff [20,21].
Efforts to improve the safety of critical carenurses are essential to assure quality patient care.Nurses who are injured or suffer from musculo-
skeletal pain may not be able to provide rapid andeffective responses when urgent patient care isneeded. Insuring the health and safety of critical
care nurses also will help alleviate the currentnursing shortage by keeping nurses on the joblonger, reducing the risk for disruption of nursing
practice, and reducing the risk for a prematurecareer-ending injury.
References
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[10] Waters T, Putz-Anderson V, Garg A, et al. Revised
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[11] Waters T, Garg A, Putz-Anderson V. Applications
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143WMSD RISK IN CRITICAL CARE
Psychosocial Factors in Musculoskeletal DisordersNancy N. Menzel, PhD, RN, COHN-S
University of Nevada Las Vegas School of Nursing, 4505 Maryland Parkway, Box 453018,
Las Vegas, NV 89154-3018, USA
Work-relatedmusculoskeletal disorders (MSDs)have a multifactorial etiology that includes notonly physical stressors but also psychosocial
risk factors, such as job strain, social supportat work, and job dissatisfaction. Once an injuryhas occurred, psychosocial factors, such as de-
pression and maladaptive pain responses, arepivotal in the transition from acute to chronicpain and the development of disability. Inter-
ventions to prevent MSD incidence and addresspsychosocial risk factors for delayed recovery aredescribed. There is broad agreement that work-
related MSDs have a multifactorial etiology, withworkplace and nonwork risk factors playinga role in their cause [1–3]. In its preamble to itsErgonomics Standard, the Occupational Safety
and Health Administration (OSHA) defineda risk factor (stressor) as
a characteristic of the work environment that
research has shown to be associated with an
elevated occurrence or severity of MSDs. Risk
factors can involve purely external exposures,
such as shock or percussion, that act on the
musculoskeletal system. They can also involve
intrinsic response to a load or task, such as lifting
or rapid and awkward movement. The effect of
a risk factor may be modified by personal
characteristics, such as anthropometry and phys-
ical conditioning, or by concurrent or previous
non-work exposure. Risk factors can also involve
work organizational or social factors [4].
OSHA [4] defines biomechanical stressors as‘‘the physical aspects of workstation, work piece,
tools, and work process that exert stress on thebody.’’ OSHA does not define ‘‘psychosocial riskfactor.’’ It justifies its exclusive focus in the
standard on biomechanical risk factors by con-cluding that they ‘‘contribute independentlyfrom psychosocial factors, and exposure to bio-
mechanical risk factors has been observed to begenerally stronger than for psychosocial factors’’[4].
Similar to the conclusions drawn by OSHA,there is widespread scientific agreement about therole of biomechanical risk factors in causing
MSDs in nurses, with strong research studiesand a comprehensive epidemiologic evidencereview supporting this conclusion [2,5–7]. The
evidence is not so clear, however, about psychoso-cial risk factors, such as stress, as causative fac-tors. Although many studies find an association,the role these factors play in causation is unclear:
Are they independent factors or do they act as ef-fect modifiers, altering the association betweenphysical stressors and MSDs? If they are indepen-
dent factors, what is the mechanism by which theyare believed to produce MSDs?
Psychosocial factor definitions
Psychosocial factors are defined in a variety ofways. The National Institute for Occupational
Safety and Health [2] points out that it is a ‘‘catch-all term’’ for the following: ‘‘1) factors associatedwith the job and work environment, 2) factors as-
sociated with the extra-work environment, and 3)characteristics of the individual worker.’’ It pointsout further that these factors are believed to inter-
act with each other, affecting health and job per-formance. Some factors specific to nursingpersonnel that are identified in the literature fallinto all three categories.
Work-related factors include job satisfaction[8], job strain (performing psychologicallyE-mail address: [email protected]
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.006 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 145–153
demanding tasks under time pressure while havinglow control over the job) [9–11], time pressure[12,13], high mental pressure [14,15], work rela-
tionships with coworkers [16], support at work[11,15,17], and stress [18,19]. An extra-work envi-ronment risk factor, amount of leisure time exer-cise, was correlated negatively with low back
pain in Chinese nurses [18]. Individual (notwork-related) characteristics include pain copingskills [20], premenstrual tension [14], having chil-
dren [14], and affective states (depression and anx-iety) [21,22].
Why the contribution of psychosocial risk factors
remains unclear
The reasons that psychosocial factors lacka supporting body of research evidence are
many. One is imprecision in psychosocial con-struct definition. For example, work-related stressin health care is defined and measured differently
in many articles on this topic, which may useother terms, such as burnout or strain, instead ofstress [23].
A second problem is measurement of psycho-social constructs. Whereas there are establisheddefinitions of physical force and shear and how to
measure them, the opposite is true of constructs,such as job strain or stress coping ability. Unlikeusing objective computer programs with biome-chanical models to calculate spinal compression
from lifting or strain gauges to measure push-pullforces, to cite two ways to measure physicalstressors, psychosocial stress in nursing (and other
occupations) is measured using self-report (sub-jective) instruments. These include diaries of un-known reliability and validity [24], interviews that
leave the definition of stress up to the interviewee[25], and instruments with acceptable psychomet-ric values (reliability and validity), such as the Per-
ceived Stress Scale [20]. Finally, many of thestudies that have been done on psychosocial fac-tor association with MSDs are cross sectional;cross-sectional designs preclude inferring cause
and effect because it is not possible to determinetemporal plausibility. For example, a direct pa-tient care provider may report back pain and de-
pression. Is the caregiver depressed because ofthe pain or did the depression cause the pain?
A third problem is the lack of knowledge
about the biologic plausibility of psychosocialfactors as etiologic agents. In epidemiologicstudies, biologic plausibility occurs when the
association between two factors is consistentwith current medical knowledge. For examplehow a psychosocial factor, such as job dissatis-
faction, is associated with the incidence of MSDsis unknown, based on the state of the science ofthe mind-body connection.
Four pathways for biologic plausibility are
hypothesized. The first is that psychosocial factorsresult in muscle tension and increase spinalloading; there are laboratory studies demonstrat-
ing this link [26–28]. The second hypothesizedpathway is that psychosocial factors may influ-ence body awareness and result in reporting of
musculoskeletal pain or attribution of work fac-tors as the cause. Third, psychosocial factorsmay influence that transition from the originalacute injury to chronic pain, even after the origi-
nal muscle damage heals [29]. Finally, psychoso-cial demands may be associated with physicaldemands, making it seem that psychosocial fac-
tors are associated with MSDs when, in fact,they may be confounders (not part of the real as-sociation between exposure and disease) or effect
modifiers [30].A fourth difficulty is the variability in outcome
definition and measurement, with some studies
using MSD pain but most using reported injuryincidence or lost days because of injury. Giventhat occupational injuries are shown to be under-reported by orders of magnitude, the latter out-
come is an unreliable and lagging indicator ofmusculoskeletal stress and pain [31].
Because of the lack of standardization of terms,
tools, and outcomes, it is difficult to use meta-analyses (the highest level of evidence) to assemblea body of evidence using the same construct
definitions and the same measurement instrumentsfor psychosocial factors. One meta-analysis, how-ever, does find an increased risk of prevalence ofoccupational back pain from job dissatisfaction in
the general working population [8].
Conceptual models
The Institute of Medicine (IOM) [3] Panel onMusculoskeletal Disorders and the Workplacepublished a conceptual model for MSD etiology
that emphasizes physical risk factors, sideliningindividual risk factors outside the main causalpathway. Although several other conceptual
models are proposed for the role of psychosocialfactors in the development of work-relatedMSDs [32–34], there is none that has received
146 MENZEL
widespread acceptance, which hinders hypothesisgeneration and research.
What is the evidence for psychosocial factors
as etiologic agents?
According to the Institute of Medicine [3], job
strain is the most prominent among the psychoso-cial risk factors for upper-extremity disorders.Other studies similarly have identified job strainas a psychosocial risk factor for developing
MSDs [10,11,35,36].Job dissatisfaction is associated with MSDs in
Norwegian nursing aides [37] and in Japanese, Ca-
nadian, and Icelandic nurses [14,38,39]. Similarfindings are reported for other occupationalgroups [40–42]. Limited social support at work
is another psychosocial factor that has emergedas a risk for MSDs among nurses [11,15,43].
Some individual factors are shown through
longitudinal studies to be associated with thedevelopment of back pain: psychologic distressor stress [19,44–46] and negative coping styles [46].No extra-work risk factors are identified consis-
tently as etiologic risk factors.
What is the evidence for psychosocial factors
in disability and return to work?
There is evidence that psychosocial factors areimportant in determining length of disability,
transition from acute to chronic pain, and returnto work, once a nurse or other worker reports anMSD [17,47–50]. In a longitudinal study of more
than 1800 Canadian nurses, job strain and low so-cial support at work were associated with sickleave incidence and length [51] (although the study
does not identify the work-related injury that pre-cipitated the absence). In another longitudinalstudy of more than 4000 Norwegian nursing aides,
low support at work was associated with long-term low back pain–related sick leaves [17]. Ina systematic review of six cohort studies of lowback pain, distress, depressive mood, and somati-
zation were associated with the transition fromacute to chronic pain [48]. For low back pain,there is strong empiric evidence from prospective
studies that psychosocial factors are the predomi-nant risks for developing chronicity and disability,leading to calls for intervention early in the con-
tinuum of disease [49,50,52].These empiric findings support the multidi-
mensional view of pain adopted by the pain
research community and reflected in the Interna-tional Association for the Study of Pain [53] defi-nition of pain, which states that pain is ‘‘Anunpleasant sensory and emotional experience as-
sociated with actual or potential tissue damage,or described in terms of such damage.’’ Key tothis definition is the recognition that pain is mul-
tidimensional and includes not only sensory inputbut also cognitive and emotional components.Pain is a psychologic construct, not a physical di-
agnosis of tissue damage or other physical pathol-ogy. When considered from this perspective, it isnot surprising why psychosocial factors, such as
emotion [54], work satisfaction [49], and psycho-pathology [50], are important determinants ofpain chronicity and related disability. Further-more, pain is a significant predictor of disability
[49,50], offering a direct path for the emotionalcomponent of pain perception to influencedisability.
Because pain is a symptom that has sensory,affective, and cognitive dimensions, its clinicalassessment depends on subjective reports. Because
disability is defined as restricted function, it can beassessed reliably by self-report or work absence/modification [55]. In chronic pain, in particular
low back pain, there may be no discernible struc-tural impairment [55]. Tate and colleagues [56]found that disability in back-injured nurses pre-dicted the incidence of lost time, whereas self-
reported pain predicted how much time was lost.A study by Waddell and coworkers [57] shows
little association between pain and disability.
Fear-avoidance beliefs about physical activity(kinesiophobia) and work, however, were associ-ated strongly with work loss and disability in ac-
tivities of daily living. These findings arereplicated in other studies [47,58,59].
In addition, pain catastrophizing (an exces-sively negative orientation toward pain) is associ-
ated with chronic low back pain and disability[47]. According to a conceptual model developedby Vlaeyen and colleagues [58] and adapted by
Pincus and coworkers [48], when pain from anoriginal injury is interpreted as threatening (paincatastrophizing), it results in fear of re-injury,
which leads to movement avoidance, hypervigi-lance, and muscle reactivity, which lead to disuse,depression, and disability, all of which maintain
pain. Individuals who do not catastrophize theirpain return to daily activities and recover quickly[48,58].
These studies highlight the relationship be-
tween physical disability and psychosocial
147PSYCHOSOCIAL FACTORS IN MSD
function. Much like pain, disability is not a phys-ical diagnosis and has only a loose associationwith tissue damage and measurable physical
pathology. This largely is because, from patients’perspective, disability results from an appraisal oftheir functional abilities, the associated risks andbenefits of function, and the expectations of the
consequences of function. Like pain, disability canbe considered a psychologic construct influencedby psychosocial factors as demonstrated in the
empiric literature.Coping skills is a term found in the literature
on MSD pain and disability. Coping is defined by
Lazarus and Folkman [60] as ‘‘constantly chang-ing cognitive and behavioral efforts to managespecific external or internal demands that are ap-praised as exceeding the resources of the person.’’
When a stressful situation is viewed as unchange-able, emotion-focused coping is used to minimizeemotional distress. Examples of emotion-focused
coping are using alcohol or drugs, overeating, orparticipating in a distracting activity. If a stressfulsituation is viewed as changeable, then problem-
focused coping is called up to assess the situationand choose among the best solutions. In meaning-focused coping, a third strategy, stressed individ-
uals modify interpretation of a stressful situationby drawing on values, beliefs, and goals [61]. Al-though escapist strategies often result in poormental health outcomes, other strategies, such as
seeking social support or choosing to changea stressful situation, may have positive or negativeoutcomes depending on individual appraisal of
the impact of the ‘‘important goals [that] havebeen harmed, lost or threatened. These appraisalsare characterized by negative emotions that are
often intense’’ [62]. Cognitive-behavioral therapy(CBT) is effective in teaching coping skills [62].
According to this brief overview (above), psy-chosocial factors, not tissue damage, are the most
important factors in determiningwhether or not in-dividuals develop disability and chronic pain afteranMSD. In addition, they are paramount in deter-
miningwhether or not injured individuals take timeoff from work and the length of that leave. Despitethis evidence, theworkers’ compensation treatment
paradigm does not include approaches to addressthese factors until individuals have progressed sofar into disability and psychologic deterioration
that the chance for recovery and return to work isremote [63]. Given the high cost of rehabilitation(tertiary prevention) compared with screeningand early intervention (secondary prevention),
this treatment approach is not evidence based.
Interventions to reduce psychosocial risk factors
for the incidence of musculoskeletal disorders
In the psychosocial risk factor domain, only
factors associated with the job and work environ-ment are under the appropriate control of em-ployers. Although it might be possible to screenfor and refuse to hire nurses who have personal or
extra-work risk factors, it is not legal, underfederal equal employment opportunity laws, andimpractical in light of the nursing shortage.
Although evidence for the role of work-relatedpsychosocial risk factors in the etiology of MSDsis not as strong as for physical risk factors,
employers are well advised to address the factorsthat have emerged simply as good businesspractices that may reduce turnover and increaseproductivity, no matter what their musculoskele-
tal health benefits.Job strain is a conceptual model developed by
Karasek and colleagues [64–68] that states that
work conditions involving the greatest mental de-mand and lowest control over those conditionsproduce the largest physical responses. They devel-
oped the Job Content Questionnaire to measurejob strain and other concepts [69] and found thatjob strain is most severe among nursing aides,
who are at the lowest level of the health care hier-archy. Registered nurses (RNs), however, also feellittle control over their work environment. Em-ployers can address job strain through increased
participation, by letting nurses have a role in mak-ing assignments and agreeing on staffing ratios andby allowing nurse representation when important
management decisions are made.Job satisfaction for nurses involves several
variables, including pay [70,71], work organiza-
tion and workload [70,71], autonomy [72], stress,and leadership issues [73]. Remedies for all theseissues are under employers’ immediate control,based on an assessment of which ones are the
most vexing to nurses in their institutions. Exitsurveys, conducted whe nurses leave employment,are one way to gather this information.
Low social support at work (from supervisorsand peers) is identified as an MSD risk factor inmany studies. Such support is vital to retain new
graduates [74]. Social support equally is impor-tant, however, for all nurses because it serves asa coping mechanism, reducing stress from the de-
manding job of nursing [75]. Employers shouldpromote social support by encouraging collegial
networks and offering management training thatemphasizes nonpunitive approaches to leadership.
148 MENZEL
Interventions to reduce psychosocial risk factors
for musculoskeletal disorders and disability
Once an MSD is reported, the no-faultworkers’ compensation system is activated.
Nurses receive immediate medical care at nocost. Treating health care providers determinewhether or not nurses can return to full or
modified duty or should remain away from workfor a specified number of days until a follow-upvisit. Whether or not nurses are paid for the days
away from work depends on whether or not theyhave any paid sick leave and jurisdictions’ waitingor elimination period for indemnity (wage re-
placement) benefits. The treatment providedfollows the jurisdiction protocol and other occu-pational health guidelines, depending on the in-jury. These protocols and guidelines focus on
rapid return to work. In the acute stage of injury,the guidelines do not recommend any screeningfor psychosocial risk factors, despite evidence that
these determine whether or not the pain transi-tions to a chronic state, whether or not disabilitydevelops, and the length of time workers stay out
of work. One reason for this avoidance is the fearof employers and insurers that any referral forpsychologic assessment will result in a costly
workers’ compensation claim for stress or mentalhealth issues, such as depression. No studies havebeen conducted, however, to validate or disprovethis concern.
Cognitive-behavioral therapy
CBT is shown effective as treatment forchronic pain and depression [76–79]. CBT is based
on the premise that thought influences emotionand behavior. Several cognitive styles, such aspain catastrophizing, are related to poor outcome
[80]. CBT is a psychologic treatment approachaimed at reducing distorted thinking patternsand behaviors by replacing them with more realis-tic substitute patterns that are critical to adjusting
to pain and injury (eg, exercise, relaxation, oravoidance). Linton and Ryberg [81] found thatCBT prevented low back pain disability [82].
Hasenbring and associates [82] replicated thisfinding.
Psychosocial stress and affective responses topain cause or worsen MSDs and associateddisability in direct patient care providers. CBT isshown effective in helping individuals cope with
stress and pain and preventing or reducing MSDsand disability [20]. Fig. 1 is a conceptual model ofhow CBT is believed to work. Accordingly, em-
ployer and workers’ compensation insurers shouldconsider asking occupational health care pro-viders to screen those who have new MSDs for
psychosocial risk factors and refer them toa pain center for CBT. Screening tools includethe Beck Depression Inventory [83], Fear-Avoid-
ance Beliefs Questionnaire [57], Tampa Scale forKinesiophobia [58,84], Pain Catastrophizing Scale[85], and the Pain Disability Index [86].
Case study
Kathy is a 58-year-old RN who has worked in
a medical ICU at a large, tertiary-care medical
center for 15 years. Although she has had work-
related back pain intermittently for the past 5
years, she has not reported it because of fears of
reprisal or job loss. Staff members who report
workers’ compensation injuries are shunned by
other staff members, who feel they have to
assume additional work for the person who is
on modified duty or absent. Her goal is to
complete 4 more years of work until she turns
62, then apply for social security retirement. She
does not like her nurse manager and her author-
itarian style. Kathy is older than all the other
RNs on her unit and finds little in common with
them. She lives alone, after a divorce 10 years
ago. She has no outside activities and spends her
days off watching television and eating to excess.
Because she works in a unit with mandatory
overtime, the nurse manager tells her she must
work 16 hours on a day that later requires her to
push an occupied stretcher. As she maneuvers the
stretcher around a corner, she assumes an awk-
ward posture and feels intense pain in her lower
back. Pain radiates down her right leg; she is
unable to complete the patient transport and calls
for assistance. Too much in pain to complete her
work assignment, she goes to the employee health
department for evaluation and treatment. Be-
cause of her incapacity, she is sent home from
work with a prescription for pain and muscle
relaxants.
CBT CopingSkills
StressPain
MSDDisability
Fig. 1. CBT to reduce MSDs.
149PSYCHOSOCIAL FACTORS IN MSD
The next day, she has difficulty arising from
bed without incurring severe pain and decides to
stay in bed all day not only that day but also the
next 2 before her follow-up appointment. She
barely is able to show up for her appointment, so
afraid is she of pain from moving. At the same
time, she has thought with dread about the effect
this injury will have on her plans for working 4
more years until retirement. She is certain that
she has suffered a career-ending injury, which will
have profound economic consequences.
The treatment provider refers her to physical
therapy to assist her in movement, but she misses
most of the appointments because of fear of pain
from travel and therapy. A radiograph of the
back reveals no damage other than age-related
degenerative changes in the spine. The workers’
compensation adjuster calls her to threaten claim
denial if she misses any more appointments.
Kathy calls an 800 number flashed on a television
advertisement for a workers’ compensation at-
torney and retains counsel. Her nurse manager
calls to ask when she will be coming back to work
because they are short staffed. Kathy is unable to
cope with the stress and spends her days in bed
crying and overeating. After Kathy has missed 3
months of work and received extensive medical
testing and treatment, she is referred to a neuro-
surgeon for back surgery evaluation. The neuro-
surgeon treats her chronic pain by operating on
her spine. The result is no improvement. At 6
months, the adjuster sends Kathy to a functional
rehabilitation program, but she fails the prepro-
gram psychologic screening tests for likelihood to
benefit from the program. Kathy never returns to
work.
Analysis: The work-related psychosocial risk
factors for back injury incidence were obvious
and unaddressed, making an MSD inevitable,
given the interaction of those factors with a phys-
ical stressor and the nature of cumulative trauma.
The employer could have improved social sup-
port for Kathy and similar experienced nurses by
forming a ‘‘brain trust’’ that meets periodically to
network and plan mentoring programs for new
graduates. The employer could have eliminated
its mandatory overtime policy, which creates job
dissatisfaction and stress.
Once Kathy experienced pain severe enough to
report an injury, the health care provider failed to
assess or intervene in any domain but the
physical. Kathy was exhibiting signs of depres-
sion even before the injury; once the acute injury
occurred, the depression worsened and resulted in
disability. She developed pain-related fear of
movement and pain catastrophizing, which
served to maintain the pain state. Her coping
skills consisted of distracting behaviors and were
no match for the perceived threat of the injury.
No amount of neurosurgery could cure her
depression and maladaptive pain-related behav-
iors, but when all you have is a hammer, every-
thing looks like a nail. Had the health care
provider done some simple screening tests at the
first follow-up visit, when it was obvious that
Kathy was not making progress, the outcome
would have been much different had she been
referred to appropriate resources with the cost
covered by workers’ compensation.
Summary
Epidemiologic studies provide only supportingevidence of the causes of a disease, not direct
proof [87], a fact that tobacco companies wereable to exploit for many years in getting the publicto believe there was scientific uncertainty that cig-arettes cause lung cancer. For diseases, such as
MSDs, that have multifactorial origins, a singlesmoking gun never will be discovered. What isneeded is a conceptual model that acknowledges
the contributions of each factor and allows hy-pothesis generation and empiric testing. Controlof psychosocial risk factors by federal regulators
is not on OSHA’s agenda, after its ErgonomicStandard to control physical risk factors was re-scinded by Congress and the White House in
2001. With no mandatory control imminent,health care employers, treatment providers, andrisk managers should use the precautionary prin-ciple (taking protective action in the face of lack
of scientific proof of a threat) to act as if psycho-social factors were important contributors to theincidence and severity of MSDs and provide ap-
propriate interventions for job strain, job dissatis-faction, and inadequate social support at work.Once injury occurs, workers’ compensation in-
surers should support holistic treatment and notfocus exclusively on physical risk factors. Moodstate and abnormal reactions to pain complicateor prevent recovery if they are not addressed along
with measures that promote physical healing.
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153PSYCHOSOCIAL FACTORS IN MSD
Ergonomic Assessment of a Critical Care UnitSheri Stucke, PhD, APN,
Nancy N. Menzel, PhD, RN, COHN-S*University of Nevada Las Vegas School of Nursing, 4505 Maryland Parkway,
Box 453018, Las Vegas, NV 89154-3018, USA
Direct patient caregivers experience a high in-cidence rate of musculoskeletal disorders (MSDs)and a high prevalence of musculoskeletal pain [1].
The back is the body part injured most frequently,but injuries to the shoulder, neck, arm, and kneesalso are reported. Nursing assistants have higher
rates of injuries than licensed nurses, but registerednurses (RNs) are a perennial finisher in the Top 10of most MSDs reported [2]. Although patient han-dling is the reason cited most recently for MSDs,
shift work and long work hours are known to pre-dispose to injury [3,4].
Unlike the body of knowledge that documents
the musculoskeletal risks associated with manualpatient handling in nursing homes [5–7], there arefew studies about similar risks for critical care
nurses. There is, however, some evidence that crit-ical care nurses experience MSDs at least as muchas other nurses. One study from Canada founda back pain point prevalence of 25% for critical
care nurses compared with 30% for orthopedicnurses [8], whereas another study in the Nether-lands found a 12-month prevalence of low back
pain of 75% in intensive care nurses comparedwith 76% for nonspecialized nurses [9]. Intensivecare nurses in an Australian study had a manual
patient handling injury incidence rate of 52%[10]. As researchers, administrators, and legislatorsimplement safe patient handling interventions for
nursing homes and other areas with high incidencerates of injury, such as orthopedics, the incidenceand severity of injuries to the back, neck, and
shoulder in those workplaces will begin to decline.The next challenge is protecting the health andsafety of nurses working in lower-risk specialty
areas, such as operating rooms and critical careunits (CCUs). Because nurses under-report work-related injuries [11,12], the true injury incidence
rates of these units likely are much higher thannow supposed.
Background
As with many modern approaches to nursingcare, the concept of intensive care originated from
innovations implemented by Florence Nightingalein the Crimean War, when she grouped thesoldiers injured most seriously together and pro-vided revolutionary approaches to the prevention
of infection and epidemics [13]. Today, criticalcare nursing is not limited to a specific unit orarea but is located wherever critically ill patients
are receiving care. This may be emergency rooms,operating rooms, cardiac catheterization labora-tories, progressive care units, telemetry units,
postanesthesia care units, or CCUs, also knownas ICUs. CCUs are special areas designed tocare for patients who are medically unstable and
at risk for death. They are characterized by highnurse-to-patient ratios, such as 1:1, 1:2, or 1:3,the most common ratio being 1:2. Even thoughCCUs may vary significantly by their number of
beds, specialty, and design among hospitals, theyare designed to provide constant nursing andmedical surveillance of patients who have multiple
problems and are receiving multiple treatments.According to the American Association of
Critical Care Nurses statement to the Institute
of Medicine Committee on Work Environment
* Corresponding author.
E-mail address: [email protected]
(N.N. Menzel).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.005 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 155–165
for Nurses and Patient Safety [14], there are nearly1.3 million RNs taking care of hospitalized pati-ents, with an estimated 403,000 of them critical
care nurses. CCUs are staffed with highly trainedRNs. These RNs receive advanced education byattending critical care courses, usually offered bythe hospitals where they are employed. These
courses offer advanced education in systems,such as neurology, cardiovascular, respiratory,gastrointestinal, nephrology, and in areas, such
as hemodynamic monitoring and 12-lead EKGinterpretation, among other topics. The focus isexclusively on the care of complex patients, not
on recognition of and protection from the specialoccupational risks faced by critical care nurses.
A report released by the Health Resources andServices Administration (HRSA) found that pa-
tients in acute care hospitals currently receivemore than 18 million days of care in ICUs everyyear [15]. During the next decade, the demand for
ICU services is projected to grow rapidly becauseof increased acuity of hospitalized patients andthe growth of the aging population. According
to the HRSA, the number of available physicianswho specialize in critical care, also known asintensivists, likely will not meet the demands of
the aging population by the year 2020 [15]. Thishas a direct impact on nursing because this short-age will place increased demands on critical carenurses, who already are scarce because of the
current and projected nursing shortage [16]. Aspatient load or hours of work increase, the riskfor MSDs from manual patient handling exposure
increases.Many of the patients located in critical care
areas are physically dependent and require spe-
cialized medical equipment, such as cardiac mon-itoring, ventilator support, multiple intravenous(IV) infusions, and possibly other technology thatcan crowd the work area around patients. This
abundance of machines can make it difficult fornurses to provide direct patient care withoutmaneuvering the equipment. A typical patient
room in a CCU (often retrofitted from anotheruse) has many pieces of equipment and furnitureat the bedside, which can restrict access to patients
and force nurses to assume awkward postureswhen delivering care. There are many cables andIV poles that also put nurses at risk for tripping.
Critical care nurses may be at high risk for MSDsfrom repetitive movements, such as lifting heavyloads and frequent patient repositioning.
Ergonomics is the science of adjusting job
tasks to match the capabilities of the worker.
The nursing workforce is approximately 95%female [16], meaning that work tasks should bedesigned to accommodate a workforce that is
shorter and has less upper body strength, a shorterreach, and less grip strength than a workforcewith a higher percentage of men. Health care,however, has lagged behind many other indus-
tries, such as warehousing and transportation,that long ago instituted protections for their pri-marily male workers from heavy, frequent lifting
and holding awkward postures. Reasons thatnurses have not received similar protections in-clude a singular focus on patient (not worker)
health; a tradition in nursing schools of teachingineffective lifting procedures, such as bodymechanics [17]; lack of occupational health andsafety regulation; and a primarily female work-
force kept at the bottom of a hierarchic manage-ment structure [18].
Because the nursing shortage is severe and
persistent, some institutions have begun to look atways to improve retention of their existing nursingworkforce. One key is reducing the number and
severity (length of absence) of work-relatedinjuries, of which MSDs are the most costly andmost likely to result in days lost from work or on
modified duty [19]. The most effective way toreduce these injuries is by conducting a thoroughergonomic assessment that identifies hazardoustasks and conditions and instituting an ergonom-
ics program designed to reduce these risks.
Purpose
Because of the dearth of knowledge aboutspecific risks associated with the provision of
critical care, the authors conducted an ergonomicassessment of a 23-bed medical ICU in 409-bed,acute-care hospital in Las Vegas. The second
purpose was to evaluate the applicability tocritical care settings of the instrument, ErgonomicWorkplace Assessment Protocol for Patient Care
Environments in the Patient Care ErgonomicsResource Guide (the Guide) [20].
Methods and materials
This was a qualitative study. The researchers
followed steps 1 through 7 of the protocol de-scribed in the Guide:
1. Collect baseline injury data.2. Identify high-risk units.3. Obtain presite visit data.
156 STUCKE & MENZEL
4. Identify high-risk tasks.5. Conduct team site visit at each high-risk unit.6. Perform risk analysis.7. Formulate recommendations.
8. Implement recommendations; involve endusers in selecting equipment
9. Monitor results; evaluate program; continu-
ously improve safety.
Steps 1 and 2: collect baseline data and identify
high-risk units
Because this was purposive and conveniencesampling, the authors did not select among areasfor the one with the highest injury rate. Thehospital allowed the researchers access to its 23-
bed medical ICU (MICU), where the staffing ratiowas one nurse for every two patients.
Step 3: obtain presite visit data on high-risk units
After receiving Institutional Review Boardapproval, the authors requested that the CCU
manager complete the Pre-Site Visit Unit Profile(Fig. 1) before their visit. Because of a recentchange in the position, however, the new nurse
manager did not feel she had the required knowl-edge or time to complete the questionnaire. She,therefore, designated another management-level
RN (the supervisor) who assists with the MICU(and also is the facility’s risk manager) as theperson to complete the Pre-Site Visit Unit Profilebefore the visit.
The Occupational Safety and Health Adminis-tration log showed no MSDs for the MICU in2004, 2005, and the first 9 months of 2006. The
maximum number of RN full-time equivalent RNsassigned to the unit was 51. The supervisor did notanswer the question about the percent of full-time
equivalents filled. On the day of the focus groups,two participants from the MICU were not regularemployees (one agency nurse and one travel nurse).
There were no planned changes to staffing levels orbed numbers. Themanager checked the box next to‘‘dependent’’ without filling in a percentage. Infocus groups with staff members, nurses estimated
the percentage of dependent patients as 85% to90%. For patient handling equipment, the super-visor listed fourHoyer lifts (‘‘rarely used’’) and two
slide boards (‘‘frequent use’’). The Hoyer lifts werestored on another floor, however. Staff seemedunaware of their existence. She did not identify
built-in scales in the beds. The supervisor identifiedas a problem area the inability of patients to moveand a need for ‘‘improved beds.’’ Although she
identified storage as a problem, she felt there wasadequate room in patient units to carry out patientcare tasks.
Step 4: identify high-risk tasks
The authors then conducted three focus groups
with 11 RNs (two men) working on the 12-hourday shift (7:00 AM to 7:00 PM) on August 18, 2006,to identify high-risk tasks. The focus groups wereconducted in the nurses’ break room, which was
located within the MICU. This was a private, con-venient location. Participation in the focus groupswas voluntary. Breakfast items were offered to
those RNs who inquired or participated in the fo-cus groups. After a prospective participant readthe informed consent and had an opportunity to
ask questions about the study, the researchersgave a $20 gift card to a local store to thosewho agreed to participate. Both researchers were
present during the entire interview process. Thefocus group outline, modified from the one inthe Guide, is as follows:
1. What conditions or situations in critical careput you at risk for back strain and injuries?
2. What critical care lifts or transfers are themost difficult and present the highest risk?
3. What are the factors that make a lift or trans-fer a high-risk activity?
4. What types of critical care patient conditionscontribute to high-risk situations?
5. What do you think can be done to reduce or
minimize a high-risk situation?6. What are the barriers to risk reduction? In
other words, what are some of the reasons
that you don’t take precautionary steps?
Although the protocol recommends this step
only for identifying high-risk tasks, other issues,such as staffing, emerged during the focus groups.The data were reduced to common themes. The
most frequent or most intensely reported themesfor MSD risks were
1. Patient characteristics: heavy (obese), depen-dent, resistant/combative
2. Hazardous tasks
� Transporting patients and their extensiveequipment (while manually ventilatingthem on occasion) in beds with balky wheels
and IV poles that do not glide� Frequent turning and repositioning patientsin bed
157ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
Fig. 1. Pre-site visit unit profile.
158 STUCKE & MENZEL
� Reading body fluid levels 6 inches off the
floor� Emptying urine drainage every hour from 6inches off the floor
� Having to maintain awkward postures forprolonged periods of time during procedures
3. Equipment
� Lack of safe patient handling and liftingequipment, in particular self-propelled beds� Need to get help from other staff members
for manual patient handling because oflack of equipment
Fig. 1 (continued)
159ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
4. Staff� Not enough staff to allow nurses to helpother nurses reposition or transport their
patients. Causes delays in patient care.� Large variation among caregivers in heightand strength� 75% of staff complaining of current or
recent musculoskeletal pain� Staff reluctance to report MSDs because offear of management repercussions (‘‘being
blackballed’’)5. Maintenance� Wheels on beds are not well maintained to
ease push/pull stress of bed transports� IV poles broken
6. Shift length and scheduling� 12-hour shifts and frequent overtime con-
tribute to fatigue and musculoskeletal pain7. Unit layout� Extensive walking required
� Limited opportunities to sit
Some of the participants had misconceptions;namely, that body mechanics are effective inpreventing injury and that if a nurse was injured,
it was because of his or her lack of fitness ortechnique. The facility perpetuates this belief byproviding annual training in body mechanics. Staff
members did not know that there was a recommen-ded weight limit for patient handling or what thatrecommendation was, which is a maximum of 35
pounds [17].From the preliminary questionnaire and focus
group data, the authors prioritized high-risk
patient handling tasks according to the protocol(Table 1). The researchers did not include all ofthe tasks in the Guide, as many were not applica-ble or uncommon in this MICU (eg, lifting a pa-
tient from the floor or bathing a patient ona shower trolley). Instead, the researchers addedtasks to the list that were more common in the
MICU.
Step 5: conduct team site visit for ergonomicassessment
Aftermeeting with the acting supervisor and thehead nurse, the researchers toured the MICU to
evaluate observable risks. The unit seemed to havebeen converted from a standard semiprivate med-ical-surgical floor by removing one bed from each
room to create single rooms. This layout reducedor eliminated visibility of patients from the nurses’station, however, so staff nurses established
makeshift substations near their assigned patients.The medication carts were not height adjustable.The hallways were crowded with furniture and
medical equipment, making navigating an occu-pied bed to or from the elevator difficult. The staffreported that the doors to the CT scan room areopened manually, requiring nurses to hold an
awkward posture with hips and feet to keep thedoor open until the bed is pushed through.
Based on information from the supervisor,
focus groups, and the site visit, the researcherscompleted a unit summary sheet (Table 2).
Step 6: risk analysis
After reviewing the baseline injury, presitevisit, focus group, observational data, and the
identification of high-risk tasks, MSD risk factorswere identified. These include
1. Lifting/moving heavy loads2. Reaching and lifting with loads far from the
body
3. Pushing a load a significant distance4. Squatting5. Maintaining awkward postures
Environmental hazards included cluttered hall-ways, broken bed wheels, monitors not adjustableto accommodate the gaze of the shortest nurses,
and a physical layout that required nurses to walklong distances for medications, supplies, andcharting. Walking more than 3.5 miles per shift
is considered a risk factor for musculoskeletaldiscomfort [21].
Step 7: formulate recommendations
The Guide suggests that recommendationsshould be achievable and simple and includes
two categories: engineering design and adminis-trative solutions. Engineering controls involveexternal changes to the way a job is performed,
for example, the use of a mechanical lift to movea patient from a bed to a stretcher. Administrativecontrols affect the way work is done or the hoursof exposure to risk. For example, if a hospital
offers 8-hour shifts instead of 12-hour, eachcaregiver’s exposure to hazardous MSD risks isreduced by 4 hours per day, allowing adequate
recovery time between work periods.The researchers made the following recom-
mendations. Because ergonomic concepts are new
to this facility, the first step is for the supervisor tobring her concerns about staff safety and risks tohospital management for further discussion.
160 STUCKE & MENZEL
Table 1
Prioritization of high-risk patient handling tasks
Patient description
Unit
description
Miscellaneous
information Equipment Problems identified Solutions
Medical patients with
multiorgan system failure,
80%–85% dependent,
many on ventilators
and all attached to monitors,
IVs, and other equipment
23-bed medical
ICU, all
private rooms
with private
baths
Recent
change in
unit manager
2 slide/surf
boards; 4
specialty
beds on
order for
trial
High risk from transporting
patients in beds
Self-propelled beds or ERGOtug Medical
Mover. Clear halls of extra equipment. Put
electric doors on CT scan room
For profit hospital
Staff is unionized Turning side to side in bed
or pulling up in bed a problem
Explore value of friction-reducing devices
No preventive maintenance on
bed wheels
Institute routine maintenance program
Large proportion
of obese patients
On admission for patients over 250 lb, rent
bariatric beds or consider purchase if
percentage of bariatric patients exceeds
30% in a 3-month period
Transferring patients from
stretcher to bed
Powered lateral assist device or AirPal
Fatigue from long shifts Limit overtime; provide seating and break
opportunities
Reading urinary output bags
or chest tube drainage when
stooped
Provide mirrors on poles to visualize levels
without stooping. Change emptying
frequency to every 3 hours once level
is read and recorded.
Extensive walking Redesign unit layout with mini–nurse stations.
Provide chairs reserved for nurses in recessed
hall areas and in nurses station, where chairs
often are taken by medical residents
High reported prevalence of
MSD pain but zero injury
reporting for 2.5 years
Encourage early reporting and intervention
for MSDs
Awkward postures from applying
femoral pressure manually
Rearrange standing medical order form to list
Femstop first to encourage this choice over
manual pressure
Awkward postures from using
medicine cart
Obtain height adjustable cart
Awkward postures from reading
cardiac and other monitors
Increase downward height adjustability of
monitors or provide short staff with step stools
161
ERGONOMIC
ASSESSMENT
OFA
CRIT
ICALCARE
UNIT
Without management support, no program inergonomics will succeed.
Prior to meeting with hospital management,
the supervisor should prepare a business case(cost-benefit analysis) for intervening by compil-ing information on the direct and indirect costs of
MSDs in the facility’s staff for the past 2 years.Direct costs usually include workers’ compensa-tion medical care and wage replacement (data
available from insurer), whereas indirect costsinclude the cost of hiring replacement nursesto cover absences, among many other consider-
ations. Indirect costs are estimated as equal todirect costs [22]. In this facility, with a nearly3-year record of no reported injuries, the supervisormust recognize that there has been suppression of
reporting, based on the prevalence of MSDs thestaff described during the focus groups and theirfear of reporting. A better indication of the direct
cost of MSDs in this facility is the number of un-scheduled absences (ie, the number of days whennurses call in sick or take a personal day with
no prior notice). These absences translate intocosts for overtime and agency nurses. An addi-tional cost is turnover; when a nurse feels herhealth is at risk, she may move to an area
with less perceivedMSDrisk.This is aphenomenoncalled the ‘‘healthy worker effect.’’ A management
approach based on ergonomics is to encourageearly reporting, when intervention can be moreeffective, rather than waiting until pain and dis-
ability are severe. In addition, the supervisorshould have a cost estimate for engineeringand administrative controls recommended.
The supervisor also should come prepared withevidence that ergonomic interventions actuallyreduce injuries, absenteeism, and turnover [5,23].
The supervisor can find resources at the PatientSafety Center’s Web site [24].
Once hospital management is convinced that
there is a costly problem that can be prevented orlessened, the facility can embark on a participatoryergonomics program involving staff nurses in allareas. Staff nurses’ participation is vital to the
success of any program because they must havea say in engineering and administrative controls toensure they will be accepted.
Discussion
The researchers found challenges in followingthe Guide’s protocol; some steps seemed out of
sequence or redundant. In particular, the unitsummary sheet in step 5 calls for a list of solutionsbefore risk analysis is completed or
Table 2
Unit summary sheet
Patient handling task Frequency of task Stress of task Ranka
Transporting patient
off unit
H H 1
Repositioning patient
from side to side
H H 1
Lifting patient
to head of bed
H H 1
Bathing a patient in bed M H 1
Transferring patient:
bed to stretcher
M H 1
Transferring patient:
bed to chair
L H 1
Making an occupied bed H H 1
Weighing a patient M L 10 (beds have built-in
scales)
Emptying catheter
drainagebH H 1
Reading chest
tube drainagebL H 1
Applying pressure
on femoral arterybM H 1
Abbreviations: H, high; L, low; M, moderate.a 1 indicates high risk; 10 indicates low risk.b Indicates high-risk task added to list in the Guide under ‘‘Other.’’
162 STUCKE & MENZEL
recommendations formulated. In addition, step 4calls for identifying high-risk tasks by ‘‘job obser-vation, questionnaires to employees or brain-storming sessions with patient handlers’’ before
the site visit occurs in step 5, which implies two sitevisits. The protocol’s list of high-risk tasks in step 4seems most appropriate for a nursing home
setting, not critical care. Judging from missing orinappropriate responses, some questions on thePre-site Visit Unit Profile form were difficult for
the supervisor to understand. The protocol shouldbe edited to make it more generic and easier tofollow. Finally, it should be expanded to include
gathering information on other risks that affectMSD incidence, such as the average number ofhours a nurse works, the facility’s climate forreporting work-related injuries and other signs
that lifting burdens may be too great, such as staffturnover.
The researchers noted the following differences
between MSD risks in this MICU and nursinghomes.
1. In this MICU, almost all patients werecompletely dependent. In nursing homes,some proportion of residents can assist at
least partially.2. Nursing home patients almost always are
ambulated or transferred to wheelchairs
daily. In this MICU, patients are not trans-ferred out of bed as frequently.
3. Bed transport is frequent in MICU, infre-quent in nursing homes.
4. Staff are all RNs in MICU; the majority arecertified nursing assistants in nursing homes.
5. Medical procedures are performed more fre-
quently at bedside in MICU.6. MICU patients have much more equipment
attached to them than those in nursing homes.
7. Nurse-to-patient ratio is 1:2 in MICU; it maybe 1:12 or more in nursing home.
8. MICU patients do not require feeding very
often; caregivers often must feed nursinghome patients (awkward postures).
The data were obtained from one CCU in onehospital during one shift in one city, so thefindings are of limited generalizability. They do
indicate, however, that MSD risks are present incritical care environments. To preserve the valu-able resource of highly skilled practitioners safeand at the bedside, hospital administrators must
begin to pay attention to the special risks theyface and provide effective interventions. The
nurses who work in these areas also shoulddemand these protections. A major nurse union,United American Nurses, is a cosponsor withthe American Nurses Association for the Handle
with Care campaign to eliminate manual patienthandling. It also passed a resolution to takepolitical action to seek federal and state legislation
to protect nurses from the hazards of manual pa-tient handling [25].
Recommendations
Judging from this small study and a search of
the articles published in critical care nursingjournals, critical care nurses are only minimallyaware of the MSD risks they are exposed to during
their shift. During the focus group interviews inthe MICU, nurses were able to articulate theimportance of properly arranging patients and
necessary equipment before procedures are per-formed to prevent awkward positioning of theirbodies. Most nurses were unaware, however, of
the special equipment available to assist them inpreventing musculoskeletal injuries, when trans-ferring patients, for instance. Critical care nursesmust be educated about the urgent need for
assistive equipment in their specialty areas, sothey can demand this equipment and safer workpractices. Nurses seeking to change employers
should inquire about ergonomic protections avail-able in their potential new workplaces and refuseto work where they do not exist.
It is necessary for critical care nurses to changetheir paradigm from patient focus to the nurse/patient safety dyad. Nurses need to be aware that
although they need to provide safe care to theirpatients, they also need to protect their own safetyand that of their peers. The men in the studyreported that they were asked more frequently
than female staff members to help with patientmovement, thereby increasing their exposure tohazardous tasks. With the current nursing
shortage, retention of critical care nurses is vital,especially with the elderly population growing atsuch a fast rate. Two younger nurses in the focus
groups recognized they are at risk for muscu-loskeletal injuries by stating they currently do nothave back pain but realize they probably will inthe next few years. This resigned way of thinking
must change to one of optimism for a long career,given proper workplace protection from thehazards of manual patient handling, awkward
postures, and repetitive motion leading to cumu-lative trauma.
163ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
Even with the safe patient handling initiativesthat have been introduced during the past fewyears, critical care nurses still are unaware of
the alarming statistics regarding MSDs in healthcare. Dissemination of new knowledge is pre-sented to the nursing community at conferencesthrough poster presentations and oral presenta-
tions. Many nurses may not attend conferencesand, therefore, miss the information presented.Another method for distribution of new knowl-
edge is through articles published in clinical andresearch journals. When nurses read professionaljournals, it usually is a journal in their field of
practice and expertise; therefore, publishingarticles related to musculoskeletal injuries (suchas this one) in critical care journals (such as thisone) is one way to reach this specialty. Some
nurses may not read journal articles, howeverda dissemination dead end.
Another way to distribute information to
critical care nurses is through their professionalorganizations. Local chapters of professionalorganizations, such as the American Association
of Critical Care nurses, are a good venue fordisseminating information to nurses who special-ize in critical care. For instance, chapters have
meetings and educational offerings at local facil-ities that are more convenient for nurses to attendthan national conferences, especially if continuingeducation credits are offered.
A change in paradigm may create some re-sistance, especially when the change involvessomething that has been accepted and done the
same way for many years. Lewin’s model ofplanned change describes a three-step frameworkfor instituting change. The initial step is the
unfreezing stage or preparation for change [26].During this step, unions and professional organi-zations inform nurses about MSD statistics inhealth care, MSD hazards from manual patient
handling, critical care tasks and environmental fac-tors that have the highest risks, actions they cantake to prevent injuring themselves, and modern
technologic assistance available to reduce the risksthat lead toMSDs. This is the step where nurses areinfluenced and become interested in engaging in
change to improve their current practices.The second step in Lewin’s model of planned
change is movement or changing. During this step,
nurses shift their behavior to a new level. They canspeak with their nurse managers regarding thenecessary changes needed to initiate a comprehen-sive ergonomic program in their facility, including
trying out available assistive devices to determine
what equipment is most beneficial for high-riskcritical care tasks. Feedback from end users iscrucial, because they are the nurses who use the
equipment every day. Equipment that requiresdistant storage or that slows down the time it takesto deliver care is destined to be abandoned. If staffnurses are not comfortable or satisfied with the
equipment, then the equipment goes unused andthe nurses revert to manual patient handling.
The final step in Lewin’s model of planned
change is the refreezing stage. During this step,nurses have implemented the new changes in theirpractice with the equipment they have chosen to
be most beneficial for them. Because the nursesactively were involved with this change from thebeginning and should be experiencing the benefitsof reduced pain and fatigue, they are more likely
to accept and continue the new safe patienthandling practices.
Summary
Although the ergonomic assessment tool pro-vided a good foundation for assessing a CCU, itshould be revised to improve its clarity, sequencing,
and applicability in a range of settings. Thisqualitative study indicates that even in a criticalcare area where there are no reported injuries,
MSDs can be prevalent. The critical care workenvironment may involve risks in addition to thosepresent in all nursing workplaces by virtue of the
preponderance of dependent, obese patients; thechallenge of delivering multiple, concurrent in-terventions to patients surrounded by a collection
of modern technology inserted into an architec-tural space not designed to accommodate it; theneed for bed transports to centralized technologyor services; expenditures for high-tech equipment
for patient care and not worker safety receivingbudget priority; and the frequency of repetitivetasks involving awkward postures. Hospital
administrators, professional organizations, unions,researchers, and equipment vendors should turntheir attention to protecting critical care nurses
from manual patient handling, an antiquatedwork practice unable to meet the demands ofa twenty-first century work environment.
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165ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
Evaluation of Critical Care Space Requirementsfor Three Frequent and High-Risk Tasks
Sue Hignett, PhD*, Jun Lu, MArch, BEngHealthcare Ergonomics and Patient Safety research Unit (HEPSU), Department of Human Sciences,
Loughborough University, Loughborough, Leicestershire, LE11 3TU, UK
Many investigators have identified that staff
and patient safety can be compromised if in-sufficient space is provided [1–5]. Even if sufficientspace is available, the layout and ergonomic de-
sign of workspace may restrict activities and con-tribute to adverse events [6,7]. In the UnitedKingdom (UK), there are health and safety lawsthat, for example, require ‘‘every room [to] have
sufficient floor area, height and space for the pur-poses of health and safety’’ [8]. This is a cross-industry regulation that appliesmostly to employee
activities but also to all users of a space, includ-ing patients and visitors.
Many guidance publications are available to
assist designers (architects) in planning hospitalspaces; they include topics on health and safety,hospital design, and clinical guidance. The recom-
mendations for bed space (single rooms or cubiclesin shared rooms) have increased since 1992, butlittle empiric evidence is published to support theproposed dimensions.
To test the space requirements for critical caretasks, three frequent or space-critical tasks weresimulated in a full-size mock-up. The mock-up was
based on the measured dimensions from four UKcritical care units built since 2000. The selectedtasks were determined by a previous field study [9]:
washing and dressing patients and moving them
from a bed to wheelchair using a lifter (bed wash/
lifter task); transferring patients from bed to an-other bed (bed-to-bed task); and resuscitatingpatients (resuscitation task).
Background
Patient bed space (room or cubicle) is the most
important and largest repeating space envelope ina health care facility because it is the center ofnursing activity [10,11]. The design of hospitals hasbeen viewed as an important and integral part of
the therapeutic environment since the time of Flor-ence Nightingale, with the effectiveness of healthcare delivery determined, in part, by the design
of the physical environment and the spatial organi-zation of work [12,13].
The first ICUs were built in the early to mid-
1950s, with open wards and no partitions exceptcurtains or screens. The second- and third-gener-ation ICUs (1970s and 1980s) had individual
rooms, moving from walled cubicles to foldingor sliding doors with increased level of control. Itis predicted that the future ICUs will have in-dividual rooms with increased privacy [14]. The
challenge is to design critical care units that facil-itate the provision of care and also provide a lowstress environment for patients and their families
or significant others [15,16]. In the United Statesof America (USA), there are recommendationsto decrease patient transfers through the use of
adaptable acuity design [17–20]. This allows pa-tients to be accommodated in the same singleroom throughout their stay with the room adjustedfor the requirements of care and treatment. The di-
mensions and configuration of the room includea patient area, family area (including recliner bed
This work was supported by Grant no: B(02)13/
HUJBA from the Department of Health Estates and
Facilities Management Directorate (UK).
The views and opinions expressed in this article do
not necessarily reflect those of the Department of
Health.
* Corresponding author.
E-mail address: [email protected] (S. Hignett).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.004 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 167–175
and so forth), caregiver area, and hygiene area[15,17]. The critical care bed space needs to haveworking space for staff, appropriate clinical equip-
ment and furniture, and movement space for rou-tine and emergency care [17].
There is a difference in professional spacerecommendations in the USA and the UK. In the
USA, the recommended space envelope has in-creased from 13.94 m2 (rooms) [21] in 1996 to 16.72m2 (rooms or cubicles) [22] in 2001 and 36 m2 for
universal (acuity adaptable) rooms (Fig. 1) [18].In the UK, the recommended space has increasedfrom 20.25 m2 (cubicles) [23] in 1992 to 26 m2
(rooms or cubicles) [24] in 2003. No empiric re-search was located to support the space recommen-dations shown in Fig. 1.
The development of evidence-based health care
has paralleled the availability of information, withtechnology increasing the availability of researchfindings. These concepts are starting to be seen in
20.25
12
25
20
13.94
15.75
25.5
20
23.23
33
16.72
39.48
25.08
18
26
37.16
22.5
36
30
40
0 5 10 15 20 25 30 35 40 45
1992 (HBN 27[23]: cubicle[UK])
1993 (Marans[35]:room[USA])
1995 (Wedel et al[34]: room[USA])
1995 (Wedel et al[34]: cubicle[USA])
1996 (AIA[21]:room [USA])
1998 (Koay[33]: room[Singapore])
1997 (Intensive CareSociety[32]: room [UK])
1997 (Intensive CareSociety[32]: cubicle [UK])
1999 (HermanMiller forHealthcare[31]: room [USA])
2001 (Hamilton[30]: room[USA])
2001 (AIA[22]: room/cubicle[USA])
2001 (Stichler[29]:room[USA])
2001 (Gallant & Lanning[28]:room [USA])
2003 (Held[27]:cubicle[Switzerland])
2003 (HBN 57[24]:room/cubicle [UK])
2003 (Sponsler[26]:room[USA])
2004 (Hendrich[18]:roomwithout family space [USA])
2004 (Hendrich[18]:room[USA])
2004 (Takrouri[25]: cubicle[Saudi Arabia])
2004 (Takrouri[25]: roomwith storage [Saudi Arabia])
Area of room/cubicle in square metres
Fig. 1. Recommendations for bed space in ICUs (m2). Data from Refs. [26–35].
168 HIGNETT & LU
health care architecture, where it is recognizedthat health care architects must aim to achieve thesame high standards as clinical evidence-basedpractice [36,37]. There are several narrative re-
views summarizing the literature [38–43] but nosystematic reviews looking at health care design.As health care treatment and care procedures pre-
dominantly are evidence based, the lack of a sys-tematic review to present a critical appraisal ofdesign research limits the usability of this research
for clinicians and designers (architects).
Aim
The aim is to determine the space requirements
for critical care bed space envelope (rooms orcubicles) for three space-critical high-risk tasks:(1) washing and dressing patients and then mov-ing them from bed-to-wheelchair using a lifter, (2)
transferring patients from bed to another bed, and(3) resuscitating patients.
Method
Functional space experiments (FSEs) were de-veloped to test the space required. This method ofspace testing originally was used in 1955 [44] and
has been used to recommend minimum patienthandling space requirements in bed spaces [11]and shower or toilet rooms [45].
The importance of clinical staff participating in
health care building design is highlighted byseveral investigators [7,10,46–48]. The use ofmock-ups as part of the participatory design
process is recommended by several investigatorsto enable staff to experience all aspects of the de-sign, including getting the feel of the space, evalu-
ating various aspects, and providing feedback[10,49–53].
The templates for the FSEs were derived fromfour UK hospitals built or refurbished since 2001.
The bed spaces (defined by boundaries of walls orcubicle curtains) were measured in each ICU, asshown in Table 1. As more recent guidance rec-
ommends that rooms and cubicles need the sameamount of space for clinical activities [22,24]; noallowance is made for room and cubicle space
envelopes in these experiments.
Participants
Participants were recruited from the cardiacICU of a large regional hospital (with more than11,500 total staff on three sites). A poster
advertising the FSE and seeking participation
was displayed on the cardiac ICU notice boardfor several weeks before the start of the FSEs.Eighteen nurses were recruited, including sevenregistered nurses, eight health care assistants, and
three student nurses. Their experience working incritical care ranged from 6 months to 20 years,with an average of 5.3 years. Participating nurses
were given an information sheet and signeda consent form at the FSE.
Tasks
Patient rooms are described in terms of fourzones: patient area, family area, hygiene area, andcaregiver area [15,17]. This experiment looked at
the patient (bed, bedside table, and chair) andcaregiver areas but excluded the family and hy-giene areas and in-room storage.
Data from a previous observational study wasused to determine the tasks to be used in the FSEs[9]. Three task scenarios were chosen: (1) washingand dressing patients and then moving them from
bed to wheelchair using a lifter (bed wash/lifter),(2) transferring patients from bed to another bed(bed to bed), and (3) resuscitating a patient; the
techniques and equipment used for the three taskswere based on recommendations for practice bythe Royal College of Nursing [54].
The task scenarios were reviewed with the helpof expert nursing staff in prepilot and pilot stagesto determine, for example, how many participants
were needed for a task, what equipment would beused, the start and end points of the task, themock-up design, and camera locations.
Six groups of nurses tested the layouts by
performing the three tasks repeatedly. Differentcolored tapes were used to mark the laboratoryfloor to represent the boundaries of the bed space
templates with additional parallel lines at 20-cmintervals on both sides of a boundary line to recordand measure the exact space required for nursing
tasks (Fig. 2). The mock-up used in this FSE useda module rail (gantry), as the bed space templateshad gantry systems rather than headwall services.
Table 1
Critical care unit bed space templates
Layout Date Width (m) Length (m) Area (m2)
1 (room) 2002 5.28 5.10 26.93
2 (room) 2001 6.12 4.10 25.09
3 (room) 2002 4.64 4.37 20.28
4 (cubicle) 2001 3.30 4.00 13.20
169EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS
A 17-kg fully articulated mannequin was used asthe patient in all the FSEs.
Data were collected using video recording fordetailed frame-by-frame analysis. Link analysis
was used to record the movements of components(ie, nursing staff, equipment or device, and furni-ture) and the participants’ (nurses’) movements
between equipment or device, furniture, and pa-tient. Links were defined as movements of positionand components [55,56]. AutoCAD was used to
draw the link diagrams as output to convey spatialinformation.
Ethical issues
Ethical approval for this study was granted byLoughborough University and National HealthService (MREC 04/MRE09/31 and LCPRA
05/Q2501/45). Research governance was grantedby the participating NHS Trusts and honorarycontracts were issued to both researchers.
Results
The multidirectional video data (from fourcameras) were analyzed frame by frame using link
analysis. The movement of each nurse was plottedindividually and then overlaid with that of theircolleagues for each task and template to give 48
data sets of the composite link analyses; Fig. 2ashows the bed-to-bed transfer, Fig. 2b the bedwash/lifter, and Fig. 2c resuscitation. The average
space occupied was measured for each trial andan average calculated for each task; Fig. 3 showsthe area, Fig. 4 the width, and Fig. 5 the length.
Fig. 2. Link analyses for bed-to-bed transfer (a), bed wash/lifter (b), and resuscitation (c).
170 HIGNETT & LU
The complexity of the task scenarios was empha-sized during the link analysis where the movementof individual nurses could be plotted from the mul-
tidirectional data before combination with thedata for the other nurses. The overlaid diagrams(see Fig. 2) are detailed but give a true reflection
of the complexity of the working activities.The bed-to-bed transfer task occupied the most
space, with an average area of 23.26 m2 (see
Fig. 3), followed by the resuscitation task (22.87m2) and the bed wash/lifter task (22.36 m2).Only layout one (26.93 m2) accommodated allthe average spatial requirements for all the tasks.
Layout two (25.09 m2) was exceeded for the bed-to-bed task but accommodated the bed wash/lifterand resuscitation tasks. Layout three (20.28 m2)
accommodated the bed-to-bed and resuscitationtasks but not the bed wash/lifter task. Layoutfour (13.2 m2) was exceeded for all the tasks. To
investigate the spatial requirements further, theaverage dimensions for width and length alsowere determined.
The results of width analysis found that theresuscitation task needed an average of 4.89 m(see Fig. 4), followed by the bed-to-bed transfer
task (4.87 m) and the bed wash/lifter task (4.81m). Again, layouts one (5.28 m) and three (4.64m) accommodated all the tasks. Layout two
(6.12 m) just accommodated the tasks, with thefull width used for the resuscitation task. Therewas concern that the data from layout two mightskew the results. This was checked in detail from
the video recording and it was concluded thatnursing task behavior was unchanged when com-pared with the other three layouts. Layout four
(3.3 m) was exceeded for all three tasks.The results of length analysis (see Fig. 5) found
that the bed-to-bed transfer task needed an average
24.4
5
25.6
5
23.3
1
24
26.1
6
27.3
8
19.5
2
21.1
3
21.3
21.4
5
20.0
8
19.4
822.3
6
23.2
6
22.8
7
1517.5
2022.5
2527.5
3032.5
35
Bed Wash/lifter Bed-to-bed Resuscitation
Layout 1 (26.93m2) Layout 2 (25.09m2) Layout 3 (20.28m2)Layout 4 (13.2m2) Average
Fig. 3. Bed space envelope dimensions: area (m2).
4.97 5.04
4.81
5.5
5.93
5.85
4.24 4.3
4.57
4.54
4.19 4.
34
4.81 4.87
4.89
3
3.5
4
4.5
5
5.5
6
Bed wash/lifter Bed to bed transfer Resuscitation
Layout 1 (5.28m) Layout 2 (6.12m) Layout 3 (4.64m)Layout 4 (3.3m) Average
Fig. 4. Bed space envelope dimensions: width (m).
171EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS
of 4.80 m, followed by the resuscitation task (4.67
m) and the bed wash/lifter task (4.66 m). Most ofthe resulting dimensions approximated to squareshapes. Layout one (5.1 m) accommodated all the
tasks. Layouts two (4.1 m), three (4.37 m), andfour (4.0 m) all were exceeded for all three tasks.
Discussion
The average spatial requirement from all theFSEs was 22.83 m2 (average width of 4.68 m and
length of 4.71 m), similar to the recommendationfrom Hendrich and colleagues [18] for a roomarea of 22.5 m2, excluding family space. The result
is within the current UK recommendation (26 m2)but greater than the guidance [23] that would havebeen used for all the benchmark sites (20.25 m2).
One of the limitations of the FSEs was the exclu-sion of space considerations for family, hygiene,and in-room storage areas and it is likely that an
additional 3 m2 would be needed to accommodatethese areas. In comparison, recommendations foradaptable acuity rooms usually include storageand services, giving space recommendations of
36 m2 (of which 13.5 m2 is family space) [18]and 40 m2 (of which 10 m2 is storage space) [25].The shape of the bed space envelope was impor-
tant. The average spatial dimensions for the threetasks differed. The limiting factor was found to bethe length for layouts two (bed-to-bed transfer
task) and three (bed wash/lifter task) where theaverage area was insufficient for the specifiedtasks. The shape of the layout for all the tasks
resulted in a greater width than length, with the
resuscitation task needing 20 cm more widththan length and the bed wash/lifter task 15 cmmore width than length.
The three tasks offered frequent (bed wash/lifter and bed-to-bed transfer) and safety critical(resuscitation) challenges to the spatial require-ments. The resuscitation task required the greatest
width to accommodate the increased number ofstaff (up to six were available for the FSEs) andthe equipment and circulatory space around the
bed. It was anticipated that the bed-to-bed trans-fer and bed wash/lifter might require greater spacethan the resuscitation task because of the addi-
tional equipment (second bed and lifter). Thelength requirements are less surprising, with thebed-to-bed transfer requiring the largest dimen-
sion to accommodate the access and egress of thesecond bed. It was expected that the resuscitationtask might require a greater length than the bedwash/lifter task. A previous pilot study on adult
acute ward bed space envelopes identified thatwidth was the critical spatial factor when usinga lifter, whereas length was the critical factor for
resuscitation (bed-to-bed transfer spatial require-ments were not investigated) [11]. The results fromthe critical care environment suggest that width is
equally important for the resuscitation task andrequires more space than when using a lifter.This presents a challenge to hospital designers:Should a bed space envelope be designed for the
safety critical task, giving a larger envelope(23.80 m2)? Or for the frequent tasks, 23.23 m2
or 22.27 m2? The location of openings (doorways)
4.92 5.
09
4.85
4.36
4.41
4.68
4.61
4.91
4.664.73 4.79
4.494.
66 4.8
4.67
3
3.5
4
4.5
5
5.5
6
Bed wash/lifter Bed to bed transfer Resuscitation
Len
gth
(m
)
Layout 1 (5.1m) Layout 2 (4.1m) Layout 3 (4.37m)Layout 4 (4.0m) Average
Fig. 5. Bed space envelope dimensions: length (m).
172 HIGNETT & LU
within a layout was found to affect the results. Forexample, in layout two, the doorway was close tothe patient bed head and services (electricalpoints, oxygen, air, and so forth) and perpendicu-
lar to the bed. When the nurses wanted to movethe mobile lifter, the resuscitation trolley, secondpatient bed, or any other big equipment or furni-
ture into the bed space from outside, a lot of spacewas needed between the door and bed to maneu-ver the equipment without difficulty. It is sug-
gested that this might be the reason the architecthad to design the width of 6.12 m and why thedata from this layout seemed to skew the results.
It was important to give the results withspecific dimensions (length and width) and floorareas. For example, a 24-m2 room could be 4 m inwidth with 6 m in length (or 4 m in length � 6 m
in width) or 3 m in width by 8 m in length (or 3 min length by 8 m in width), depending on the func-tionality and usability. This might be a problem,
as architects and clients could talk about the floorarea of a room without taking account of theshape. This approach might work when designing
buildings, such as shops, museums, libraries, andeven residential buildings, because professionalknowledge, personal experience, and common
sense can inform the architect. But hospital build-ing design presents different challenges and archi-tects need to know that the lack of 0.5 m in thelength or width of a room could affect the safety
and efficiency of care and treatment.A limitation of this research was the lack of
evaluation for the designof the provisionof services
(electrical, vacuum, air, and oxygen). There are twoprincipal systems for the delivery of these services,a modular rail or power column [57,58]. A rail sys-
tem has the intravenous lines, tubes, and so forthfanning out from patients. The benefits of the railsystem (gantry) include minimal tangling, adjust-ability for different patients, access for right- and
left-handed caregivers, and freeing floor spacewith everything hanging from the rail but mustwork from both sides of the bed [7,49]. The power
column (pendant) has the lines, tubes, and so forthleaving a patient and converging in one area. Thiscan facilitate 360� access to patients, decrease the
amount of walking, and increase efficiency withcontrols at fingertips and equipment congregatedin one area, but the lines can get tangled [17,49,59].
The choice to provide care in rooms or cubiclesneeds to be considered in more detail to look atthe risk balance for safety and social issues. Twostudies report that isolated patients (in single
rooms) were visited half as often as nonisolated
patients (5.3 versus 10.9 visits per patient) [60] andwere twice as likely to have adverse events (31 ver-sus 15 events per 1000 patient days) [61]. Twostudies looking at patient stressors in ICUs (with
six bed units) found that lack of privacy was notconsidered a priority [62] and ranked only four-teenth as a stressor [16].
Summary
The provision of functional space in a critical
care environment is recognized as important forpatient and staff safety. This research providesempiric data to support a spatial requirement of22.83 m2, as the average task space based on the
average length (bed-to-bed transfer) and width(resuscitation) dimensions are given as 4.8 mand 4.89 m. The method of link analysis was
found effective for plotting the movements ofthe nurses and accounting for the complexity ofthe tasks. This method, in combination with ob-
servational field studies, provides a simple but ef-fective way of determining the functional spacerequirements for nursing activities.
Summary of important points
� There has been a gradual increase in the rec-
ommended dimensions for critical care bedspaces since 1992.� Empiric data are lacking to support the rec-
ommendations from professional guidelinesfor critical care bed space envelopes.� The use of mock-ups with systematic FSEs
provides a simple but effective method for de-termining the spatial requirements.� An average bed space envelope requirementof 22.83 m2 is recommended to accommodate
frequent and safety critical tasks in ICUenvironments.
Acknowledgments
The authors would like to thank JonathanMill-
man (Department of Health Estates and FacilitiesManagement Division) for his support during theproject; andMoira Durbridge and Allison Godfrey
Vallance and the staff from the Cardiac ICU atUniversity Hospitals of Leicester NHS Trust forfacilitating access and participating in the project.
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175EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS
Technology Solutions for High-Risk Tasksin Critical Care
Andrea Baptiste, MA (OT), CIEPatient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL 33612, USA
Critical care units present a unique set ofchallenges to nurses and health care professionalswho work with this patient population. These
challenges come in various forms, ranging fromjob requirements, work organizational issues, en-vironment, and equipment. This article focuses onpotential technological solutions in critical care.
Before understanding the solutions to high-risktasks in critical care, the job content and thephysical demands of specific tasks that place
critical care nurses under stress should be un-derstood. The job requirements of intensive carenurses are different from those of other specialties,
resulting in different occupational hazards forintensive care or critical care nurses. A study inThe Netherlands analyzed the relationship be-tween the physical and psychologic work-related
risk factors and musculoskeletal complaints ofnurses from operating rooms and intensive care;x-ray technologists; and nonspecialized nurses.
Results indicate that intensive care nurses per-ceived fewer prolonged neck-shoulder complaintsthan nonspecialized nurses and that an ergonomic
environment seems predictive for low back com-plaints (odds ratio 1.11; 95% CI, 1–1.24) [1].
The findings of this study explained further
that intensive care nurses perceive force exertionand dynamic loads as high. Force exertion isdefined in this study as ‘‘lifting, pushing andpulling, carrying, forceful movements with arms,
high physical exertion, lifting with loads above thechest, lifting with bad grip, lifting with very heavyloads, short force exertion, or exerting great force
in hands.’’ Dynamic load is described as ‘‘trunkmovements, movements of the neck, shoulders or
wrists, reaching, make sudden and/or unexpectedmovements, pinching, working under, at or aboveshoulder level’’ [1].
Ergonomic environments predictive of lowback complaints is consistent with feedbackfrom nurses and can be seen by analyzing theuse of technology in critical care environments.
The reasons for these challenges are because notall units have the same patient population andrequire the same patient handling tasks. Types of
transfers vary and dependent on the needs ofpatient populations. For example, in nursinghomes, the demand for lateral transfers is greater
than in critical care units, because of the medicalconditions of critical care patients. The medicalstatus of patients is a determining factor inconsidering which type of equipment should be
used to perform patient transfers. Types of trans-fers typically performed in critical care units varybut most include the following high-risk tasks:
Lateral transfersRepositioning patients up or side to side in bed
Bed-to-chair or -wheelchair transfersPericare of bariatric patientsToileting in bed
Sustained limb holding for dressing woundsPatient transport
Lateral transfers
Lateral transfers can be a physically demand-ing task performed by nursing staff. Because ofthe frequency of this task, technological solutionsoffer a means to perform this labor-intensive task
with little or no impact on patients or caregivers.Lateral transfers can be performed more safelyE-mail address: [email protected]
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.011 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 177–186
through use of mechanical lateral transfer devices,ceiling lifts, air-assisted devices, and friction-reducing devices (FRDs).
Mechanical lateral transfer devices
There are many technological solutions for
performing lateral patient transfers safely, butunfortunately many caregivers still do this taskmanually, subjecting themselves and patients to
risk for being injured. The best, most preferablesolution to making lateral transfers safer is via theuse of an engineering solution, such as using
a mechanical device, such as a ceiling lift ormechanical lateral transfer aid. Both of thesetechnologies diminish the manual labor typicallyused by caregivers in such a task.
The mechanical lateral transfer device consistsof a rod that is rolled into a sheet and powered.Patients lie on this sheet and two retractable
straps are attached from the base unit to the rodin the sheet. Pressing a button on the base unit’scontrol panel retracts the straps, thus pulling
patients across to the destination surface withoutcaregivers moving patients manually. Fig. 1depicts the use of this type of mechanical lateral
device.
Ceiling lifts
An alternate solution to accomplish lateraltransfers is via use of a ceiling lift with a supinesling (Fig. 2). Ceiling lift systems function by
using an overhead track, which is mounted to
the ceiling. The track typically is positioned overa patients’ bed but may extend into the washroomif needed. There are two types of tracks: a single-
track design allows the lift to run along that ded-icated track only, whereas an X-Y track allowsmore versatility as two tracks intersect, permittingthe lift to change directions and allowing more
coverage in the room or bathroom.If a ceiling lift is used for a lateral transfer, the
track has to be perpendicular to the direction of
the bed or stretcher to safely move a patienthorizontally. In this case, a supine sling or slingcovering the length of the entire body is placed
under the patient while the subject is lying ona bed or stretcher. The patient then is elevated offthe bed, using the ceiling lift, then moved across tothe destination surface and then lowered. Care-
givers’ manual work is reduced drastically duringthe lateral transfer using this method. Thismethod still requires caregivers to position the
sling manually under a patient, however, whichstill is a physically demanding task. There needs tobe solutions that eliminate sling insertion and
removal, because these two tasks are deemedhigh-risk tasks. One might ask, ‘‘Why not leavethe sling under the patient?’’ Although there is no
evidence or literature on leaving slings underpatients, the following questions need to beconsidered:
Does the patient have compromised or thinskin?
How breathable is the material of the sling?
Fig. 1. Mechanical lateral transfer device. (Courtesy of VISN 8 Patient Safety Center of Inquiry, Tampa FL; with
permission.)
178 BAPTISTE
Does the sling present rough, uneven edgesthat can produce pressure points on thepatient?
Can the sling be left under a patient and tuckedinto the mattress when not in use?
Currently, manufacturers are working on ex-panding the types of slings that can be left underpatients to address these questions.
Air-assisted devices
If there is no mechanical solution (lift systemor mechanical aid) available, then the next best
choice to perform a lateral transfer of critical carepatients is the use of an air-assisted device. Thesesystems are composed of special mattresses, which
have no weight limit, often are radiolucent, andare constructed with material that offers reducedfriction during a transfer. The system consists of
a portable electric air pump, a hose, and aninflatable mattress. Air is pumped into the mat-tress via the hose by pressing a button. Oncea mattress is filled with air, patients (lying on the
mattress) can be pulled onto the destinationsurface with little effort. The reduced effort isdue to the holes underneath the mattress, which
allow air to escape, and in doing so, providea reduction of friction between the underside ofthe mattress and the bed.
Air-assisted devices were rated most preferablein a study in critical care units where eight deviceswere evaluated for lateral transfers. Caregivers
reported that the air-assisted products were best inoverall comfort, ease of use, effectiveness inreducing injuries, time efficiency, and patientsafety [2]. Because of the lack of weight restric-
tions, caregivers may be more likely to use theseproducts than others in transferring heavierpatients.
Friction-reducing devices
These products offer a remarkable, low-costsolution to performing lateral transfers when thepreceding two solutions are not possible. The
primary purpose of FRDs is to transfer patientsfrom bed to stretcher. These products also areused, however, to reposition patients up or side to
side in bed. The size, shape, and function of theseproducts determine how well they can performa transfer. For example, a FRD designed forlateral transfers may be able to reposition patients
in a chair but may not perform this task wellbecause of the physical length of the device. Whenpatients are pulled up in a chair, they slide back
down if the FRD is not removed quickly becauseof the low friction of the material. It is importantthat each product is used in its intended way to
promote and maintain safety for all participantsinvolved during transfer tasks.
FRDs are made from a slippery-type materialthat reduces friction, making it easier to move
patients. Some products are made with twoseparate sheets, where one slides over the other,whereas others are designed with one tubular
piece of material that rolls over itself. Some ofthese devices have handles or extended pull strapsmaking gripping easier and reducing reaching,
respectively. FRDs with extended pull straps areproved effective in reducing the biomechanicalstress at the low back, thus reducing the risk for
injury [3].Significant factors that affect the performance
of a lateral transfer device are caregiver andpatient characteristics, device design and features,
and organizational and environmental factors.
Repositioning
Repositioning patients up in bed
Ceiling lifts predominantly are used for verticaltransfers (bed to chair) in long-term care facilities;however, in critical care, there is a greater need to
reposition patients up in bed or turn them on theirside. Fig. 3 indicates the typical posture used bycaregivers who have to move patients up in bed
Fig 2. Ceiling. lift track. (Courtesy of Liko, Franklin,
MA; with permission.)
179TECHNOLOGY SOLUTIONS IN CRITICAL CARE
manually without any assistive devices. As seen in
this illustration, caregivers use a forward bentposition at the waist, the shoulders are extended,and the wrists are under the armpits of the
patient. This constitutes a poor posture and placescaregivers at a risk for potentially injuring theirwrists, shoulders, low back, or neck.
Fortunately, there are several technologicalsolutions to assist in the task of repositioningpatients up in bed. The first solution involves use
of repositioning aids.Repositioning patients in bed can be
performed safer and more efficiently by use ofthese aids. These devices vary in style, size, and
function. Some are made of a material that hasfriction-reducing properties to allow caregivers toslide patients up in bed easily. Some devices have
the ability to engage a specific area on the sheetitself to introduce friction and prevent patientsfrom sliding back down.
Another type of repositioning device is onethat attaches to a hospital bed. A sheet is fed froma roller at the foot of a bed to a roller at the headof a bed. A caregiver turns a handle manually,
which activates the roller, and moves the patientto the head of the bed. The handle can bedetached from the head end and reattached to
the foot end to facilitate repositioning in theopposite direction if needed (Fig. 4).
The benefit of using repositioning aids can be
seen in a study by Collins and colleagues [4];friction-reducing sheets were used to repositionpatients in bed. There is evidence showing that
use of such devices can reduce musculoskeletal
injuries associated with patient handling tasks.The purpose of this study was to test the effectof a best practices program, which involved use
of patient handling equipment, on staff injuries,workers’ compensation costs, and lost workdayinjuries. The study found that a best practices
musculoskeletal injury prevention program con-sisting of mechanical lifts and repositioning aids,a zero lift policy, and employee training on lift
usage significantly reduced resident handlinginjury incidence, workers’ compensation costs,and lost workday injuries after the intervention.
For further information on repositioning
devices, refer to the Web site, http://www.visn8.med.va.gov/patientsafetycenter/resguide/TechnologyResourceGuide.doc#RepositioningDevices [5].
Fig. 3. Manual repositioning of a patient up in bed. (Courtesy of VISN 8 Patient Safety Center of Inquiry, Tampa FL;
with permission.)
Fig. 4. Repositioning device on bed. (Courtesy of EZ
Way, Inc., Clarinda, IA; with permission.)
180 BAPTISTE
This link describes supine repositioning devices andthose used for repositioning patients in sitting.
Repositioning patients on the side
Technological solutions continue to improveand expand as health care manufacturers realizethat the manual effort of caregivers needs to be
eliminated. This realization is evident in a reposi-tioning product, which can replace or work witha bed sheet as it is placed under a patient and can
remain there when not in use. This sheet can beused to turn or move patients up in bed. Thesetwo tasks are accomplished by using an overheadceiling lift system and an appropriate spreader
bar. There are two versions available, one thataccommodates up to 440 lb and another forlarger, bariatric patients (up to 1100 lb). If the
latter sheet is used, it is essential that the lift usedhas the capacity to accommodate up to the sameweight as the sheet. Fig. 5 shows an example of
a repositioning sheet used for turning patients inbed.
Changing the type of lift, sling, and spreader
bar is another way to move patients up in bed oron their side. Fig. 6 shows a supine sling in
conjunction with a floor-based lift that is used tolift patients up off of a stretcher.
To accommodate turning patients to the side,the boom of the floor-based lift has to be high
enough to accomplish turning.Another mechanical device used to make this
task of repositioning in bed easier is the use of
a ceiling lift in conjunction with a supine sling. Byusing the mechanical lifts (floor based or ceilinglift), caregivers do not have to exert any effort
manually except to place a sling under a patient.Sling insertion and removal is a high-risk taskelement for caregivers and research is lacking in
this area. These forces affect the upper body joints(wrists, elbows, and shoulders) and neck, inaddition to caregivers using an awkward posture,which in turn, affects the low back negatively.
Mechanical equipment should be used if avail-able, as it can assist greatly in reducing injuries forcaregivers during the various repositioning tasks.
Use of such equipment also benefits patients,because there is no dragging or pulling of patientsmanually on a bed sheet to the head of a bed or
across to the side of a bed. As a result, frictionalforces are eliminated, which protects the skinintegrity of patients.
McGill and Kavcic [6], in 2006, looked at theeffect of a friction-reducing assistive device onlow back mechanics. They quantified and com-pared three lateral transfer devices by measuring
the coefficient of friction, muscle activity of care-givers, and spinal loading during the lateral trans-fer. Results showed that during a lateral transfer
of a mannequin (72.7 kg) on a cotton sheet, thecoefficient of friction was 0.45. In comparison tothis standard condition, the three assistive devices
reduced the coefficient of friction to 0.18 to 0.21.Consequently, there is evidence to prove the ben-efit of using FRDs for caregivers and for patients.
Frictional force studies are lacking and there
needs to be more research regarding the effect oftransferring patients manually across surfaces andthe direct impact on patients’ skin, especially
concerning pressure ulcers.
Bed-to-chair transfers
One transfer task common to critical care unitsis bed-to-chair transfers or vertical transfers.Moving patients who have been in bed for
a prolonged period of time from a lying position(bed) to a seated position in a chair can bea difficult task. This in part is because of the
Fig. 5. Repositioning sheet used for turning a patient.
(Courtesy of Liko; Franklin, MA; with permission.)
181TECHNOLOGY SOLUTIONS IN CRITICAL CARE
awkward posture used by caregivers and the
mass of the patients. This type of transfer can beunpredictable, as the functional strength andmobility of such patients is poor, as they usually
are weak from inactivity. There are severalsolutions, however, to making this transitioneasier. The ideal way is to eliminate the manual
work of this task by using a mechanical liftsystem.
The choice of lift used is dependent on
patients’ level of assistance, weight-bearing capa-bility, physical condition, level of cooperation,and comprehension.
For bed-to-chair transfers, three solutions are
offered: floor-based lifts, ceiling lifts, and sit-to-stand lifts.
Floor-based lifts
Floor-based lifts have served well in reducing
caregiver effort in transferring patients from bedto chair or vice versa. The original floor-based liftworked by activating a pump manually, which
raised and lowered a boom arm while the legs ofthe lift also were operated manually by a lever.These lifts have been replaced by electric floor-
based lifts, which operate by pressing a button
that elevates and lowers the boom and opens andcloses the legs. To transfer patients from a bed toa chair, caregivers apply a sling (appropriate for
the patients) while patients are lying in bed.Patients are log rolled and the sling is insertedunder them, the legs on the lift are opened for
stability, and the boom then lowered enough toattach the sling to the spreader bar. Patients areraised off the bed by pressing a button on the
control panel. The lift then is moved over a chairand patients then lowered. Once patients arepositioned properly in the chair, the sling then isremoved.
Floor-based lifts are useful in critical care forbed-to-chair transfers, picking patients up fromfloor level, and lifting a limb for a sustained
period of time when performing wound dressingchanges.
Ceiling lifts
The second solution to bed-to-chair transfers is
the use of a ceiling lift (discussed previously). Thesteps for transferring patients via a ceiling lift aresimilar to using a floor-based lift, except that the
Fig. 6. Supine sling with floor-based lift. (Courtesy of Arjo; Roselle, IN; with permission)
182 BAPTISTE
ceiling lift is the existing infrastructure hangingabove on the rail. A sling is inserted undera patient, the lift is lowered, and the sling isattached. Then, a caregiver presses a button and
the patient is raised, guided on the track, and thenpositioned over the chair. The caregiver thenlowers the patient into the chair and the sling is
removed.
Sit-to-stand lifts
Sit-to-stand lifts are useful provided patientsmeet the criteria for using such a lift. Patients
should be able to weight bear partially, under-stand and follow simple commands, and holdonto the handles of a lift. This type of lift can be
used in rehabilitation when teaching someonehow to transfer from sitting to standing. Usinga sit-to-stand lift requires some leg and arm
strength from patients but support still is providedin the event of patients losing their balance. A sit-to-stand lift works by attaching a sling aroundpatients’ back and waist, then placing their legs on
a stand while they are sitting on the edge of thechair or bed. A caregiver then presses a button toraise a patient up off the chair or bed and into
a standing position. The patient is moved to thedestination surface and lowered by pressing a but-ton on the lift, and the sling then is removed from
the patient. Sling insertion and removal remaina challenge and efforts are being made to designslings that can be left under patients withoutcompromising patients’ sling integrity or increas-
ing their risk for developing or aggravatingexisting pressure ulcers.
Pericare of bariatric patients
Pericare of obese patients presents a challenge
because of the amount and weight of redundanttissue, weight, and size of patients’ legs and thedifficult access of perineal area. Currently,pericare is performed manually after bowel move-
ments and urination and for patients who haveindwelling catheters. Pericare can be accom-plished without turning patients by spreading
apart the legs of patients for access to the genitalarea. This task requires caregivers to lean overa bed for a sustained period of time while moving
redundant tissue to gain access and provide theability to clean the genitals. This task can bemade easier with use of an abdominal binder,
limb straps, and an expanded capacity ceiling liftsystem.
Abdominal binders can be used to hold someof the redundant tissue from the leg together more
compactly, thus providing easier access to thegenitals. Limb straps can be attached to the ceilinglift, to lift and separate the legs and hold them in
a sustained position while a caregiver cleans thegenitals. This solution eliminates lifting and hold-ing of a heavy leg for a long period of time and
allows caregivers to concentrate on cleaningpatients more effectively and comfortably.
Another approach to this problem is using
a floor-based lift. The advantage of using a ceilinglift is that there is no storage needed for this lift, asit is stored on the track overhead. The process ofusing a floor-based lift is the same as discussed
previously except that the limb straps are con-nected to the floor-based lift versus the ceiling lift.
Toileting in bed
In critical care units, patients present a wide
array of dependency levels. If patients need totoilet and are able to lift their buttocks, caregiversslide a bedpan under patients’ buttocks. If
patients are unable to turn independently, care-givers turn patients to the side manually, thenplace a bedpan in position and turn patients backonto a bedpan with knees slightly bent. Once
toileting is complete, caregivers have to turnpatients on their side to clean them while ensuringbedpans do not spill. After toileting is completed,
patients are turned back to the supine position.The physical effort needed to turn dependentpatients manually makes this a high-risk task.
The manual turning involved in this task can beeliminated by using an overhead ceiling lift withturning straps. Straps are positioned under the
heaviest parts of a patient, typically the torso andupper legs. The straps used should be wide enoughso they do not cut into patients’ skin. Once inplace, these straps are attached to a ceiling lift via
a spreader bar. The ceiling lift is used to raise andlower patients in preparation for toileting. Oncepatients finish their bowel movement, the lift is
raised and bedpan removed. Caregivers shouldnot have to move the straps to access the genitalsto clean patients because of properly placing the
straps of the correct width beforehand. Straps areavailable in various widths and can accommodateup to 1000 lb. It is important that patients’ weight
183TECHNOLOGY SOLUTIONS IN CRITICAL CARE
does not exceed the capability and weight limit ofthe straps or the ceiling lift.
Sustained limb holding for dressing wounds
The sixth high-risk task discussed in this articleis holding a heavy limb for a sustained period of
time while dressing a wound. This task is consid-ered a high-risk task for many reasons. Some ofthese include the weight of the limb, position of
a caregiver’s hand while gripping that limb, andthe posture of caregivers during this task.Typically, caregivers bend at the waist, leaningover the bed, extending one arm to hold the limb,
and using the other hand to clean the wound andapply a dressing.
A preferable, alternate solution to assist care-
givers in sustained limb holding for dressingwounds is the use of limb straps with a ceilinglift system or floor-based lift (Fig. 7).
As shown in Fig. 7, a special sling used forholding limbs is placed under a patient’s leg andattached to a lift to suspend the leg in place.
This task can be accomplished with the use ofa floor-based lift or a ceiling lift. The benefit ofusing these special straps is that they are availablein different widths, and proper placement of the
straps on the affected limb can allow easier accessto dress a wound. The advantage of using eitherlift (ceiling or floor based) is that the weight of
the limb is held by the lift, which allows caregiversto use both hands, if needed, to take care ofpatients.
To illustrate the physical demands placed onsomeone holding a leg for a period of time, a study
was conducted simulating this task. This researchstudy was conducted in the biomechanics labora-tory at the VISN 8 Patient Safety Center of
Inquiry (James A. Haley Veterans’ Hospital) andevaluated the physical demands of patient transfertasks performed by nurses in a controlled labora-tory setting. Fifty-three tasks were analyzed and
broken down into subtasks to quantify the peakforce required to perform each subtask. One ofthese tasks was limb holding for a sustained
period of time. A 200-lb mannequin was used tosimulate a dependent patient. The anthropometryand weight of the mannequin’s limbs were compa-
rable to that of a human being. Results indicatedthat the amount of force required to lift and holdone leg is comparable to the force needed to pulla draw sheet through from under a patient (200
lb) who is lying on the side. In addition, use ofa ceiling lift device to raise and let down the lowerleg requires significantly less force than the force
needed to perform this task manually. These find-ings indicate the benefit of using a floor-based liftor ceiling lift to suspend a limb and avoid manual
limb holding. Use of such technologies shouldresult in less strain on the upper body joints, im-proved posture in the low back, and reduced
risk for injury to caregivers.
Patient transport
The last high-risk task in critical care does notinvolve handling patients directly but is related to
patient movement. Transport of patients hasbeen and continues to be a difficult task physi-cally because of the push forces required (weight
of transport vehicles plus patients), the workingcondition (steering, castors, and brakes) trans-port devices (beds or stretchers), and confined
spaces in transport routes. The excessive load inaddition to the frequency of the task and postureused by transporters all contribute to an in-
creased risk for injury. To alleviate the physicaldemands of this task, many facilities have startedusing powered transport technologies. Thesedevices are available commercially in different
types.The first type is a stand-alone, detachable, or
independent device that attaches to a bed, linen
cart, or trolley (Fig. 8). Once the unit is attachedsecurely to a bed or object to be powered, anoperator is able to move and steer the device.
A bed mover is powered by batteries andenables the device to move forward or backward.These devices have a wide range of weight
Fig. 7. Limb sling for dressing wounds. (Courtesy of
Liko, Franklin, MA; with permission.)
184 BAPTISTE
capacities (up to 2500 lb). The disadvantage ofusing such a device is that it may not fit into theelevator when attached to a bed, so careful
measurements and planning should be takenbefore purchase. The advantage of using a detach-able, powered device, however, is that it can be
attached to many items, such as linen carts,trolleys, or beds. The cost of these detachableunits is cheaper than the alternate type of powered
technology that is integrated into beds.The second type of transport technology is one
that is incorporated into beds and powers them byunplugging a bed, releasing the brakes, and
pressing two buttons. Use of powered transportdevices is beneficial especially when movingheavier patients, because there is minimal force
exerted to initiate movement of a bed.Another type of patient transport device is
a powered wheelchair mover. This device (Fig. 9)
is designed to be attached to a standard manualwheelchair via a securing hitch. Once connected,a caregiver is able to operate and steer the deviceby toggling a lever. This powered wheelchair
mover has two variable speeds and an emergencystop button.
Use of these powered transport devices is
becoming popular in health care facilities, asthey reduce the risk for caregiver injury. Todate, there is no literature found regarding the
use and benefit of patient transport technologies.Currently, a research team at the VISN 8 PatientSafety Center of Inquiry (James A. Haley Vet-
erans’ Hospital) is conducting a laboratory study
to quantify the push forces required when usingoccupied beds and wheelchairs manually on differ-ent surfaces. This evaluation is designed to com-
pare the biomechanical factors required toperform transport tasks manually versus usingpowered devices (described previously). Patient
Fig. 8. Powered bed mover. (Courtesy of Ergotech, Danbury, CT; with permission)
Fig. 9. Wheelchair mover. (Courtesy of Dane Industries,
Minneapolis, MN; with permission.)
185TECHNOLOGY SOLUTIONS IN CRITICAL CARE
transport can be made safer for caregiversthrough the proper use of powered patient trans-port technologies.
Summary
There are several high-risk nursing tasks in the
critical care environment discussed in this article.These tasks include lateral transfers, repositioningpatients up or side to side in bed, bed-to-chair
or -wheelchair transfers, pericare of bariatricpatients, toileting in bed, sustained limb holdingfor dressing wounds, and patient transport. Thereare, however, technological solutions available to
perform these tasks more safely. Evidence-basedresearch currently is in development to prove thatpatient handling technology works for suggested
high-risk tasks. Although there are few studiesthat currently provide objective data regardinguse of technology in reducing caregiver injuries,
the aforementioned patient handling equipment ispromising. There are reports of improved jobsatisfaction and employee morale among health
care staff when using these technologies. Usingthese technologies properly is the only true way torealize the benefits these devices provide. Techno-logical solutions are available and should be
implemented in critical care to promote the safetyof all involved in patient care.
References
[1] Bos E, Krol B, van der Star L, et al. Risk factors and
musculoskeletal complaints in on-specialized nurses,
IC nurses, operation room nurses and x-ray technol-
ogists. Int Arch Occup Environ Health 2007;80(3):
198–206 [E-published ahead of print, 2006 June 24].
[2] Baptiste A, Boda S, NelsonA, et al. Friction-reducing
devices for lateral patient transfers: a clinical evalua-
tion. AAOHN J 2006;54(4):173–80.
[3] Lloyd J, Baptiste A. Friction-reducing devices for lat-
eral patient transfers-a biomechanical evaluation.
AAOHN J 2006;54(4):113–9.
[4] Collins JW,Wolf L, Bell J, et al. An evaluation of best
practices musculoskeletal injury prevention program
in nursing homes. Inj Prev 2004;10:206–11.
[5] Department of Veterans Affairs (VHA). Technology
resource guide. Accessed August 31, 2006. Available
at: http://www.visn8.med.va.gov/patientsafetycenter/
resguide/TechnologyResourceGuide.doc#Reposition
ingDevices.
[6] McGill SM, Kavcic NS. Transfer of the horizontal
patient: the effect of a friction reducing assistive de-
vice on low back mechanics. Ergonomics 2006;48(8):
915–29.
186 BAPTISTE
Justification for a Minimal Lift Programin Critical Care
Arun Garg, PhD, CPEa,*, Suzanna Milholland, MS, OTRb,Gwen Deckow-Schaefer, MS, OTRb, Jay M. Kapellusch, MSbaCenter for Ergonomics Industrial & Manufacturing Engineering University of Wisconsin-Milwaukee,
P.O. Box 784, Milwaukee, WI 53211, USAbIndustrial & Manufacturing Engineering University of Wisconsin-Milwaukee,
P.O. Box 784, Milwaukee, WI 53211, USA
Back and shoulder injuries are a major and
serious problem for nursing personnel in all areasof patient care, including hospitals, long-termcare, and home health care. According to the
Bureau of Labor and Statistics [1,2] nursing assis-tants led all other occupations in overexertion in-juries in the United States in 1993. The rate of
overexertion injuries among nursing assistantswas four times higher than the average rate forall other private industries. This overexertionrate continued to be four times higher through
1995. In 1995, the Bureau of Labor and Statistics[3], reported home health care workers’ injuryrates that were double, and hospital health care
workers’ injury rates were nearly double that ofinjury rates in private industry. In 2000, the Bu-reau of Labor and Statistics [4] reported that the
injury incidence rate for nursing personnel wasthe second highest in the United States for nonfa-tal occupational injuries. Furthermore, these in-
juries were severe enough to require medicaltreatment or produce lost workdays. With thesehigh injury rates come significant costs. Directcosts including medical treatment, medications,
therapies or surgeries have been estimated torange between $9,000 and $30,000 per injury.One example can be cited by Dunn and De Peralta
[5]. They documented that 17 injuries occurred ona spinal cord unit in 2002 resulting in $162,815.53of direct costs. Meanwhile, the indirect costs
(ie, replacement personnel, training, insurance
premiums) of these injuries are estimated to befour to ten times greater still [5]. These injurieswere all attributed to patient-handling tasks. The
Bureau of Labor and Statistics [4,6], in 2001stated that among full-time hospital workers, in-juries were 8.8 per 100 full-time hours and 13.5
per 100 full-time hours among nursing homeworkers. This compared with all other industrywork injuries and illnesses including rates of 4.0per 100 full-time workers in mining, 7.9 per 100
full-time workers in construction, and 8.1 per100 full-time workers in manufacturing. Nursingaides and orderlies were surpassed only by truck
drivers and nonconstruction laborers when rank-ing lost day injuries [1]. These nursing personnelinjuries do not appear to be isolated to the United
States. The Health and Safety Executive [7] inLondon cited that approximately 70% of work-place injuries involved health care workers associ-
ated with patient-handling tasks [6]. Anotherstudy cited that nurses in Israel ranked first inlow back injury rates compared with most otheroccupations, including light and heavy industry
workers, farmers, bus drivers, and others [7]. InSweden, the National Board of OccupationalSafety and Health reported the highest frequency
of back injuries was among bath attendants andnursing aides [8]. Injuries among nurses arelargely unreported. French and colleagues [9]
sent a questionnaire to 47 nursing personnel inan acute care hospital. They reported that80.9% had back pain at some time during their
* Corresponding author.
E-mail address: [email protected] (A. Garg).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.002 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 187–196
career; however, more than 90% never reportedany back pain to their employer. In 1995 Vasilia-dou and colleagues [10] conducted the first ever
study on prevalence of back pain among Greeknursing personnel. They administered a question-naire to 407 nursing personnel in a tertiary carefacility in Athens. Of the participants, 63% re-
ported work-related low back pain within the pre-vious 2 weeks and 67% within the previous6 months. Prevalence was higher in conjunction
with heavier physical duties. Although it is diffi-cult to directly compare these studies in variouscountries, the statement can be made that all of
the nursing positions were classified as high-riskoccupations for low back injury.
Causes
Although the exact mechanism of injury is notclearly defined, many of the injuries to nursingpersonnel have been attributed to patient-
handling tasks. Overall, many studies cite patientlifting and transferring as the most common causeof back injuries [9–21]. Owen [22] stated that as
many as 89% of low back injury reports filed bynurses in a hospital setting indicated that a pa-tient-handling task was the precipitator of their
injury. Kumar [23] suggests that cumulative loadexposure predisposes the spine to pain or injury.Cumulative spinal loading can be defined in threeways: (1) accumulated demands on the spine dur-
ing a single patient-handling task, (2) additive ef-fects of lifting loads over a workday, or (3)accumulation of loads throughout the lifetime.
Others have added the risk factors of frequentbending, twisting, carrying, and pushing of bedsas contributors to musculoskeletal complaints
[24–26]. Still others have added that forward flex-ion, lateral bending, twisting of the spine, or an in-creased horizontal distance of the load from the
body during lifting further increases the chancesof low back injury [27–29]. A study performedin Hong Kong by French and colleagues [9] notonly cited transferring patients and lifting patients
as two major causes of back pain but also in-cluded the static posture of stooping during vari-ous patient care tasks as contributing to pain.
Others have cited bad work technique or lack oftraining as contributors [30,31]. Hignett and Ri-chardson [32] add that unpredictable patient fac-
tors such as shape and size, disability, andcapacity for compliance may interfere with theuse of safe handling techniques. Many also state
that any previous history of back pain has shownto be a risk for future episodes of back pain[33,34]. It has been noted that nurses perceive
that their low back symptoms were caused by orexacerbated by work [35].
Biomechanical evidence
Garg and colleagues [26,36,37] conducted lab-oratory studies to evaluate five different manualtechniques and three different mechanical hoists
for transferring patients to and from bed to wheel-chair, wheelchair to shower chair, and wheelchairto toilet. Static biomechanical evaluation showed
that estimated compressive forces ranged from1973 N to in excess of 5000 N and shear forcesranged from 442 N to more than 900 N. Thesestudies also reported that less than 40% of female
workers have sufficient muscle strength to per-form manual lifting and transferring tasks evenwhen using two nursing aides. The studies found
that estimated compressive forces exceeded theNational Institute Of Occupational Safety AndHealth (NIOSH) recommended acceptable limit
of 3400 N. The studies also found that use ofa walking belt in combination with a pulling tech-nique, rather than lifting, produced less biome-
chanical and perceived stresses on the nursingpersonnel, and the patients found it to be morecomfortable and secure than the manual lifting.Further, two of the older hoists were perceived
by the nurses to be more stressful than the useof walking belts with pulling technique. Also, pa-tients found the older hoists to be less comfortable
and less secure than the walking belt.Marras and colleagues [38] estimated compres-
sive and sheer forces on the low back using an
electromyograph-assisted biomechanical modelfor transferring a 50-kg, non-weight–bearing co-operative woman. They also studied the probabil-
ity of membership in the high-risk low-back group(LBD) by using a lumbar motion monitor. Thepatient transfer tasks studied were transfers be-tween bed and wheelchair and between toilet chair
and hospital chair. The estimated compressiveforces ranged from 4463 N to 6408 N, anterior-posterior shear force ranged from 913 N to 1116
N, and LBD risk ranged from 76.9% 93.8%, de-pending on patient transfer technique used andnumber of nursing personnel involved in the
transfer. The study concluded that patient han-dling is an extremely hazardous job. The task ofpatient handling has substantial risk of causing
188 GARG et al
a low back injury whether one or two nursing per-sonnel are used for patient handling.
Winkelmolen and colleagues [39] studied repo-sitioning patients in bed (moving upwards toward
the head of the bed). Passive patients between55 kg and 75 kg were used to study five differenttechniques (Australian lift, Orthodox lift, barrow
lift, through-arm lift, and under-arm lift). Usinga two-dimensional, static biomechanical model,the estimated compressive force on the low back
ranged from 3315 N to 4003 N for the 55-kg pa-tient and 3869 N to 4487 N for the 75-kg patient.The authors concluded that for almost all trans-
fers, the compressive forces exceeded the NIOSHacceptable limit of 3400 N.
Skotte and colleagues [40] studied low backloading for nine patient-handling tasks including
turning, lifting and repositioning a male strokepatient using a dynamic three-dimensional Biome-chanical model. The main compressive force
ranged from 1618 N to 4433 N, peak anterior-pos-terior shear force ranged from 106 N to 661 N,and ratings of perceived exertion on the Borg
CR-10 scale ranged from 0 to 8. The study con-cluded that the peak compression during twotasks involving lifting the patient was significantly
higher than all other tasks. The four tasks involv-ing repositioning the patient in bed had lowerpeak compression than the two tasks involvinglifting the patient. The task involving turning the
patient in the bed had the lowest compressiveforce. The study further concluded that, basedon peak compressive force or peak moment on
the low back, the patient-handling tasks can beclassified into three groups: (1) lifting tasks, (2)repositioning tasks, and (3) turning tasks.
Ulin and colleagues [41] studied six differentpatient transfer methods, three manual and threemechanical, to transfer two totally dependent pa-tients weighing 56 kg and 95 kg, respectively. The
study concluded that peak compressive forceswere greater than 10,000 N for manual transfermethods, exceeding the NIOSH maximum limit
of 6400 N. When mechanical lifts were used, theback compressive forces ranged from 437 N to719 N, well below the NIOSH recommended limit
of 3400 N. The study reinforced the need to usea mechanical lifting device when transferringtotally dependent patients.
A preliminary study by Lloyd and Baptiste[42], working to develop new patient transfer tech-nologies, reported that initial push and pull forcesrequired to manually transport an unoccupied
hospital bed over a smooth flat surface were
146 N and 134 N, respectively, whereas an occu-pied bed required push and pull forces of 189 Nand 196 N. The forces encountered over a thresh-old, such as the opening of an elevator, for an
empty bed were 151 N and for an occupied bedwere 198 N. Hospital beds found in medical-surgical units are typically heavier and require
more transport. Therefore, the investigators statethat forces required to transport these types ofbeds come close to or exceed strength capabilities
of most female workers.Zhuang and colleagues [43] conducted a biome-
chanical evaluation of nine battery-powered lifts,
a sliding board, a walking belt, and a manualmethod for transferring nursing home patientsfrom a bed to a chair. The study concluded thattransfer method and patient weight affect a nurs-
ing assistant’s low back loading. The use of me-chanical lifts (portable or overhead devices)reduced low back compressive forces by approxi-
mately two thirds compared with the baselinemanual lift method.
Daynard and colleagues [44] reported that use
of new assistive equipment resulted in higher com-pliance with interventions. This was particularlytrue when the perceived risk of injury during pa-
tient handling increased because of an increasein patient size or a reduction in patient physicalcapability. The study found that use of new assis-tive handling equipment reduced spinal loading in
several tasks.Several other studies have confirmed that
patient-handling tasks result in high compressive
forces on the low back [43,45–51]. Consideringthese and other biomechanical studies collectively,it appears that patient-handling tasks requiring
a vertical lift produce the highest compressiveforces on the low back, followed by patient-handling tasks that require repositioning patientsin a bed or lateral transfers; whereas, turning pa-
tients in bed produces the least amount of com-pressive force on the low back.
Nursing personnel perception
Insufficient staffing of nursing units can con-tribute to work overload, which, in several stud-
ies, has been reported to contribute to feelings ofstress among nursing personnel [52,53]. Cato andcolleagues [52] reported that 73% of nurses with
low back problems reported feeling overly stressedat work compared with those nurses without lowback problems. Ore [54] reported that 35% of
189JUSTIFICATION FOR A MINIMAL LIFT PROGRAM
nurses responding to a questionnaire consideredchanging jobs related to their idea that low staff-ing levels would contribute to a higher risk of in-
jury caused by patient-handling tasks. Along theselines, a study by Yassi and colleagues [51] foundthat overly stressed staff perceived the inabilityto obtain and use correct assistive lifting equip-
ment because of time constraints. Yet anotherstudy by Yassi and colleagues [19] found thatnursing personnel with low back injuries perceived
that the cause of their injuries was inadequatetraining in patient-handling techniques. Job satis-faction is another factor that may predict low
back health according to a prospective study byReady and colleagues [55].
Perceived stresses
Many studies have found that nurses ratedperceived stresses on the low back and shoulder ashigh during patient lifting and repositioning tasks
[56,57]. Winkelmolen and colleagues [39] studiedperceived stresses for repositioning patientsweighing 55 kg and 75 kg in bed. The perceived
stresses on the Borg scale (rating scale of 6-20)ranged from 13 (somewhat hard) to 19 (extremelyhard). The perceived comfort ratings ranged from
3.3 to 4.3 on a six-point scale (rating scale of 0-5).Studies addressing nurses’ perceived stresses werealso conducted by Owen and colleagues [57,58]and Garg and Owen [56]. In all studies, nursing
personnel using assistive devices reported de-creases in perceived physical exertion to the shoul-der and low back during performance of all
patient-handling tasks. Yet another study byGarg and colleagues [36] showed that perceivedstress ratings for the whole body, including shoul-
der and upper and lower back, were lower for pa-tient-handling techniques based on pullingmethods rather than lifting methods. Owen and
Fragala [59] found similar results of decreases inperceived exertion during a specific transfer taskthat involved a pulling rather than lifting motion.
Yassi and colleagues [51] conducted a study in-
volving nursing personnel on medical, surgical,and rehabilitation units. Each unit was assignedto one arm of the study. One unit served as the
control group and received instruction in bodymechanics and lifting only on request. The ‘‘safelifting’’ unit was supplied with transfer belts in
each room and one mechanical lift for the unit.The ‘‘no strenuous lifting’’ program unit receivednew assistive equipment for patient-handling
tasks. The equipment was supplied based on theneeds of the patient population on the unit.Both the ‘‘safe lifting’’ and ‘‘no strenuous lifting’’
units were also given education on back care andhandling techniques in addition to training in theuse of assistive devices. Perceptions improved inboth the ‘‘safe lifting’’ and ‘‘no strenuous lifting’’
units, including perceptions of work fatigue, backand shoulder pain, safety, and frequency and in-tensity of physical discomfort. However, the nurs-
ing personnel on the ‘‘no strenuous lifting’’ unitshowed greater improvement.
Education and training
Historically the approach to decreasing lowback injuries in nursing personnel has been toprovide education and training in body mechanics
and lifting or transferring techniques [33,51,60,61]. A few studies have shown a decrease incompressive force on the low back with the proper
use of training and correct body mechanics[44,62]. However, manual patient-handling tasksare intrinsically so hazardous that no amount of
training alone can make the job safe. Also thecompliance with use of proper body mechanicsand techniques is lower when relying on education
and training alone [44,63]. Pheasant and Stubbs[64] showed that there was an initial reduction inback injury occurrence immediately after propertraining in patient-handling techniques; however,
this effect only lasted 18 months before the injuryrate climbed back to the original level.
There has been evidence to suggest that edu-
cation and training alone, without work modifi-cations, does not decrease the number ofoccupational low back injuries [33,56,65–72]. La-
gerstrom and Hagberg [60] conducted an educa-tion program for nursing personnel includingtraining on transfer technique, physical fitness
and exercise, and stress management techniquesover a 3-year period in a Swedish hospital. Al-though most participants expected that participa-tion in this program would lead to a decrease in
injuries, the results did not show any decrease inneck, shoulder, or back symptoms. Videman andcolleagues [33] compared nurses that did and did
not participate in an extensive training programand their incidence of low back pain. Similarly,the investigators found no significant differences
in occurrence of low back injury between groups.In summary, ‘‘although instruction on manuallifting and transferring patients is widely believed
190 GARG et al
to have prophylactic value, there is no scientificevidence that it alone is effective in reducing thefrequency or severity of back pain, especially innursing practice’’ [56].
Intervention programs
The focus of education and training programs
has been to change the way nursing personnelperform the task instead of changing the task itself[57]. As previously discussed, although this ap-
proach has not been able to show a reduction of oc-currence in lowback injury, an ergonomic approachto patient handling has shown success [58,61,
73–75]. In an ergonomic approach to patient han-dling the physical demands of the job are assessedand then changed to decrease the risk factors thatmay contribute to low back or shoulder injuries.
The changes to decrease the risk of injury are metby developing alternate methods of performingtasks todecrease stresses to thebodyand thenapply-
ing them to the job through education and training.Owen and colleagues [57] conducted a 5-year
follow-up study on nursing personnel after train-
ing and incorporation of several assistive liftingdevices in one of two hospitals. The second hospi-tal served as a control and the personnel were
given only a 1-hour in-service on proper liftingtechniques. By introducing the assistive devices,in effect, the physical job demands were changed.This study also showed a postintervention de-
crease of back injuries of 40%. This study con-firmed results found earlier in a study by Gargand Owen [56] conducted in a long-term care facil-
ity. Compressive force on the low back andstrength requirements were significantly decreasedwith the introduction of lifting devices, making
the job of patient-handling tasks safe for 83% offemale workers versus only 41% before interven-tion. Furthermore, lost work days also decreased
significantly showing a decrease in severity ofinjury.
Silverstein [61] stated that, with a systematicand thorough approach to initiating zero lift pro-
grams in nursing homes, decreases in injuriescould be seen for nursing personnel and patientsalike. This is with the caveat of engaging manage-
ment commitment through the entire process.Klebenow and colleagues [74] also showed a de-crease in number and severity of injuries with
the institution of a minimal lift program in a hos-pital setting and long-term care facility. The au-thors also reported positive by-products of an
improved safety image to the public, an increasein productivity, and an increase in recruitmentand retention of nursing personnel.
Collins [76] reported on a long-term study in-
stituting a minimal lift program in six long-termcare facilities. Results showed that low back in-juries caused by patient lifting and transferring
decreased steadily after implementation of theprogram from 47 injuries immediately after inter-vention to 16 injuries after 5 years of the program.
Severity of injury was also reduced as the lostwork days decreased from 488 before interventionto 229 after intervention. Injuries caused by trans-
fers in and out of bed, and during toileting andpicking patients off the floor were reduced by50%. Injuries caused by turning or rolling resi-dents in bed were also reduced by 50%. A 35%
reduction was seen in injuries attributed torepositioning patients in bed. Worker’s Compen-sation costs were decreased by approximately
50% over the same follow-up period.Evanoff and colleagues [77] introduced me-
chanical lifts in acute care hospitals and long-
term care facilities. After training in proper useof the assistive devices, the follow-up period lastedapproximately 3 years. Within that time period,
the results showed a decrease in musculoskeletalinjuries and lost workdays caused by injury. In-jury reduction was greater in long-term care facil-ities compared with acute care hospitals. Also,
injury reduction was greater on nursing unitsthat reported more consistent use of the assistivelifting equipment. Another implementation of
a ‘‘no lifting’’ standard in England reiterated theprevious study findings in that there was reductionof injuries and lost work days after introduction
of assistive devices on the nursing wards [78].Others have suggested that the development of
a lift team responsible for all patient handlingwith proper mechanical assists reduces low back
injuries [72,79,80]. Donaldson [80] conducteda study in acute, subacute, and extended care unitsof a 296-bed hospital. Acute care consisted of
telemetry, medical-surgical, intensive care, andoncology units. Low back injuries and Workers’Compensation costs for nursing personnel showed
significant decreases over the 6.5 years after the in-stitution of the lift team. Similarly, Charney [79]found that during a 1-year follow-up to the lift
team program, although the team performed3,188 lifts, there was only one injury reportedwith no lost time for the team members. Twomodified duty days were reported for that specific
injury. This substantially decreased injury costs.
191JUSTIFICATION FOR A MINIMAL LIFT PROGRAM
Critical care
Although there has been an abundance ofresearch in the area of physical stresses from
patient handling in hospitals and long-term carefacilities, there is virtually no published literaturedealing with stresses to nursing personnel incritical care settings. Based on informal discus-
sions with nurses and other operating roompersonnel, several observations were made. Theseare discussed below.
Patients require critical care in operatingrooms for preoperative preparation and duringperioperative and postoperative care. They re-
quire critical care in emergency rooms, intensivecare areas, cardiac care areas, and on many otherhospital units. Lifting and repositioning patientsto and from hospital bed, to and from an
operating room bed, on and off stretchers, andin and out of cardiac chairs, are frequent occur-rences. Patients are transferred from stretchers,
transport carts, and beds to operating room tablesand back to stretchers, transport carts, and beds,both before and after surgery. Patients may need
to be transported for medical imaging (eg, com-puted tomography scan, magnetic resonance im-aging, ultrasound scan, x-rays) or any number of
other diagnostic procedures. Nursing personnelface a serious risk of musculoskeletal injuries, inparticular back and shoulder injuries, when han-dling patients in these environments. Some of
these patients are completely dependent becauseof general anesthesia, stroke, or sedation. Theymay be unconscious or comatose and cannot help
during transfer tasks. Nursing personnel, alongwith perioperative team members, are often re-quired to manually lift patients or patients’
extremities.As stated earlier, manual lifting of a normal
patient is considered hazardous to health careworkers. Lifting and handling of patients requir-
ing critical care is an even greater hazard forseveral reasons: (1) these patients often are totallydependent, and their entire body weight must be
lifted; (2) depending on the patient’s injury andillness and type of surgery performed, it may benecessary to maintain a patient in a dependent
position (eg, hips cannot be moved because ofsurgery); and (3) there may be equipment attachedto the patient such as oxygen, intravenous line,
respirator, catheters, or casts. Some of thesepatients may be obese or bariatric, weighing inexcess of 400 to 500 pounds. For example,a hospital in Milwaukee, Wisconsin is purchasing
specialized beds to care for patients in excess of700 pounds. In addition to lifting the entirepatient weight, certain surgical procedures require
lifting or supporting a limb of the patient fora prolonged period. Depending on the weight ofthe patient and the body posture used, liftinga patient limb could be hazardous to nursing
personnel, producing large compressive forces onthe spine along with the possibility of producinglarge torques on the shoulders. Some limbs of
obese or bariatric patients’ may weigh in excess of50 pounds alone. The Revised NIOSH LiftingEquation [81] recommends a maximum weight of
51 pounds under ideal lifting conditions fora smooth, continuous lift. If a nurse has to reachhorizontally about 20 inches away from the anklesduring lifting, then the recommended weight
limit significantly decreases to approximately25 pounds. Certainly, when reaching for and lift-ing a limb of an obese or bariatric patient, it is
quite likely that the nursing personnel could ex-ceed the recommended weight limit from NIOSH.Further, the recommended weight limit does not
account for holding a limb of the patient for a pro-longed period, which often may be the case duringa surgical or diagnostic procedure. It is well estab-
lished that a person’s ability to hold or supporta weight decreases nonlinearly with an increasein holding time. For example, Garg and col-leagues [82] have shown that endurance time for
holding a weight of 10 pounds or less with onehand is less than 60 seconds. They also showeda significant accumulation of fatigue in the shoul-
der girdle during such a task.A few studies have recognized the high risk
associated with patient-handling tasks in preop-
erative patient-handling tasks. For example Owen[83] identified several high-risk perioperativetasks. Some of these included transferring patientson or off operating room beds, repositioning pa-
tients in operating room beds, lifting and holdingpatients’ extremities, and holding retractors forextended periods. Wicker [84], in the United
Kingdom, stated certain unique aspects of high-risk patient-handling tasks associated with preop-erative limb preparation, supporting limbs during
surgical procedures, and patient handling duringpostoperative recovery. Wicker stated that nurs-ing personnel have to raise a limb to prepare it
for surgery. The nursing personnel may have tohold a limb manually during the entire timeneeded for skin preparation. Wicker also raisedconcerns regarding fatigue and pain from static
posture during surgical procedures. In addition
192 GARG et al
to patient handling, there is also concern regard-ing pushing and pulling of heavy equipmentsuch as operating room tables, imaging machines,microscopes, beds, or instrument trays. Some of
the patient-handling tasks may require lateraltransfer of a patient lying in a supine or prone po-sition from stretcher to operating room bed and
vice versa. These tasks may require moving thepatient from a prone position to a supine positionor supine position to prone position. Some perio-
perative tasks may require positioning and reposi-tioning a patient on the operating room bed ina supine position. Other perioperative tasks may
require positioning and repositioning the patientsin a semi-Fowler’s position, lithotony position, orlateral position. Other tasks may require liftingand holding of a patient’s leg, arm, or head.
Unlike patient handling in long-term carefacilities that mostly requires vertical transfers(eg, from bed to wheelchair), most patient han-
dling in critical care requires lateral transfers (eg,supine position to supine position from stretcherto operating room bed) and lifting and holding
of a patient’s limbs such as leg, arm, or head.Therefore, ergonomists need to pay more atten-tion to patient transferring devices that would be
able to perform lateral transfers such as fromoperating room bed to stretcher for patients inneed of critical care. Also, ergonomists need topay attention to devices that would be able to lift
and support patients’ limbs. Creativity and in-genuity are needed to develop devices that willturn patients from one position to another posi-
tion such as from supine to prone and vice versa.Regarding lateral transfers, many patient
transferring devices are commercially available.
Some of these devices have been used successfullyby long-term care facilities and hospitals. It isrecognized that when dealing with patients re-quiring critical care, some of these devices may
need to be modified. Regarding lifting and sup-porting a patient’s limb, currently both ceilinghoists and portable hoists are designed to lift the
entire patient. With appropriately designed slingsor with some creativity, these mechanical devicescan be used to lift and support patient’s limbs
during perioperative care. Regarding reposition-ing of a patient in an operating room bed, such asfrom supine to supine position, semi-Fowler’s
position to semi-Fowler’s position, or lithotonyposition to lithotony position, it is quite possiblethat some of the devices that are commerciallyavailable for repositioning a patient in a supine
position in bed may be useful. Another option for
repositioning a patient in these positions would beto use battery-operated hoists with properly de-signed slings that are capable of lifting a patientwhile maintaining the desired position. The issue
of turning a patient from a supine to a proneposition or from a prone to a supine position aswell as supporting a patient in a semisupine
position is difficult, because currently, there isa lack of commercially available devices to ac-complish this. In this regard, principles of bio-
mechanics can be used to make the job easier. Forexample, working with biomechanical principles,it is often less stressful to the body to pull a patient
toward you rather than to lift a patient. Similarly,supportive wedges or pillows can be used to makethe job easier on the critical care worker and morecomfortable for the critical care patient. These
recommendations are consistent with Owen’s [83]observations. Owen [83] conducted her study inmedical-surgical units. She concluded that her
findings could be useful to perioperative nursesbecause the type of horizontal transfer performedin the operating room and medical-surgical units
are similar.It is clear from the above discussion that
patient handling in critical care settings is a serious
hazard. It is also clear that no amount of bodymechanics and training in safe lifting and patienttransferring techniques will make the job safe.Therefore, the only safe solution for patient
handling in critical care settings is with incorpo-ration of the use of patient handling and assistivedevices to eliminate or minimize lifting and
supporting of patient weights as much as possible.These programs have worked extremely well inlong-term care facilities as well as in hospitals, and
there is no reason to believe that they would notbe successful in reducing musculoskeletal disor-ders in critical care settings.
Summary
Numerous studies and statistics clearly showthat low back injuries are commonplace among
nursing personnel. The prevalence of work-relatedlow back pain is higher in this population thanalmost all other working groups. Shoulder pain is
also an issue for nursing personnel that is oftenoverlooked. The primary causes of injuries arethought to be patient-handling tasks, specifically
lifting and transferring of patients. Repositioningof patients is also reported to be as physicallystressful as lifting. Biomechanical studies show
193JUSTIFICATION FOR A MINIMAL LIFT PROGRAM
that compressive and shear forces exceed accept-able levels of exposure. The strength requirementof the job also exceeds the physical capabilities of
most female workers. Therefore, patient-handlingtasks are inherently very hazardous and posea high risk for injury.
Training in bodymechanics and lifting technique
is not enough to reduce low back and shoulderinjuries. Several epidemiologic studies have shownthat ergonomic interventions are effective in re-
ducing the risk of injury and the severity of injury.Critical care poses a very challenging environ-
ment because patients are usually more debilitated
and unable to assist during transfers. Therefore,the needs of this population as a whole are greaterthan some other patient or resident populations.Also, the risk of injury is also greater to nursing
personnel caring for this population. The onlylong-term solution is to introduce assistive devicesinto this specialty area of nursing care. This may
require some ingenuity in using current commer-cially available devices as well as creativity todesign new and improved equipment.
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Sustaining Staff Nurse Support for a Patient CareErgonomics Program in Critical CareLinda L. Haney, RN, MPH, COHN-S, CSPa,*,
Laurette Wright, RN, MPH, COHN-SbaDiligent Services, ARJO, Inc., 711 North Tenth Street, Wausau, WI 54403, USAbDiligent Services, ARJO, Inc., 1200 Theodore Lane, Durham, NC 27713, USA
Approximately 70% of all change initiativesfail, according to Beer and Nohria [1] of the Har-vard Business School. Ergonomic change initia-tives, such as safe patient handling in critical care
units, certainly are not immune from this discour-aging fact. Managers have only to look at pastpurchases of patient equipment to find it languish-
ing in the back of a storage room. Moving to a safepatient handling environment, with the purchaseof appropriate equipment, in any setting requires
nothing less than a cultural change demonstratedas new and consistent use behaviors of nurses.From the beginning of their training nurses aretaught to lift and move patients using ‘‘body me-
chanics’’ with the implication that if a task simplyis done properly it is safe for patients and care-givers. This notion is reinforced through in-service
trainings and managers who give well-meaning re-inforcement. A significant body of literature dis-putes the safety of body mechanics alone as an
effective way to prevent injuries [2].As research becomes available, nurses have
supported and rallied around evidence-based
practice for patient care. Malloch and Porter-O’Grady [3] define evidence-based practice as theapplication of the best possible research with evi-dence from clinical expertise channeled toward the
needs of patients. Partly for complex historicaland sociologic reasons, nurses tend to be self-sac-rificing and slow to move to evidence-based
practice for themselves. The research is clearthat safe patient handling programs can achievesafety goals for caregivers, although there isa dearth of research on the issue of improved pa-
tient safety as a result of the programs [4]. The an-ecdotal evidence, however, strongly indicatesreduced patient falls and increased comfort during
patient lifts and transfers when a safe patient han-dling program is in place. Additionally, there isbeginning recognition among rehabilitation pro-
fessionals that safe patient handling equipmentcan be used to further rehabilitation goals [5].
In spite of training, education and research tothe contrary, caregivers in general do not appear
to view mobility, such as sitting on the edge ofa bed or transfer to a chair, as clinical issues.Positioning of patients relative to lung function
clearly is seen as a clinical issue in critical careunits, however [6]. The general belief regardingmobility is important especially in critical care
units where the major focus is on life-threateningconditions, not the sometimes devastating after-math of immobility. Physicians routinely write or-
ders for patients to be ‘‘out of bed,’’ althoughinformal discussions with critical care nurses vali-date the belief that these orders often are unrealis-tic given patients’ condition. As a result, they do
not carry the same criticality as most other orders.The average age of a nurse is expected to rise to
45.4 years by 2010, as compared with 41.9 in 2000
[7]. Older caregivers who now predominate in theworkforce remember earlier practice mandatinglengthy enforced bedrest after open-heart surgery.
It is now widely accepted that patients do consid-erably better when they are mobilized quicklyafter surgery, usually within several hours. The
This work was supported through funding by
ARJO, Inc.
* Corresponding author.
E-mail address: [email protected] (L.L. Haney).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.003 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 197–204
conclusion is that mobility is just as much a clinicalissue as correct medication, procedure, or diet.There are many reasons, therefore, why mobility
and transfer tasks should be made as safe aspossible.
Sustaining staff support for a safe patienthandling program implies that support was present
at one point or for some period of time. Exploringthe nature of change, how it happens, how peopleare motivated to accept it, what barriers prevent
it, and how it is sustained all are inextricablylinked. Society actively seeks quick fixes andengages in limited long-term planning. Cultural
change, expressed as new and different behaviors,occurs slowly. Consider only the initiative to usegloves to understand the difficulty. Wearing glovesconsistently and appropriately has taken nurses
more than 15 years even with the knowledge andevidence of an associated frightening disease(AIDS) and a federal law (Bloodborne Pathogens
Standard) [8]. Safe patient handling programs arenot associated with a frightening disease, althoughthe toll of musculoskeletal injuries may be far in
excess of AIDS, and there is no a federal regulationspecific to the problem, although several states arehave enacted safe patient handling laws, with more
expected to come. Thus, it is important to under-stand that the change to an environment of safepatient handling may take many years.
The natural question is why change initiatives
are so difficult to maintain and fail so frequently.Field discussions with managers and employeesattest to the fact that beginning a change initia-
tive, although sometimes difficult, can be donewith relative ease compared with sustaining orcementing a change. There is a significant amount
of literature that provides insight, particularly inthe business and management realm, on changemanagement. As Harrington states, ‘‘[Permanent]change is not a simple process. It requires a lot of
thought, a well-developed plan, a sophisticatedapproach, and unfaltering leadership’’[9].
Other articles elsewhere in this issue address
the rationale and assessment of need for a safe pa-tient handling program. The remainder of this ar-ticle focuses on some of the issues related to
change management and communicating andmaintaining a successful safe patient handlingprogram in critical care units.
Change process models
Change is about seeking new and improvedways of doing things. Weick and Quinn [10] de-scribe two slightly different models of change,
based on the classic work of Kurt Lewin. Episodicchange follows the sequence of ‘‘unfreeze, transi-tion, refreeze,’’ whereas continuous change is
framed as ‘‘unfreeze, rebalance, refreeze.’’ TheUnited States Army uses the PMOC model, devel-oped from the work of an early French engineer,Henry Faylol. It consists of planning (setting goals
and the process for achievement), motivating(providing incentives for a group to work towardthe goal), organizing (how best to group activities
and resources), and controlling (monitoring andcorrecting ongoing activities toward the goal) [11].
Experience shows that there are two basic
approaches. The first is a common onedheavyhanded, top down, and ‘‘holding people account-able’’ with concomitant strictly applied punitivemeasures for those who do not comply, particu-
larly if there is a written policy in place. Thesecond approach is one of a softer and morerelaxed approach of building trust and emotional
commitment through a planned approach ofcommunication. Proponents believe this is themore effective approach, although they acknowl-
edge that this approach does take more time. Beerand Nohria [1] make the case that the most effec-tive approach is a combination of the two basic
approaches that includes setting direction fromthe top and engaging people from below. Changeimposed only from the top down tends to result inminimal compliance if not outright evasion.
More recently, Kotter [12] developed an 8-stepprocess-of-change model. He emphasizes that therole of leadership is more important than that of
management, although increasing leadershipdoes not mean decreasing management:
1. Create urgency.2. Build the guiding team.3. Get the vision right.
4. Communicate for buy-in.5. Empower action.6. Create short-term wins.
7. Do not let up.8. Make change stick.
All change models require organizations andindividuals to move from one entrenched positionto another one. All typically encompass variationsof the following and are similar to the familiar
nursing process [13]:
1. Recognizing a problem or an opportunity Assess
2. Assessment of the current situation Assess
3. Development of possible
ideas to solve the problem Diagnose
198 HANEY & WRIGHT
Covey [14] includes the following as one of hisseven habits of highly effective people: ‘‘begin withthe end in mind.’’ This is true especially when be-ginning a program with the goal of behavioral
change. Kirkpatrick [15] provides a useful modelfor determining the effectiveness of training, usingfive tiered levels of evaluation. His work, adapted
to effectiveness of a change initiative, suggests thatbehavioral-change end goalsdcost-effective andconsistent use of devices to reduce injuries for
patients and staffdand the planned step-by-stepobjectives to achieve those goals are essential tosuccess.
Communication
Critical care nurses are familiar with the pro-cesses of assessment, diagnosis, and planning.
They may not be as familiar with the businessliterature on communication processes. How wellcommunication is planned and delivered through-out the change process has critical implications
for the successful implementation and mainte-nance of the new behaviors. Every change man-agement model includes or implies the importance
of effective planning and communication aboutthe proposed change. Duck [16] states that man-aging a successful change initiative means manag-
ing the communication between those who seekthe change, those who are expected to implementit, the context of the change within the organiza-
tion, and the emotions that go along with thechange. She goes on to say that because peopleneed time to hear the message, integrate it intotheir thinking, and believe it, change proponents
need to talk about the change over and over andover. She expresses it well: ‘‘When you are sosick of talking about something that you can
hardly stand it, your message is finally startingto get through. Until managers have listened,watched, and talked enough to know that the an-
swer to all of the following questions is yes, theyhaven’t communicated at all: did they hear it, dothey believe it, do they know what it means,
have they interpreted it for themselves and havethey internalized it?’’ [16].
Social marketing is a new concept that aids incommunication. It is defined by the Social Mar-
keting Institute as the planning and implementa-tion of programs designed to bring about socialchange using concepts from commercial market-
ing [17]. The goal of social marketing is to initiateand sustain a change in behavioral action in indi-viduals and society through application of mar-
keting principals of communication andpersuasion [18]. The Centers for Disease Controluses social marketing in their public health efforts
and participates in the Turning Point Social Mar-keting National Excellence Collaborative spon-sored by the Robert Wood Johnson Foundationand housed at the University of Washington
School of Public Health and Community Medi-cine. The collaborative provides resources forsocial marketing, collaborative leadership,
performance management, information technol-ogy, and public health law modernization to en-courage the use of social marketing at state and
local levels. A helpful resource is the TurningPoint CD-ROM Toolkit available at no charge.It includes a wide and extensive variety of innova-
tive tools, worksheets, and resources, including‘‘The Basics of Social Marketing,’’ ‘‘Guidebookfor Performance Measurement,’’ and ‘‘Manager’sGuide to Social Marketing’’ [19]. Change that is
preceded and supported by ongoing social mar-keting seems to have a better likelihood of aneffective outcome.
The act of communicating and persuadingpeople to move from one way of thinking andbehaving to the adoption of another way is
important in all social settings. It allows progressto be made and permits research to move to reality.Various means of changing behavior have been invogue since the industrial revolution. Classic
Theory X and Theory Y approaches, developedby McGregor, attempted to categorize manage-ment believed as either one of work being a nega-
tive (X) or a positive (Y) for workers [20]. Newerthinking and changing social demographics havemoved management science to a more collabora-
tive model, although the heavy-handed approachwith workers remains surprisingly common.Duck [21] states that the new management style
recognizes that change ultimately is about feelings.Emotions must be recognized and addressed iffacilities or units want employees to contributetheir heads and their hearts to their work. Fournies
[22] emphasizes the importance of explaining the
4. Selection of best approach Plan
5. Identification of barriers Plan
6. Communication, Implement
7. Implementation Implement
8. Monitoring results Evaluate
9. Maintenance
199NURSE SUPPORT FOR A PATIENT CARE ERGONOMICS PROGRAM
cause/effect relationship in detail between the in-tended actions and the expected results.
The Social Marketing Institute and Turn Point
literature, based on the work of Weinreich, statesthere are several key concepts associated with so-cial marketing, including action as the objective,focus on the target audience, understanding that
the exchange is critical, analyzing the competition(in this case, for time, but also possibly for budgetdollars), flexibility and monitoring (the change),
and use of the 4 Ps (Table 1) [23]:
Create an enticing product (ie, the package of
benefits associated with the desired action).Minimize the price the target audience believesit must pay in the exchange.
Make the exchange and its opportunities avail-able in places that reach the audience and fitits lifestyles.
Promote the exchange opportunity with crea-tivity and through channels and tactics thatmaximize desired responses.
Training
New behaviors require initial and ongoingtraining. Some object to the term, training,
although it is in widespread use, preferring theterm, facilitating learning. Educating caregiversshould not be a one-time exercise but a process,
particularly if the scope of the information isextensive. Nin writes, ‘‘There are very few humanbeings who receive the truth, complete andstaggering, by instant illumination. Most of
them acquire it fragment by fragment, on a smallscale, by successive developments, cellularly, like
a laborious mosaic’’ [24]. Education in isolationrarely achieves goals. Benner [25], in her classicbook, From Novice to Expert, expresses the same
beliefs when she states that nursing practices andskills develop through experiences and are con-veyed through experiences. She states that thelearning derived from those experiences are
learned most easily and safely when based ona good educational foundation. Too often, educa-tion is an isolated process with little follow-up,
little monitoring, and limited review [26]. Adher-ence to the generally recognized principles of adultlearning and Kirkpatrick’s model help to insure
that real learning takes place and achieves thestated goals rather than training merely for thepurpose of compliance.
The purpose of training is change and action,
but it is not sustainable without an analogouschange in the supporting management process,according to Harrington [8]. He states that man-
agers must direct action within the first week aftera class by applying the information presented tothem. If they cannot or will not apply the infor-
mation quickly, there is only a 20% chance thatthey ever will use the techniques or methods thatwere taught [8]. In short, behaviors change in
large measure because of what managers do ordo not do.
Motivation
Herzberg’s [27] classic article on change re-viewed the various factors that motivate em-
ployees. His research concludes that motivationoccurs when people are given interesting work,
Table 1
Applying social marketing to safe patient handling
Target population Product Price Promotion Place
Caregivers within
critical care
units
Slide sheets
to reduce friction when
moving patients
within a bed
Perceived barriers:
Too much time to apply
Requires two people
to use
Other perceived
benefits:
Task made
physically easier
Reduces total
fatigue for shift
Reduces potential
for back/shoulder
injuries
Evidence-based
literature
Staff meetings
Success stories
Naming of
campaign
Task force
Incentives
Symptom
reductions
Facility newsletter
Unit bulletin
board
Signs for location
of the sheets
Pay roll stuffers
200 HANEY & WRIGHT
challenges, and increasing responsibility. Coombs[28] suggests that the following factors are neces-sary for motivation for intensive care nurses:pay conditions, clinical requirements, organiza-
tional requirements, interaction, autonomy/re-sponsibility, and prestige/status. Controversiesexist about whether or not it is even possible for
one individual to motivate another, although theconsensus seems to be that a leader’s responsibil-ity is to create the conditions where individuals
‘‘own’’ their motivation. Three short case studies,although not all specific to critical care, serve toemphasize the key role of leadership:
Case study 1
After extensive review, a large university-based
system made the decision to create a safe patient
handling environment and selected a critical care
unit to pilot the project, because this nursing staff
had the best compliance with equipment use.
When looking at the salient factors, the following
was discovered: a unit manager was committed to
the change and took the time to take pictures of
her staff in the equipment; a poster placed in
a prominent location on the unit where staff and
patients could see it easily; a small weekly
newsletter for the staff with a regular column
on the safe patient handling initiative; and
a manager who stated regularly that her staff
were absolutely terrific and she was very proud of
them. The enthusiasm and compliance with the
program resulted in no staff or patient injuries
related to patient handling for more than a year.
When this manager subsequently left because of
personal health reasons, compliance went down
to the level of other units in the hospital.
Case study 2
In a critical care unit of one hospital, a single
personal care technician who had sustained a pre-
vious back injury readily saw the benefits for
herself and others on her unit of a safe patient
handling program. She became a peer leader,
defined as unit champion, and the driving force
for the use of slide sheets to transfer patients from
bed to stretcher.With the support of her manager,
she insisted that they be placed on all of the beds
and doggedly pursued the goal of compliance on
the unit. It was not long before she was called
‘‘Purple Sandy’’ because of her advocacy of the use
of the purple slide sheets. This individual played
a strong role in creating an acceptance for the
change in behaviors on the unit.
Case study 3
One hospital, part of a 200-bed health care
system, approached the change to a safe patient
handling environment in a different way. The
entire system put together a task force that
created a baseball theme for the change to
a safe patient handling program. The initiative
included baseball shirts for unit champions,
themed posters and newsletter inserts, game score
cards, and initially used incentives to capture the
excitement after the training. The task force
continues to keep the initiative alive and the
hospital has seen sustained dramatic reductions
in staff injuries over 2 years.
Bringing motivation factors to life requires anenthusiastic walk-the-talk attitude and the abilityto lead others to a better way. Modeling the
behavior is one important way for managers toexpress their commitment to the change by in-dicating graphically that they not only say that they
want a change but also are demonstrating theircommitment. Modeling may mean actually doingthe task, such as using a new ergonomic piece ofequipment, giving positive reinforcement when the
equipment is used, including the desired perfor-mance in performance evaluations, and even pro-moting those who exhibit the desired performance.
One of the best methods is for managers, ona weekly basis, to round the units and randomlyrequest various employees to put a manager in the
equipment and demonstrate its use. Another rec-ommendation is to discuss the status of individualcompliance periodically during informal coaching
sessions and formally at the time of performancereviews. Employees intuitively know that if an issuedoes not appear in their performance evaluations itis not important.Whenmanagerswalk the talk they
build predictability. Duck [16] states that predict-ability leads to trust, and trust and competenceare necessary to achieve change. Ifmanagers ignore
behavior that does not reflect the desired change,they have sent a powerful message that the changeis not important or a priority, and caregivers are
not expected to change their actions. And, if thisis the case, it is difficult for the initiative to succeed.
Incentives
Human behavior research, beginning withSkinner [29], asserts that people do things forwhich they are rewarded and do not do things
for which there is no reward. Performance thatis rewarded increases in frequency; the reward re-inforces the behavior. Behavior psychologists,
201NURSE SUPPORT FOR A PATIENT CARE ERGONOMICS PROGRAM
such as Daniels, are applying theories and practi-cal applications to the fields of safety, health, er-gonomics, and change management. Daniels’
work indicates that if a change within an organi-zation is to be successful, leaders need to rewardit in a way that causes people to increase their ef-forts, cooperation, and quality of their work [30].
Beer and Nohria caution that incentives should beused to reinforce change rather than drive it [1].
Using behavior analysis techniques to examine
the antecedent of the behavior (what comesbefore), the behavior, and the consequence(what happens after) is the cornerstone for be-
havioral change. According to Daniels, anteced-ents have limited control over behavior. Theirfunction is to get a behavior to occur once or atbest a few times. Positive consequences, alterna-
tively, are the key to getting a behavior to occuragain and again. Daniels [30] succinctly summa-rizes by saying, ‘‘If performance is not improving,
reinforcement is not occurring.’’ Fray [26] puts ita slightly different way: ‘‘In reality a continuousinput of motivation is required to keep the change
process moving. Personal experience has shownnonmonetary or low monetary incentives to bethe most effective. A simple smile, pat on the
back, or personal note can serve as powerfuland inexpensive incentives. Selecting the right in-centive to motivate behavior may be individual;it is determined best simply by asking the
employee, ‘What motivates you?’’’
Peer leaders/unit champions
Coaching implies an expertise in a specialized
area. It generally is acknowledged that unit-basedcoaches or peer leaders for safe patient handlingare useful, although the evidence-based literature
is sparse. Safe patient handling coaches havevarious names, such as transfer mobility coaches,back injury resource nurses, and ergocoaches
(Netherlands). Peer leaders are defined as staffcolleagues who work alongside new staff or thoselearning new skills to assist with the transfer ofknowledge (learned in a class) to skills (ability to
apply the knowledge) in the real world [31]. Withstrong management support, specialized trainingfor this these individuals serves to extend the
reach of managers on units as it relates to safe pa-tient handling behaviors. Unit champions can bea strong factor in changing behaviors in support
of the goals. Cook [32] states that effective coach-ing moves learners from thinking only of them-selves to thinking about what is best for units or
organizations. The ideal ratio of coaches, allowingcaregivers to have ready unit-based access toa coach at all times, is 1 to 2 per shift per unit.
Coaches for safe patient handling typicallyincorporate this role into their existing responsi-bilities on a unit. Training includes the followingbasic skills: ergonomics, introduction of equip-
ment to patients and families, problem solving,techniques for improving compliance on a unit,review of patient handling injuries that have
occurred, and thorough knowledge about theavailable equipment and coaching skills. Backedby regulatory reinforcements and national fund-
ing, the Netherlands has a long and successfulhistory of changing the culture of health careproviders to one of safe patient handling. Theirergocoaches are supported through national con-
ferences, specialized training, and their own Website. A large, 600-facility–based study soon will beunderway to examine the value of ergocoaches in
a systematic way [33].
Resistance to change
Change and resistance are linked closely. Plan-
ning needs to identify possible barriers to thechange initiative and determine a plan to reducethem. There may be many reasons why there is
resistance to a safe patient handling environment,including distraction as the result of too manyinitiatives happening simultaneously, the beliefthat the change is unnecessary, a feeling that the
initiative has been tried unsuccessfully before, anda lack of appropriate communication. Sometimesmanagers themselves are skeptical about projects
and do not participate in senior-level change di-alog. Their skepticism about the project can affecttheir team’s response. Dym [34] sees resistance as
an attempt by the organization to regain equilib-rium and as feedback about the disruptions.
Resistance may be observed in individual
behavior showing apathy, skepticism, denial,anger, helplessness, incompetence, or lack offollow through. It also can appear in a phrase,such as, ‘‘I don’t have time to use the equipment.’’
Examined more closely, the caregiver may besaying, ‘‘I don’t believe this is a priority in thetime that I have available.’’ Ultimately, change is
a highly personal endeavor because it requiresindividuals to think about their behavior, makea decision about whether or not they are going to
change, and then act differently [16].Resistance also may come as the result of
impatience. When projects, such as safe patient
202 HANEY & WRIGHT
handling, do not communicate realistic expecta-tions, people become impatient and conclude thatthe change is not a good one. Clear and practicaltimelines reiterated repeatedly and a strong com-
mitment to persistence are needed. Dym [34] pro-vides a 5-step approach to management ofresistance: (1) anticipate resistance; (2) explore
the problems for which resistance provides feed-back; (3) join and validate the resistance, thus em-powering those who resist; (4) form a partnership
to solve the problem addressed by the resistance;and (5) problem solve.
Combining plenty of communication, persis-
tence in the message, unwavering modeling of thebehavior, problem solving, and rewards for thedesired behavior are effective.
Summary
The ultimate goal of a safe patient handlingprogram actually is ‘‘no program,’’ and the pro-cess may take years. When safe patient handling
practices become so embedded in education andpractice that they no longer are considered ‘‘aprogram,’’ change has occurred and the culture is
one where patients and caregivers are safe duringlifts, transfers, and mobility activities. The changemay not occur solidly until the current generationof caregivers leaves the workforce and the new
generation provides the bulk of care. A safe patienthandling program with its associated benefits istoo important to be left to change or a ‘‘good
effort’’ only to see the initiative die. Sustainablepatient handling change requires a change inbeliefs about the value of mobility tasks and the
unswerving belief of the importance of protectingcaregivers and patients during those tasks.
The ability to see that a safe patient handling
environment makes sense and has advantagesrequires individual thought and strong leadership.Sustaining the change requires a thoughtful planfrom the beginning with input from those who are
affected, a realistic attitude about the time it willtake, repeated communication, positive reinforce-ment, and dogged persistence. Change and a com-
mitment to the sustaining the change do result ingoal achievement.
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204 HANEY & WRIGHT
Safe Patient Handling Program in Critical CareUsing Peer Leaders: Lessons Learned
in The NetherlandsHanneke J.J. Knibbe, MSc, RPTa,*, Nico E. Knibbe, MSca,
Annemarie J.W.M. Klaassen, RN, MScbaLOCOmotion, Research in Health Care, Brinkerpad 29, 6721 WJ Bennekom, The Netherlands
bProject ErgoCoaches, RegioPlus Foundation, Zoetermeer, The Netherlands
An ergonomic approach in acute care
In the Netherlands, the ergonomic approach is
advocated as the most effective way to preventmusculoskeletal disorders among health careworkers. In the literature, this is referred to as
a nonlifting or minimal lifting approach, and thereis evidence of the effect of such an approach and ofthe lack of effect of other approaches [1–3]. The
primary objective is to eliminate or substitute allpotentially harmful actions. For this purpose,guidelines were developed mainly based on the Na-
tional Institute of Occupational Safety and Health(NIOSH) guidelines for manual handling of loads[4]. Patients or objects in excess of these limitsshould not be lifted or transferred manually. This
approach has been enhanced over the past 4 yearsthrough working environment covenantsdsignedagreements ensuring commitment by a range of na-
tional parties. The initial drive for these covenantsoriginates from the European Union guidelines forpromoting safe work practices. In nearly all health
care sectors (acute and critical care, nursing homes,home care, psychiatric care, and care for the hand-icapped) employers, workers (unions), and govern-ment have, on the basis of these convenants,
worked together to decrease the exposure of nursesto physical overload. The focus of the convenantsis not restricted to a nonlifting approach, but all
major sources of physical overload (lifting andtransferring patients, pushing, pulling, postural
load, reaching, prolonged standing, and so forth)are taken into account.
This article briefly overviews the implications ofthis development for critical care in hospitals. In theNetherlands, this applies to a groupof 110hospitals
across the country, which has a total population ofapproximately 16 million people. For the purposeof this article, the group of eight academic teaching
hospitals has been excluded, which, as a group,have taken a slightly different approach.
This article provides insight into the develop-
ment of the guidelines, the implementation pro-cess, and preliminary results.
Analysis of the ergonomic situation in acute
and critical care
Thefirst stepwas toassess the exact nature of theergonomic problems encountered in critical care.For this purpose, research material from differentsources was collected and the conclusions were
combined. Methods used were surveys, observa-tions, and direct measurements of exposure.
Prevalence of musculoskeletal disorders
In a survey of 4129 nurses from a convenience
sample of 27 hospitals (average nurse responserate 68% [50%–100%] per hospital; hospitalsevenly distributed across the country), it was clear
that there are back pain problems but also thatthe back pain prevalence differs widely betweenhospital wards [5]. The average 12-month back
pain prevalence of all nurses responding was63%. This is high compared with the average for
* Corresponding author.
E-mail address: [email protected] (H.J.J. Knibbe).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.009 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 205–211
the Dutch general population (42%) but slightlylower than the Dutch average for home care inthat period (67%). Preventive action, therefore,
was considered relevant and necessary. It alsowas clear that there were large differences betweendifferent specialties in a hospital. Surgery, cardiaccritical care units, ICU, emergency departments,
cardiology in general, orthopedics, and neurologyreported a higher prevalence, the latter two rank-ing first and second. Alternatively, specialties,
such as gynecology, pediatrics, and internal med-icine, reported prevalence lower than the hospitalaverage. Acute and critical care were in the mid-
range: not as high, for example, as nurses workingon orthopedic units report but higher than the av-erage for the general population (50%–62% de-pending on the ward). It also seemed that for
acute and critical care, back pain was not theonly problem, with an elevated prevalence of mus-culoskeletal disorders. Nurses working in critical
care also reported a relatively high prevalence ofneck and shoulder problems. Over a third(35%–55%) of the critical care nurses in the 27
hospitals included in the survey reported havinghad neck or shoulder pain in the 3 months beforethe survey.
These data underline that for critical care, thereis sufficient reason to undertake preventive action.
Exposure to physical load
Registration by means of a self-administeredlog (the so-called ‘‘Lift Counter’’ or ‘‘Lift Ther-mometer’’1) [2] in 12 of the 27 hospital revealed
that lifting and transferring dependent patientsoccurred frequently. On average, 5.2 transferswere performed per patient per 24 hours. Nearly
half of these patients (46%) were almost or totallypassive.
For acute and critical care, this percentage was
higher, with an average of 64%. Either they werenot able or were not allowed to move themselvesor assist in the transfers. An additional 26% werelimited in their mobility level and the remaining
10% were able to assist substantially or to moveindependently or with only verbal guidance. Theweight of the patients (average 71 kg), their
dependency level, and the type of transfer per-formed indicated that these transfers provideda health risk for the nurses if these transfers were
performed manually. The criteria for ‘‘safe,’’ inthese cases, were derived from the revised NIOSHguidelines for the manual handling of loads. More
specific assessments of the actual load wereperformed with the 3 Dimensional Static StrengthPrediction Program (3D SSPP) software programfrom Chaffin [6], which also refers to the NIOSH
guidelines [4].It seemed that 39% of the patients were
transferred with the help of two nurses, implicat-
ing an occupational health risk for both nurses. Itdid not make much difference if these transferswere performed with one nurse or with two
nurses. In both cases, the resulting load still wasin excess of safe limits for manual handling set bythe NIOSH guidelines (3400 N) [4]. In spite of thefact that dividing the weight of the patients be-
tween the two nurses made the transfer lighter,a biomechanical analysis by means of the 3DSSPP program revealed that it did not make the
transfer safe. This is in line with other research in-dicating that manual transfers of dependent pa-tients should be avoided [1–3]. The conclusion,
therefore, was that lifting with two nurses wasnot a structural solution and the guidelines forpractice now state explicitly not only that one-
person manual lifts should be avoided but alsothat two-person lifts and transfers should beavoided.
Alternatively, the frequency with which nurses
in acute and critical care lift and transfer patientsis not as high as in other wards or in nursinghomes and homes for the elderly. There, the
frequency per patient can be more than 12 perpatient per 24 hours.
Also, the type of transfers was specific to acute
and critical care when compared with other spe-cialties or situations in nursing homes. It seemedthat more than half of the transfers were performedwithin a bed itself, which is higher than in nursing
homes, where they often are a third or less.Examples of these types of transfers are reposition-ing in bed, up the bed, or sideways; rolling over; and
so forth. This means that solutions, such as mobileor overhead ceiling lifters, are not sufficient to solvetransfer problems. A well-designed, high-low pow-
ered bed and the use of sliding sheets help to solvethese problems and, therefore, have become part ofthe guidelines for practice. Another 10% consisted
of horizontal transfers: froma supine position (bed,stretcher, and so forth) to another supine position(bed, examination table, stretcher, and so forth).This type of lateral transfer occurs in less than 5%
of the transfers in nursing homes.
1 This tool is a practical but validated assessment
tool that assesses exposure to physically demanding
tasks and compliance with the use of preventive
equipment.
206 KNIBBE et al
It also seemed that other causes of physicalload, besides transfers, added to the total expo-sure level of nurses and increased their risk ofdeveloping musculoskeletal disorders. The static
or postural load especially was high. This mayoccur during daily routines, such as tending topatients in bed or elsewhere (wound care, tending
to drains, removing or placing needles, changingintravenous lines, or medical checks) and duringperiods of assisting doctors or colleagues with
treatments or other types of interventions. Duringthose activities, prolonged stooping over patientsoccurs. Besides static load during the periods of
direct patient-nurse interaction, there is a consider-able amount of static load during other activities,such as reading out the data on monitors andother types of electronic displays (often not in
ergonomically ideal positions), keeping records,sorting out medication supplies, and cleaning anddisinfection routines. This static load often is
underestimated but may provide an (additional)explanation for increased levels of sick or personalleave. Jansen and colleagues [7] found, for exam-
ple, that longer exposure to static load (witha trunk flexion over 45�) was related (relaltiverisk, 3.18) especially to more serious, disabling
back pain among health care personnel.Finally, pushing andpulling also seemed to be in
excess of safe values. Pushing and pulling occurredduring maneuvering heavy objects, such as during
the transportation of beds or heavy (diagnostic)equipment. Special types of ICU beds or specialmattresses in particular resulted in loads in excess
of the safe values of 200 N considered safe.Nurses reported these problems (transfers,
static load, and pushing and pulling) not only in
the logs and direct measurements but also in thesurvey. They reported them subjectively as majorproblems they would like to have solved. Theconclusions of subjective data and objective
measurements converged, underlining the validityof the results. In addition, some nurses reportedthe frequent use of computer terminals and other
devices and electronic patient files as unfavorableergonomic conditions and stated that this addedto their risk profile for developing musculoskele-
tal disorders.
Observations and expert walk-through
Finally, observations (expert walk-through
on all wards in 12 hospitals) pointed to a widerange of small and large practical ergonomicproblems. Some were general problems, occurring
in practically all the hospitals, and some werespecific to some hospitals. Patient rooms, exami-nation rooms, and bathrooms generally seemed tohave insufficient space for maneuvering beds and
heavy equipment. Some locations did have suffi-cient space, but the space (eg, in ICUs) often wastaken up completely by diagnostic and control
devices. It was difficult for nurses to put themselvesin an ergonomically ideal body position duringtransfers or nursing activities. They often were
working in awkward positions. For example,some of the bags with body waste or treatmentfluids were placed in difficult places and were heavy
(when full) and difficult to detach without goodvision (sometimes hanging under a bed or bed rail).
There often was not enough equipment in place.In some cases, nurses would have to go looking for
the equipment and did not do so. They consideredthis as too time consuming and not efficient. Inother cases, the equipment was not maintained
properly or it was unclear if it was maintainedproperly at all (eg, no records kept). This resulted inwheels that were clean but no longer rotated easily.
No maintenance records were kept for slings fromlifting devices (either ceiling or mobile patientlifters) as a rule. This implied that it was unclear
when the last strength test was performed andwhether or not a sling was in good working order.From a patient and nurse safety perspective, thissituation needed improvement. At times, the type
of equipment was not optimal. In some hospitals,high-low beds were present but operated partiallyhydraulically instead of electrically. Apart from
other disadvantages, this meant that patients werenot able to operate their beds themselves, leading tounnecessary dependence and lack of mobility. In
addition, nurses had to move the headrests up anddown manually, an activity experienced as heavy,especially with dependent patients in the bed.Another problem occurring frequently was that
mobile lifters often were present but frequentlywere not used because of lack of space. Overheadceiling lifters rarely were in place. When they were
present, their reach often was limited to one roomand access to another room or the hall way waslimited or absent.
Guidelines for practice
After this first research phase, a national taskgroup was formed consisting mainly of nurses and
physical therapists. It was their task to developpractical guidelines as a response to the majorproblems the studies (described previously)
207LESSONS LEARNED IN THE NETHERLANDS
pointed out. They were supported in this byhuman movement scientists.
This task group developed the guidelines in
several stages during nearly 7 months. At eachstage, they consulted with their own hospitals andtheir direct colleagues there. The purpose was todevelop guidelines that would be simple, under-
standable, andpractical for use in critical care itself.Although this was a time-consuming process, it wasconsidered necessary to ensure commitment, prac-
ticality, and quality of the guidelines. This processmeant that from the beginning the nurses them-selves were empowered to develop and produce
guidelines and implement them.Once this national group of 15 representatives
had reached consensus, the final versionwasofferedto the national covenant committee, in which
unions, employers, the health and safety inspector-ate, the inspectorate of quality of care, and twogovernment departments (health and social affairs)
participated. These guidelines were signed by theseparties to become official. After this, it was agreedthat the guidelines for practicewould form the basis
for future inspections of the health and safetyexecutive. Nationally, as of summer 2006, the finalstage has been reached, in which the health and
safety is starting their inspection process.For the purpose of the article, an outline of the
guidelines is given. For details, the authors may becontacted. The guidelines for practice cover the
major sources of physical load identified in theresearch. For hospitals, this means they coveredfive groups. In summary the guidelines are as
follows.
Repositioning in beds, on stretchers, and so forth
For all patients who are partially or totally
passive and who need repositioning in bed, the useof a powered high-low bed in combination withthe use of sliding sheets is necessary (Fig. 1).
For patients who have the capacity to assist ormove themselves, the use of a powered high-lowbed and smaller aids (monkey pole, ladder, and soforth) may be relevant and may help them to
maintain or improve their independence.When diagnostic tests need to be performed
(for example, X-ray cassettes that need to be
placed under a patient), a double-layer slidingsheet needs to be used to avoid having to lifta patient. When patients need to be positioned
carefully for treatment or diagnostic reasons,special sets of sliding sheets must to be used(Fig. 2).
Lateral transfers (bed bed, bed stretcher,and so forth)
For all patients who are passive or nearly
passive and who need lateral transfers, a slidingboard, sliding sheets, or a lifter with a horizontalstretcher frame must be used in combination witha powered high-low bed (Fig. 3).
Transfers from bed, wheelchair, and so forth
bed or wheelchair
For all patients who are passive or nearlypassive, patient lifters or hoists have to be used,either passive lifters or active lifters (Fig. 4).
Static or postural load during patient care
and so forth
For any activities lasting longer than 1 minutethat require a back inclination or rotation of more
Fig. 1. Repositioning in bed. (Courtesy of Knibbe JJ,
Knibbe NE, Geuze L. Beter, Werkpakket Fysieke Be-
lasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,
Utrecht, 2003; with permission.)
Fig. 2. Positioning for treatment. (Courtesy ofKnibbe JJ,
Knibbe NE, Geuze L. Beter, Werkpakket Fysieke
Belasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,
Utrecht, 2003; with permission.)
208 KNIBBE et al
than 30�, additional equipment needs to be used(Fig. 5). This may include powered high-low de-
vices, sitting supports, or supports for patientlimbs (wound care). If this is not possible, pro-longed tasks (longer than 1 minute) need to be al-
ternated frequently among nurses, or more breaksor microbreaks need to be used. Nurses in thesecases must be informed about the risks they mayexperience and the options they have to prevent
musculoskeletal disorders.If patients use antiembolism stockings (AES),
special devices need to be used to avoid postural
stress and excessive pulling forces in fingers andarms.
Maneuvering with heavy material
If the force required to maneuver an objectexceeds 200 N, a powered pulling or pushing(transportation) device must be used (Fig. 6).
To encourage nurses to use optimal techniquesand develop their techniques with sometimes newmaterial and equipment, special educational ma-terial (step-by-step leaflets) was developed. This
information did not replace the information thatmanufacturers offer with their equipment. In-stead, it provided additional and practical sugges-
tions to use the equipment or aids safely for nursesand patients. This was considered necessary be-cause some manufacturers suggest that sliding
sheets could be used for transfers out of bed toa wheelchair. The task group considered this anunsafe procedure for patients and nurses, so this
technique was advised against.
Implementing change in acute and critical care
After this stage of guideline development, theimplementation process started. As this was
expected to be a complex process, a choice wasmade to train and install so-called ’’Ergo-Coaches.’’ On every ward, one or two nurses
needed to be appointed and trained to becomean ErgoCoach (also called peer leaders, liftingco-coordinators, back injury resource nurses[BIRNs], lifting specialists, mobility coaches, and
so forth) [1–3,8]. In short, this ErgoCoach–nurseis responsible for starting the ergonomic processand keeping it going. These ‘‘ergonomic ambassa-
dors’’ are available for questions, problem solv-ing, introduction training, updates on newequipment, and so forth. ErgoCoaches can iden-
tify problem areas, can perform assessments, areconsulted easily (they work on wards like anyother nurse), and are trained and specialized in er-
gonomics. Theoretic advantages are that they are
Fig. 3. Lateral transfer. (Courtesy of Knibbe JJ, Knibbe
NE, Geuze L. Beter, Werkpakket Fysieke Belasting Zie-
kenhuizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;
with permission.)
Fig. 4. Lifter. (Courtesy of Knibbe JJ, Knibbe NE,
Geuze L. Beter, Werkpakket Fysieke Belasting Zieken-
huizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;
with permission.)
209LESSONS LEARNED IN THE NETHERLANDS
nurses (‘‘one of us’’), they speak the same ‘‘lan-guage,’’ and they ‘‘know what it’s like,’’ butmost of all they interact frequently with their
colleagues.For acute and critical care, this is of vital
importance, as this highly specialized setting is
from time to time complex and, as the researchpoints out, the problems are diverse in nature. Itwas considered that anyone outside this setting
not present on the ward itself and not matchingthe expertise level never would be able to generatethe necessary impulse for a preventive policy. Inaddition, the presence of and dependence on
outside experts would make the process inefficientand expensive. This makes the ErgoCoach phe-nomenon an essential and potentially effective
drive behind the ergonomic message, especiallyin acute and critical care.
Preliminary results
Nationally, the percentage of nurses on sick
leave has decreased from 5.6% in 2002 to 4.7% in2005 (2003: 5.1%; 2004: 4.8%) [9]. Monitoring ofall the hospitals revealed that the implementationprocess demonstrated a typical implementation
pattern [10]. Early innovators were in the lead,followed by a mid range of hospitals underway.These hospitals had made some changes and
were planning for more but were not workingaccording to the guidelines at this stage. The rea-sons often were oriented financially. For example,
if a hospital had a collection of hydraulic high-low beds, there was an obvious need to re-investin new powered beds. Budgetary constraints
would have forced these hospitals to plan this
over a period of 5 years or more. Another majorreason for a slow implementation process wasa difference in priorities. The national approachmeant that the time frame of the whole process
was a national one. Local hospitals may havemade different plans already. There was, for ex-ample, one hospital that made the implemen-
tation of a policy aimed at protecting theirworkers against aggressive and sometimes violentpatients and their relatives as their first priority.
Finally, there also was a group of hospitals thathad not started at all yet. An approximate divi-sion can be made of 20%/60%/20% for thesethree groups. The latter group now is ‘‘gently
but firmly’’ pushed into taking action with some
Fig. 6. Transportation device. (Courtesy of Knibbe JJ,
Knibbe NE, Geuze L. Beter, Werkpakket Fysieke Be-
lasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,
Utrecht, 2003; with permission.)
Fig. 5. Wound care. (Courtesy of Knibbe JJ, Knibbe
NE, Geuze L. Beter, Werkpakket Fysieke Belasting Zie-
kenhuizen, Sectorfondsen Zorg enWelzijn, Utrecht, 2003;
with permission.)
210 KNIBBE et al
pressure from the Health and Safety Inspectorate.Among others, they look for the presence ofErgoCoaches. In 2005, monitoring revealed thatErgoCoaches were present in 56% of the hospi-
tals, whereas there were few (!10% of the hos-pitals) ErgoCoaches 4 years ago. Long-termmonitoring will have to demonstrate if a higher
national implementation degree will be in placeand be effective.
On a hospital level, especially in the acute care
situation, the hospitals that are in the leaddemonstrate a variety of changes: smaller ones(such as better wheels under some of the equip-
ment and having a longer line on the stethoscopesso that postural stress is avoided) and bigger ones(making a plan for investing in new beds thatcomply with the guidelines and the specific de-
mands of acute and critical care) [10].In conclusion, ergonomic changes in acute and
critical care are relevant. The general guidelines
also are relevant for this specific group of nursesand patients, but the diversity and medical com-plexity of this setting indicate that tailor-made
solutions often are necessary. Interventions aresuccessful but take up considerable time. A time-frame of more than 2 years is average. To
implement this, strong professional stakeholder-ship from nurses themselves is essential. Workingwith ErgoCoaches on these types of wards canfacilitate empowerment of the nurses themselves
in this implementation process and can ensure andstimulate commitment.
References
[1] Hignett S, Crumpton E, Ruszala S, et al. Evidence-
based patient handling. London: Routledge; 2003.
[2] Knibbe JJ, Friele D. The use of logs to assess expo-
sure to manual handling of patients illustrated in an
intervention study in home care nursing. Int J Ind
Ergon 1999;24:445–54.
[3] Nelson AL, editor. Safe patient handling and move-
ment. A practical guide for health care professionals.
New York: Springer Publishing Co., 2006.
[4] Waters TR, V Putz-Anderson. Scientific support
documentation for the Revised 1991 NIOSH Lifting
Equation. Cincinnati (OH): National Institute for
Occupational Safety and Health; 1991.
[5] Knibbe JJ,HooghiemstraF,KnibbeNE.Ergonomic
problems in hospitals [in Dutch]. In: Arboconvenant
Ziekenhuizen, Stand der Techniek, Eindrapport.
Doetinchem (The Netherlands): Elsevier; 2001. p.
1–95
[6] Chaffin DB. 3D SSPP (Static Strength Prediction
Program), version 5.04. Ann Arbor (MI): University
of Michigan; 2005.
[7] Jansen JP, Morgenstern H, Burdorf A. Dose-
response relations between occupational exposures
to physical and psychosocial factors and the risk of
low back pain. J Occup Environ Med 2004;972–9.
[8] Knibbe JJ, Knibbe NE, Geuze L. ErgoCoaches in
beeld [in Dutch: a view of ErgoCoaches]. Bennekom
(The Netherlands): LOCOmotion; 2005.
[9] Available at:www.vernet.nl.AccessedMarch30, 2007.
[10] Vree F van, Petersen A van, Knibbe NE. Monitor
Arboconvenant Ziekenhuizen, Eindmeting (Moni-
tor Follow Up), [in Dutch]. Leiden (The Nether-
lands): Research voor Beleid, LOCOmotion, 2005.
211LESSONS LEARNED IN THE NETHERLANDS
Creating a Culture of Change ThroughImplementation of a Safe Patient Handling Program
Karen Stenger, RN, MA, CCRNa,Lou Ann Montgomery, PhD, RN-BCb,*,
Eric Briesemeister, MSc,1aDepartment of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, Intensive and Specialty
Services 5JPP, 200 Hawkins Drive, Iowa City, IA 52242, USAbDepartment of Nursing Services and Patient Care, CNO T100 GH, University of Iowa Hospitals & Clinics,
200 Hawkins Drive, Iowa City, IA 52242, USAcBT 1000 GH, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
Nelson and Baptiste [1] stated in 2004, ‘‘Nurs-ing can no longer afford the ‘human sacrifice’ ap-
proach to patient handling defined as replacingthe steady stream of injured nurses with newly re-cruited nurses.’’ Clearly something more must be
done to protect bedside care providers and theirpatients.
Risks when handling patients manually
The statistics are telling. The OccupationalSafety and Health Administration (OSHA) has
calculated that nearly half of all health careworkers suffer at least one work-related musculo-skeletal injury during their career [2]. More than
half of all nurses (52%) complain of chronicpain and 38% of registered nurses (RNs) have suf-fered occupation-related back injuries severe
enough to require time away from work [3,4].Twelve percent of RNs consider leaving the pro-fession because of lower back pain [3] and in anAmerican Nurses Association (ANA) survey,
almost 60% of nurses list disabling back injuriesas one of the top three health safety issues [5].
In 2000, health care injuries caused time awayfrom work for nearly 11,000 RNs and nearly45,000 nursing assistants, orderlies, and atten-
dants who said that ‘‘re-exertion and overexertionin lifting’’ were the cause of the events [6].
The National Institute for Occupational Safety
and Health (NIOSH) is the federal agency re-sponsible for conducting research and makingrecommendations for the prevention of work-related injury and illness. For 90% of men and
75% of women, the maximum weight limit forlifting, under ideal conditions, is 51 lb [7]. Idealconditions include the presence of handles for
grasping, keeping the load close to the body,avoiding twisting of the trunk, and minimizingthe distance a load is carried. Clearly, patient han-
dling in clinical settings occurs in less than idealconditions. Zuidema and colleagues [8] reportedthat the maximum weight limit for lifting several
times throughout the day under less than idealconditions ranged from 22 to 33 lb for men and15 to 22 lb for women.
Health care workers may perform many man-
ual patient handling tasks daily or during theircareers that exceed these recommendations [9]. Anoverexertion injury may occur if the forces applied
to a nurse’s musculoskeletal system exceed its me-chanical strength [10]. For example, a nurse mayreposition a 200-lb patient in bed manually that
* Corresponding author. Department of Nursing
Services andPatientCare,University of IowaHospitals&
Clinics, Intensive and Specialty Services 5JPP, 200
Hawkins Drive, Iowa City, IA 52242.1 Previously held position of Safety Manager,
Department of Safety and Security, 2002–2006.
E-mail address: [email protected]
(L.A. Montgomery).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.007 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 213–222
results in an overexertion back injury. By con-trast, overuse injury may result when the rate ofcumulative damage exceeds a structure’s capacity
for healing and repair [10]. The wear and tearthat occurs daily in lifting and working manuallyin a bent and twisted position cause cumulativedamage and increase the risk for musculoskeletal
injury [10]. For example, a nurse who has spent20 years lifting critically ill patients manuallyone day may suffer an injury when doing a routine
manual lift. This acute insult may be superim-posed on the long-term cumulative effects of over-use injuries.
To protect health care providers and patientsfrom injuries related to patient handling, ergo-nomics has been investigated and researched toreduce the incidence and severity of job-related
injuries related to patient handling tasks. TheUniversity of Iowa Hospitals and Clinics (UIHC)embarked on a safe patient handling program in
2001. The UIHC is a 725-bed comprehensivetertiary-care academic medical center. There aremore than 2500 staff in the Department of
Nursing Services and Patient Care, approximately1400 of whom are RNs. There are more than 100radiology technicians and 20 inpatient physical
therapists and physical therapy assistants.The purpose of this article is (1) to describe how
this institution created a culture of change throughimplementation of a safe patient handling pro-
gram, as guided by the Iowa Model of Evidence-Based Practice to Promote Quality Care (IowaModel) [11,12], in order to decrease lost workdays
and reduce workers’ compensation costs and (2)to share lessons learned in the process.
Iowa Model of Evidence-Based Practice
to Promote Quality Care: considering
a practice change
The Iowa Model [11,12] served as a guide touse evidence for improvement of patient care
(Fig. 1). Following is a detailed description ofthe key components used to translate the evidenceinto safe patient handling practice.
Problem- and knowledge-focused triggers
A change in practice is considered as a result ofassessing the impact of factors in an environment.In 2001, several factors, or triggers, served as
catalysts for motivating UIHC to question thepractice of handling patients manually and mov-ing toward safe patient handling. Problem-
focused triggers include clinical problems seenrepeatedly in practice. The end results of theseproblems often are seen in risk management data.
At UIHC, there were an average of 121 nursingincidents per year related to patient handling from1997 to 2000. These injuries involved mainly theback and shoulder. With this volume of exertion
injuries, the units were faced with the need to re-place staff in direct patient care activities ona more frequent basis and for longer periods of
time. An increasing number of nurses, often expe-rienced nurses, found themselves unable to givedirect patient care because of the patient handling
injuries they had suffered. Staff noticed that theirpeers were becoming injured and were concernedfor their welfare and their own possible potentialrisk for becoming injured.
In addition, several knowledge-based triggersor newly recognized information, such as stan-dards and practice guidelines available from
national agencies and organizations, becameavailable. In 1992, the United Kingdom publishedmanual handling operation regulations. These
regulations govern regulatory and compensatoryaspects of patient lifting and require a risk assess-ment to be made for handling tasks and risks to be
reduced to the lowest level reasonably practicablebefore patient lifts occur [13]. Although these reg-ulations were in existence for several years, UIHChad no knowledge of them until the year 2001.
In October 2001, the Web site, www.patientsafetycenter.com [14], became recognizedmore widely as a resource mecca for the work of
Dr. Nelson [15] from the Tampa, Florida, Vet-erans Administration Medical Center PatientSafety Center of Inquiry. The downloadable,
128-page, Patient Care Ergonomics ResourceGuide: Safe Patient Handling and Movement, be-came available to serve as a resource to those in-terested in reducing the incidence and severity of
job-related injuries.As UIHC continued to develop a safe patient
handling program, more knowledge-focused trig-
gers occurred. In 2002, the draft of the Ergonom-ics OSHA Guidelines for Nursing Homes [16,17]was published. These guidelines were designed
to help nursing homes reduce musculoskeletalinjuries but also are applicable to acute care hos-pitals. In June 2002, the ANA adopted a statement
called, ‘‘Elimination of Manual Patient Handlingto Prevent Work-related Musculoskeletal Disor-ders’’ [18]. This statement provided support foraction and policies that result in the elimination
of manual patient lifting. In November of that
214 STENGER et al
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
NoYes
Yes
Is ChangeAppropriate for
Adoption inPractice?
YesInstitute the Change in Practice
Is Therea SufficientResearchBase?
Monitor and Analyze Structure,
Process, and Outcome Data
2. National Agencies or OrganizationalStandards & Guidelines
3. Philosophies of Care4. Questions from Institutional Standards Committee5. Identification of Clinical Problem
1. Risk Management Data
Problem Focused Triggers Knowledge Focused Triggers
• Staff• Cost• Patient and Family
Pilot the Change in Practice
1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based
Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline
The Iowa Model of
Evidence-Based Practice to Promote Quality Care
2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data
1. New Research or Other Literature
ConsiderOther
Triggers
Is this Topica PriorityFor the
Organization?
No
Form a Team
Base Practice on Other Types of Evidence:
1. Case Reports2. Expert Opinion 3. Scientific Principles4. Theory
Conduct
Research
Continue to Evaluate Qualityof Care and New Knowledge
No
Disseminate Results• Environment
= a decision point
Fig. 1. The Iowa Model of Evidence-Based Practice to Promote Quality Care. (Reproduced with permission from Mar-
ita G. Titler, PhD, RN, FAAN, Iowa City, IA. For permission to use or reproduce the model, please contact Dr. Titler.)
215CREATING A CULTURE OF CHANGE
year, ANA released their ‘‘Handle with Care�’’initiative [19]. This campaign’s purpose was toseek profession-wide effort to prevent back and
other musculoskeletal injuries through greater ed-ucation and training and increased use of assistiveequipment and patient-handling devices.
Is the topic considered a priority
for the institution?
The next step in the Iowa Model is to decide ifthe topic is a priority for the organization [11,12].Safe patient handling was considered a priority
for UIHC, triggered especially by the 121 averagenumber of annual injuries to staff (discussed pre-viously). Hospital administration charged the
UIHC Environment of Care Subcommittee withforming an ergonomics task force to begin to ad-dress how to improve the process of lifting and
moving for staff to minimize their risk for injury.
Form a team
The ergonomics task force was a multidisciplin-ary team chaired by the institution’s safety man-ager with representation from nursing, physical
therapy, the health protection office, and theworkers’ compensation office. The goal of thegroup was twofold: (1) to reduce injuries to direct
caregivers while maintaining patient safety and (2)to minimize exertion injuries for staff in nondirectpatient care activities, such as food, nutrition, and
environmental services. The task force met ona monthly basis but it became apparent afterapproximately 1 year that there could be more
impact if the group was separated into directpatient care and nondirect patient care subgroups.Although injuries to workers in each group weresimilar, the processes and resolutions would differ.
Assemble, critique, and synthesize relevant
research and related literature
The Iowa Model’s next step is to gatherevidence from research-related literature to de-
termine if a change in practice is warranted[11,12]. The remainder of this article describesthe process and outcomes achieved by the direct
patient caregiver subgroup of the ergonomicstask force to improve patient handling activities.
The ergonomics task force investigated litera-
ture, research findings, and expert opinion onpatient handling. Studies show that ergonomicapproaches to safe patient handling reduce staff
injuries. Specifically, assessment of stressful tasksand development of alternatives methods todecrease the stress can reduce the number of over-
exertion injuries [15,20–22]. Also, emphasis on edu-cation and trainingwith a focus on bodymechanicsmay not be enough in controlling musculoskeletalproblems [15,23,24]. The research does not show
conclusively that proper body mechanics can bemaintained during lifting among activities. Othervariables, such as the characteristics of patients,
environment, and caregiver, interact and have animpact on an experience. It seemed that a differentapproach was needed to solve the problem.
Considering sufficiency of a research base
and the role of expert opinion
The research literature, therefore, offered animperfect solution. The Iowa Model suggests that
if there is not a sufficient base of evidence to adapta change for practice, then practice changesshould be based on other types of evidence
[11,12]. The ergonomics task force decided to so-licit expert opinion on which to base a change.
Some of the staff wanted to explore the use of
a lift team to assist in patient lifting and movingactivities. The opinion of a consultant was sought,who had published on lift teams. In this model,
assigned ‘‘lifters’’ are hired by an institution to liftand move patients on an as-needed basis. Thebenefits of a lift team can include (1) a possibleimprovement in direct caregiver satisfaction re-
lated to not having to participate in lifts, (2)reduction in number of mechanical devices neededto move patients, (3) the possible result of de-
veloping a care team of lifters with expertise inthis activity, and (4) decreased costs that wouldoccur if all staff were trained to move and lift
patients [21]. The solution would have been an at-tractive option if not for one factor: the hospitaloccupies 3 million square feet spread over half
a mile and five pavilion buildings. There was nofeasible way that a few lift teams could respondto staff calls for assistance adequately and eco-nomically 24 hours a day, 7 days a week.
In 2001, the task force invited another consul-tant, a nursing researcher, to visit UIHC, assessthe patient handling tasks, and present informa-
tion on ergonomics to the committee and nursingmanagement. She gave encouragement, support,and motivation to implement a change to protect
staff and patients. The task force became con-vinced of the need to move to a comprehensive safepatient handling program involving all units and
216 STENGER et al
staff on the front lines who would be trained to liftand move patients safely whenever a need oc-curred. Although this option would have higherinitial capital investment for equipment and train-
ing costs, they believed it was the best solution.
Pilot the change in practice
The Iowa Model [11,12] suggests that the next
step is to pilot the change in practice. The taskforce believed, however, that they had to educateand raise awareness of staff on the hazards of man-
ual lifting and needed to secure financial supportbefore instituting a change. The strategies and pro-cesses used are described in the following sections.
Collecting baseline data
Vendor fairIn 2001, one of the strategies to educate staff
and get feedback on safe patient handling was toorganize a vendor fair. This vendor fair was heldin a large open meeting room and available for
staff to visit between 8:00 AM and 5:00 PM. Theroom was separated into four major sections sothat equipment could be displayed in a meaningfulfashion: total assist devices, stand assist devices,
repositioning aids, and beds with self- propelledfeatures. At midday, there was a presentationfrom a physician from the Iowa Spine Research
Center. The physician provided hands-on demon-strations of the impact of a sudden load and repet-itive motion on the spine. This helped staff
understand the risks they were taking when mov-ing patients without mechanical assistance. Therealso were poster displays of the research con-
ducted at the VA Patient Safety Center of Inquiry(Tampa, Florida) on safe patient handling. Staffwere asked to evaluate the various pieces of equip-ment from the fair and provide input as to
whether or not they would be interested in cham-pioning safe patient handling in their areas.
Unit assessmentsAnother important strategy for implementing
safe patient handling was to assess the need for
assistive devices in various inpatient units andambulatory clinics. Members of the ergonomicstask force, with the help of a vendor of choice,
visited 23 units andmetwith the nursemanager andstaff on each unit, asking asked them to identifyhigh-risk patient handling tasks and gathering
baseline data on patient handling. There wereapproximately 100 patients who needed limitedassist (patient has upper body strength and can
bear weight but needs limited help to stand), 200who needed extensive assist (patient has minimalupper body strength and can bear at least 50% ofthe weight on one leg), and 150 who were deemed
total assist (patient totally dependent on others toperform movement activity).
Equipment trialsAfter unit clinical assessments, portable equip-
ment from three different vendors was trialed.These vendors were chosen from the feedbackreceived from staff who attended the vendor fair.These companies could meet the basic minimum
requirements of having enough equipment andclinical support to trial on several areas. As partof this process, vendors would bring equipment to
trial and provide education and clinical support.For example, staff would know which daysa particular vendor would be at UIHC. The
vendor of the day would be provided with a pager,and staff were instructed to page when theyneeded assistance with a patient lift. Evaluationtools were developed based on information in
Patient Care Ergonomics Resource Guide: SafePatient Handling and Movement [15]. Some ofthe important criteria used to evaluate the equip-
ment were staff and patient input on overall com-fort and ease of use, power source requirements(battery versus electrical), design and ease of use
of slings, weight capacity, and clinical supportavailable for implementation success.
Ceiling lift trials were more complicated.
Ceiling lifts from the same three vendors weretrialed. One particularly successful trial had ceil-ing lifts from two vendors installed in one clinicfor approximately 1 month. With this setup, the
clinic could compare the lifts side by side. Anunanticipated outcome from the trial was thatwhen the trial ended, the staff did not want the
ceiling lifts removed! They had grown accustomedto them and wanted them to stay for patient useand staff safety.
Securing financial supportIn the spring of 2002, the ergonomics task
force submitted a capital request to the capitalbudget team for a 3-year comprehensive ergo-nomics program. NIOSH recommendations,
OSHA guidelines, and key literature findings forsafe lifting were presented [7,15,16]. The relation-ship between the project and the institutional stra-
tegic plan was articulated. Lost workdays,number of injuries, and workers’ compensationcosts associated with patient exertion injuries in
217CREATING A CULTURE OF CHANGE
the department of nursing were chosen as the out-come variables. An estimated projected cost of in-juries and a return on investment that could be
captured within 3 to 5 years were demonstrated.Institutional support was shown when the
capital request was funded 100%. The ergonomicproject was funded for $667,116. Some of the
units of nursing had unit money available topurchase two stand assist, three total assist, twoceiling motors and track, and lateral transfer
devices. This was a good pilot for use of theequipment by different vendors and the informa-tion that was obtained in their clinical application
was used in making the decisions for standardizedcapital purchased equipment. Just buying theequipment and offering education on how to usethe equipment was not enough for the health care
providers to choose to use the equipment. Therewere fears of using the equipment, lack ofconfidence that the equipment made a difference,
and lack of active support from peers or manage-ment for the health care provider to take the timeto use the equipment, especially if the equipment
was not located easily.
Designing practice guidelines and implementing
the practice change
Once a practice change is decided on, the IowaModel directs developing practice guidelines. Thenext step is implementing the change [11,12].
In late 2002, plans ramped up to adopt andintegrate safe patient handling program intopractice throughout the institution. This phase
included selecting the equipment, developing pol-icies and procedures, obtaining management sup-port, and educating staff in how to use the
equipment and to coach their peers to use theequipment. It continued with empowering keycoaches, who were all nurses and patient handlingprofessionals, improving the belief among staff
that moving patients with minimum lift tech-niques is best practice for staff and patients.
Selecting equipment
In October 2002, equipment was selected,
ordered, and allocated based on data from theunit and clinic assessments done in the spring.Originally, it was believed that equipment might
be shared between units and clinics but in thepilot, there was too much manual patient han-dling occurring to depend on sharing equipment.
The purchased equipment fell into five cate-gories: minimal stand assist; stand assist; totalassist; repositioning aids, including lateral transfer
devices; and ceiling lifts. The minimal assist deviceis used to assist patients who have upper bodystrength and the ability to bear weight but needassistance to get to the standing position. It also is
used to transport patients in a sitting positiona short distance. It requires no battery or electricalsource and has a 265-lb weight capacity. For
example, the labor and delivery unit in the hospitaluses these to assist new mothers recovering fromrecent epidurals or who have pain management
regimes. It also is useful for patients who needassistance getting to a bathroom quickly.
The stand assist device is used for patients whodo not have the strength in their upper body to
assist them stand but can bear at least 50% oftheir weight with at least one leg. A belt is appliedaround the waist and the machine helps support
the patient stand. It has a 420-lb weight capacity.The machine has a commode attachment so thatpatients can be raised and lowered on a commode.
This lift feature makes it easier for caregivers toprovide necessary hygiene after toileting. Patientsfind this device helpful. One patient, who had
been diagnosed with a recent stroke, requestedthis ‘‘purple pooping machine,’’ because it didnot require him to have to use a bedpan andgave him some privacy during bowel movements.
This machine also is used as a bridge to indepen-dence when patients need short-term assistance instanding up as strength is built up. Physical ther-
apists use the device for patients who are takingtheir first steps after a period of immobility.
Two kinds of portable total assist devices were
purchased. The device used most commonly hasa 440-lb weight capacity and can be used to movepatients from laying-down, sitting-up, and on-the-floor positions. Patients do not have to follow
instructions and can depend totally on the lift. Thetotal assist also has a scale that has proved helpful.
The other total assist device was developed to
assist patients getting out of a car. The emergencydepartment and guest services department havefound this device invaluable in getting patients out
of a car. A sling is placed behind a patient,wrapped around the patient’s legs, and thenattached to the machine, which moves the patient
out of the car. Patients note that using the machineto get them out of the car is less painful comparedwith manual movement. This portable dependentlift also is used in clinic areas, as it folds up and
requires less room to store. It can be used in the
218 STENGER et al
same situations as the other total assist lift exceptthat it has a lower weight capacity, at 308 lb.
Lateral transfer devices are used to repositionpatients in bed and transfer patients from one
horizontal surface to another, such as bed to cart.A lateral transfer kit was purchased that includedtwo 6-ft slippery sheets with handles and a small
orange tube. The sheets are placed under patientsto reduce friction when moving in bed. There aremany applications for these devices, including
sliding patients up in bed, turning them, pronatingthem, and transferring them from a cart to bed.
An air lateral transfer device is helpful when
moving patients of size up in bed or laterally toanother surface. An electrical motor supplies thepower to expand the attached mattress with air.The result is the creation of an air mattress that
reduces the friction greatly beneath patients dur-ing lateral transfer. There is no reduced frictionwhen the air is not in the mattress, so patients may
lay on them safely, when the head of a bed is up,without sliding down. This apparatus is usedfrequently under surgical patients of size for easier
transfer to and from perioperative surfaces.Ceiling lifts are total assist devices that can be
used with many patient handling tasks. Assisting
patients from a wheelchair to a cart was a difficult,high-risk manual patient handling task beforeceiling lifts were installed.
Developing policies and procedures
A policy guideline was developed addressinghow the program would run and how the equip-
ment would be used. The policy comes short ofmandating equipment use. We allow choice by thecaregiver, but do follow-up, counsel, and poten-tially address disciplinary actions if injury occurs
and equipment is not used.
Educating staff and obtaining management support
By December 2002, the initial order was placedfor equipment and the task of extensive educatingstaff begun. At the same time as the equipmentwas purchased, a 3-year contract for clinical
support was signed. The clinical consultant as-signed to the hospital by this vendor presented tothe hospital management staff and nursing leader-
ship to map out the proposed education imple-mentation process. She also offered a 2-hourmeeting at several different times and days for
nurse managers to attend to provide an overviewof the proposed safe patient handling programand outline the key role nurse managers would
play to change culture on their units. Nursemanagers were asked to identify staff that wouldserve as transfer and mobility coaches, or keycoaches. These key coaches would be instrumental
in implementation of the safe patient handlingprogram. They included managers, staff nurses,advanced practice nurses, nursing assistants, nurs-
ing units clerks, and physical therapists. What isimportant is that they have passion to create theculture of change and eventually role model safe
patient handling skills in their respective units.The institution chose to roll out the equipment
and educate on the equipment by divisions of
nursing (ie, adult intensive care and specialtyservices, medical and surgical services, women’sand children’s services, and behavioral health andperioperative nursing areas). Key coaches were
taught by the clinical consultant in an 8-hourtraining session the week before divisional stafftraining. Four 8-hour classes of key coach training
were offered. Ten to fifteen staff members servingas key coaches were trained each day on ergo-nomic and coaching principles. The clinical con-
sultant worked with the nursing education centerto develop competency-based orientation check-lists for staff to use. One of the first responsibilities
of key coaches was to sign off, with returndemonstration, the staff on their unit as havingtrained on all the equipment.
The rest of the staff, who were not key coaches,
attended a 2-hour training session added to theannual mandatory competency sessions. Thisstrategy was a convenient way to educate staff
on a day when they were not responsible for directpatient care. The clinical consultants taught the2-hour class with content on risks of manual lifting
and how to use the new equipment. To assurethe ability to train individuals adequately, up to6 rooms of classes were running simultaneously sothat no more than 15 staff members were in a room
at one time. By the end of March 2003, all nursingunits had key coaches and staff trained. Allequipment was distributed to the units.
Evaluating the outcomes
Once a practice change is infused, the Iowa
Model directs evaluating the process and outcomes[11,12]. The outcomes were selected to monitorthe number of injuries, lost workdays, and cost.
Staff outcomes
Anecdotally, the staff have been impressedfavorably. One staff member left a picture of the
219CREATING A CULTURE OF CHANGE
stand assist device on the door of her unit nursemanager, reading, ‘‘Please hire 6 of these folks!’’Another nurse noted, ‘‘I was going to have to
leave this unit because of all of the lifting, nowwith the equipment, I can stay.’’ Another said,‘‘We had to pick a patient up off the floor. Wewent and got the (total assist). I think we saved
four back injuries.’’ Staff on one unit, who werecaring for a paraplegic patient, commented posi-tively on the ceiling lift. The staff previously
would try to lift the patient manually to see allof his wounds. This was a difficult and risky taskfor staff and embarrassing for the patient. With the
new ceiling lift available, they were able to use themachine to provide the necessary wound assess-ment while maintaining the patient’s dignity.
Specific indicators used to analyze the effec-
tiveness of this project included lost workdays,workers’ compensation costs, and the number ofOSHA recordable patient exertion injuries within
the Department of Nursing Services and PatientCare (Table 1). From 2002 to 2004, lost workdaysdecreased from 2881 to 529, a 76% reduction. In
addition, the cost of replacing an injured em-ployee in the workplace can be substantial. IfUIHC replaced every one of the 2352 lost work-
days with another employee, it would be equiva-lent to the hiring of nine full-time employees.The cost estimated for nine RN full-time em-ployees salaried conservatively at $66,000 per
year (including benefits) would be approximately$600,000. From 2002 to 2004, workers’ compensa-tion costs fell from $559,610 to $84,880, indicating
an 85% reduction. In 3 years, UIHC reducedworkers’ compensation costs by more than$475,000. UIHC also has seen a reduction in the
number of OSHA recordable patient exertions.From 2004 to 2006, recordable exertions de-creased by 18%, from 92 to 75. It seems that theinstitution recovered the initial investment and
noted a reduction in the number of claims.Although the OSHA recordable rates do not
continue to decline, there has been a decrease in
severity, something Dr. Nelson said likely wouldoccur (Audrey Nelson, RN, personal communi-cation, 2004). Building a culture of safety often
resolves the musculoskeletal injury underreport-ing problem that has plagued nurses for years.Effective programs are more likely to see a possibleincrease in injury rates but a significant decrease
in severity of injuries (fewer lost workdays andlower workers’ compensation costs). Most of thecurrent injuries seem related to moving patients
up in bed or moving and lifting obese patients. Inmany of these situations involving obese patients,proper technology and equipment do not exist or
are in early stages of consumer use.
Patient outcomes
Several patients have commented favorably
about the ergonomic equipment. Some of thecomments included, ‘‘Please use the machineinstead of lifting yourself’’ and ‘‘Since I have
had bone cancer, I haven’t been moved thispainlessly.’’ A patient had been in one of theadult ICUs for a long time before being trans-
ferred to an intermediate care unit. He weighed400 lb. He had not been out of bed, because thestaff could not move him. Physical therapy hadconvinced him to try the stand assist device. He
did so and eventually was able to progress to fullmobility. His story eventually was included in theUIHC annual report, because the patient wanted
to tell others that ‘‘I would have never got out ofbed if it wasn’t for that machine’’ [25].
Disseminating the results
The final step of the IowaModel [11,12] is to dis-seminate results. UIHC is dedicated to keeping asmany people as possible updated and aware of their
work. Injury data is shared on a monthly basis atthe UIHC’s Environment of Care Committee,which reports directly to the Hospital AdvisoryCouncil. On a quarterly basis, two of the authors
(Stenger and Montgomery) make rounds of thenursing shared governance committeesdincludingthe nursing administration council, advanced prac-
tice nurse council, and staff nurse councilsdtoshare injury data trends, training plans, equipmentissues, and previous and current challenges and
successes. Annually, the work was and continuesto be reported to hospital administration throughyearly reports or project summaries.
Table 1
Annual report of patient handling figures
Annual report 2002 2003 2004
Number of claims 92 83 75
Lost workdays 2881 1020 529
Workers’
compensation
costs
$559,610 $245,677 $84,088
Equipment
expenditures
d FY2003
$667,116
d
220 STENGER et al
Lessons learned
Some valuable lessons have been learned in thecourse of overseeing this project. It was essentialto partner with the Joint Office for Marketing and
Communication to get the word out throughflyers, broadcasts, and internal media to anydepartment affected even remotely by the project.
Secondly, it is important to partner with preferredvendors. They can be excellent sources to assistwith trouble shooting, maintenance and replace-
ment of equipment, and product growth. Third,key coaches are great change agents at the localunit level. They are truly the ones who affect
practice and change the cultural mindset of peersand patients. Monthly key coaches meetings areessential to keeping this group empowered andupdated regarding safe patient handling practice.
Units that have active key coaches have a highercompliance of using the ergonomic equipment.Fourth, it is important to know upfront that safe
patient handling skills take time to develop andpersistence to sustain. In this case, initial compe-tency activities and related documentation took
a year for 1500 employees. Fifth, as any newpractice, there is a need to constantly re-educatestaff and re-infuse the desired practice. Coordina-
tors have to keep this goal continually on every-one’s radar. Sixth, share the ‘‘numbers’’ andstories with shared governance councils and lead-ership. It is essential that managers in key units
know how the program is progressing so thatthey can role model necessary practice improve-ments for staff and keep the practice changes go-
ing. Seventh, be prepared to make adjustmentsin current equipment or any purchased in the fu-ture. The ergonomic equipment purchased must
interface safely with other hospital equipment.For example, one lift purchased did not fit undersome of the beds. The bed casters were too low tothe floor. These casters had to be changed out to
larger ones. Such findings were commonplace inremote areas of radiology, for example, so be pre-pared. Eighth, ‘‘think ergonomics’’ when planning
construction and renovation projects. It is easierto build with these needs considered upfront in-stead of trying to retrofit equipment into existing
plans, especially ceiling lifts. Step up and suggestthat ergonomics considerations be added to everyconstruction renovation plan in your institution.
Ninth, a consistent process for ongoing educationof new health care providers is vital. Return dem-onstration here assures check-off lists are com-plete. Content in annual competency sessions
also is important to portray the importance ofsafe patient handling and assist staff in feelingcomfortable and proficient in use of the equip-ment. Tenth, include other health care providers,
such as radiologists, on the task force. Theyhave many high-risk tasks that can be performedin a safe manner with the use of the equipment.
Finally, if the initial ordering were repeated,more portable and ceiling total assist lifts wouldhave been purchased. The need for these in this in-
stitution was grossly underestimated.
Are you moving patients safely?
Most back injuries are the result of physiologicillnesses that develop over a period of weeks,months, or years as a result of prolonged me-
chanical stressors imposed on the musculoskeletalsystem. Research indicates that lifting more than51 lb under ideal conditions is not recommended
[7]. Nurses, however, routinely believe 100 lb islightdbut it is not. All health professionals areasked to stop and consider this fact carefully be-
cause every one of us is too valuable to risk beinginjured as a result of not taking time to plan aheadand move patients safely using lifting and moving
equipment.
Acknowledgments
We would like to acknowledge the followingstaff for their assistance in developing this man-
uscript: Linda Q. Everett, RN, PhD, CNAA, BC,FAAN, Associate Director, University of IowaHospitals and Clinics and Chief Nursing Officer,
and Linda K. Chase, RN, MA, CNAA, SeniorAssistant Director–Nursing Administration, foradministrative support; Becky Hurt, Secretary III,Nursing Clinical Education Center, and Shellee
Laubersheimer, Secretary IV, Nursing Adminis-tration, for clerical support; and David Hack-barth, Safety Engineer, Health Protection Office,
for data analysis support.
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Handling of the Bariatric Patient in Critical Care:A Case Study of Lessons Learned
Marylou Muir, RN, COHNa,*,Gail Archer Heese, BEd, OTR, BMRa,
Daria McLean, RN, COHN(C)a, Sheila Bodnar, RN, BNb,Betty Lou Rock, RN, BNc
aWinnipeg Regional Health Authority (WRHA), Occupational and Environmental Safety & Health Unit,
Health Sciences Centre Site, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, CanadabMedical Intensive Care Unit and Coronary Care Unit, Health Sciences Centre,
820 Sherbrook Street, Winnipeg, MB, R3A 1R9, CanadacWRHA Critical Care, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
Literature review
The World Health Organization [1] has identi-fied that the obesity epidemic is increasing atalarming rates across all developed nations. Seen
as one of the most significant worldwide healthproblems, it is estimated that more than 1 billionadults worldwide are overweight and 300 million
are obese [2,3]. In the United States (US) alone,the incidence of obesity has doubled in the pastdecade to 38 million, 9 million of whom are cate-gorized as severely obese. This increase is occurring
in both genders and across age groups, races, andeducational levels [4]. The obesity epidemic coststhe US health care system $70 billion per year [5].
The direct medical costs attributable to adultobesity in Canada were estimated at $1.8 billionin 1997 or 2.4% of total direct medical costs [6].
Bariatrics is the science of providing healthcare for the proportion of the obese populationconsidered to suffer from extreme obesity. Bari-
atric patients are described by the followingdefinitions: overweight by more than 100 to 200lb and body mass index (BMI) greater than 40, orbody weight greater than 300 lb [7].
The increased number of bariatric patientsrequiring hospitalization and critical care matches
the increase growth in the population at an
epidemic proportion [8]. The current trend oftreating these patients through bariatric surgicalinterventions has contributed to increased admis-
sions into critical care units because of postopera-tive complications [8]. One study identified that upto 24% of bariatric surgery patients required ad-
mission to a critical care unit [9]. Nonsurgical ad-missions of bariatric medical patients to criticalcare areas also is increasing. Unfortunately, thereis a high mortality rate for these patients because
of patient delay in accessing treatment. It is be-lieved that one reason patients delay access totreatment is the inability of communities to ac-
commodate patients with expanded capacityequipment needs in medical clinic settings [9]. Ofpatients currently who are admitted to critical
care units, the prevalence of (US) patients whohave extreme obesity ranges between 1.4% and7% [10–12]. The mortality of those who are obese
in ICUs has a reported odds ratio of 2:1 comparedwith patients within normal weight ranges [13].
Nurses are challenged when caring for bariat-ric patients, because tasks require increased time
and additional patient handling solutions andskills [14]. Inappropriate equipment or staffinglevels are identified as contributing factors that
lead to staff reluctance to provide care [7]. A sur-vey of the University Health System Consortiumreports that 39% of reported accidents or
* Corresponding author.
E-mail address: [email protected] (M. Muir).
0899-5885/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.010 ccnursing.theclinics.com
Crit Care Nurs Clin N Am 19 (2007) 223–240
equipment-related problems are related to bariat-rics [15]. The same survey reports further that55% of nursing personnel report injury claims re-
lated to providing patient care. Patients them-selves also report claims, 18% of which arerelated to equipment inadequacies [15]. Overall,data addressing bariatric patients who are criti-
cally ill are scant and information on patient han-dling issues is even less available. There are toofew publications dealing specifically with patient
handling techniques and recommendations to as-sist with strategic management of these patients.
The emotional task of caring for these patients
also is affected by the high rates of morbidity andmortality in a young population. Several studieshave documented health care worker and physi-cian negative attitudes and stereotypes, including
fear of injury, disgust, or anger, which hasa negative impact on patient care [16,17].
Health Sciences Centre, Winnipeg, experience
TheHealth Sciences Centre (HSC) is a teaching,tertiary care facility in the core area of Winnipeg,Manitoba, Canada, which has a population of
600,000. The facility does not have a bariatric sur-gical program, yet receives an average of 30 to 40bariatric admissions per year. The definition used
to identify bariatric patients in this facility is weightover 350 lb. The most common weight range of ad-missions to the facility during the past 5 years wasin the 400- to 450-lb weight range (Fig. 1). During
a 5-year period (2001–2005), nurses requestedassistance consultations on patient handlingtechniques for 78 bariatric admissions (54 men
and 24 women). These patients were admitted formedical issues needing treatment, with approxi-mately 37% admitted to critical care units.
Bariatric patient handling resources
Over the past 10 years, the HSC has evolved inits provision of supports for bariatric admissions.
The facility has made provisions to assist nurseswith the necessary knowledge that is outside thenurses’ usual knowledge base. Equipment andpatient handling guidelines, access to patient
handling education, and corporate policies aresome of the ways HSC can ensure health carenursing personnel provide sensitive and dignified
patient care in a safe manner for themselves andpatients. Details of tools in place include
� Bariatric patient handling policy: identifiesadmission process, current list of and accessto equipment, team members, and methodof consulting (Fig. 2).
� Patient handling education: all new em-ployees receive a 3.5-hour class on minimal-lift patient handling. Nursing personnel are
asked to contact the trainers in the event ofbariatric admissions or transfers to assistwith specific bariatric patient handling tech-
niques and equipment needs.� Bariatric patient handling algorithms (Figs.3–7): each unit has access to a binder thathas algorithms for safe patient handling tech-
niques. These algorithms were adapted fromthe patient care and resource guide from theVeterans Affairs (VA) Patient Safety Center
of Inquiry in Tampa, Florida, directed by Au-drey Nelson. There are five algorithms specificto bariatric patient handling tasks. These
tools assist nursing personnel in identifyingthe safest methods for patient handling tasksbased on patient assessment and equipment
available.� Bariatric patient assessment tool: a tool usedto identify the equipment and procedure forproviding care to patients (Fig. 8).
� Bariatric safe patient handling work proce-dures: these are provided to nursing personnelin a written format. They describe the step-
by-step procedures for the associated patienthandling tasks when repositioning or transfer-ring bariatric patients using slider sheets.
� Bariatric equipment pool: the patient equip-ment services department provides expandedcapacity equipment to the units on request.Items available are lifts, slings, friction-reduc-
ing devices (sliders), beds, wheelchairs,stretcher chairs, footstools, commode chairs,and walkers.
051015202530
Nu
mb
er o
f
Patien
ts
300Lbs
350Lbs
400Lbs
450Lbs
500Lbs
550Lbs
600Lbs
650Lbs
700Lbs
750Lbs
With Weight Above
Fig. 1. Bariatric patients assessed on admission from
2001 to 2005. (Courtesy of the Health Sciences Centre
and the Winnipeg Regional Health Authority, Winni-
peg, Manitoba, Canada; with permission.)
224 MUIR et al
Fig. 2. Patient care policy and procedural manual of the Winnipeg Regional Health Authority. (Courtesy of the Health
Sciences Centre and the Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; with permission.)
225BARIATRIC PATIENT CARE: LESSONS LEARNED
Fig. 2 (continued)
226 MUIR et al
� Injury prevention training supports: resourcesare available for staff concerning any patienthandling or mobility difficulties from variousdisciplines. Allied health, including physio-
therapy, occupational therapy, and patienthandling trainers from the occupational andenvironmental safety and health unit are
available for consultation. Most commonly,staff request hands-on participation from thetrainers, especially during difficult patient
handling tasks. Most requests are made inthe early stages of admission or until theyfeel proficient to manage the techniquesindependently.
Process for the management of admission
When bariatric patients are admitted, corpo-rate patient care policy requires that a nurse
identify the equipment and training needs forthe unit and the health care needs of the patients.The nurse consults the patient handling manualon the unit that identifies available equipment
with its weight capacity, safe patient handlingalgorithms, safe work procedures, and a patientassessment tool template. Additionally, the nurse
determines if the space assigned is adequate forpatients’ care and their specific equipment needs.If patients require expanded capacity equipment,
the policy allows a two-patient bed space to beconverted to a one-bed space. The nurse alsodetermines the need to consult the appropriateresources for any assistance required. Team mem-
bers who may be consulted include, but are notlimited to, the following: physician, ergonomist,occupational health nurse, safety technician, phys-
iotherapist, occupational therapist, wound carespecialist, dietician, maintenance technician, andunit manager.
Fig. 2 (continued)
227BARIATRIC PATIENT CARE: LESSONS LEARNED
Fig. 2 (continued)
228 MUIR et al
Fig. 3. Bariatric patient handling algorithm #1. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
229BARIATRIC PATIENT CARE: LESSONS LEARNED
Case study
History
Mr. B was a 42-year-old man. His admissionweight was 697 lb, height 6 ft 2 in, BMI 91. Until
his illness, he was employed part time, able to
ambulate one block with a cane before becomingfatigued, and independent with hygiene, meals,and laundry. He lived with his stepmother in
a bungalow. His father had passed away 3 weeks
Fig. 4. Bariatric patient handling algorithm #2. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
230 MUIR et al
Fig. 5. Bariatric patient handling algorithm #3. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
231BARIATRIC PATIENT CARE: LESSONS LEARNED
Fig. 6. Bariatric patient handling algorithm #4. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
232 MUIR et al
before his admission. His medical history included
a diagnosis of rheumatoid arthritis, gout (mostlyaffecting his knees), and type 2 diabetes mellitus.Three days before his admission, he experiencedshortness of breath on minimal exertion. He called
an ambulance and on arrival at the emergencydepartment was unable to bear weight or maintaina sitting position. He was admitted because of
coffee ground emesis and abdominal pain, de-creased blood pressure, and decreased level of
consciousness. He was given blood products and
intubated for respiratory ventilation. He pro-gressed to develop bacteremia, acute renal failure,and elevated liver enzymes. Because of fluidretention, his weight elevated to 712 lb. He
remained in the ICU for 95 days.
AdmissionWhen Mr. B was admitted, the unit contacted
the patient handling team to assist in applying
Fig. 7. Bariatric patient handling algorithm #5. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
233BARIATRIC PATIENT CARE: LESSONS LEARNED
techniques required to reposition, weigh, sit up,
and transfer the patient. Medical problems, suchas diabetes, cardiovascular disease, hypertension,stroke, certain types of cancer, and osteoarthritis,
commonly associated with bariatric patients, can
contribute to difficulties during patient handling
tasks [17,18]. The patient assessment of Mr. Bidentified several medical problems that requiredattention during patient care and handling
activities.
Patient: Weight: Height:
Ward: Room#
Assessed by: Date assessed:
Position of Assessor: Strong side: Right Left
Staff has reviewed Large Patient Handling Guidelines
Capabilities of Patient: Requires the Following Large Patient Equipment (Equipment Pool # 5031):
Ambulatory Total Body Mechanical Lift Ambulatory with assistance (large walker)
Wheelchair
Non weight-bearing Stretcher Can move in bed without assistance Commode Can move in bed with assistance Slider Board Cannot assist movement in bed at all Step Stool
Walker Armchair and footstool Reclining stretchair Bed Slider sheets
Is the bed on the ward appropriate for this patient? Yes No, large person bed has been requested
Patient Handling Requirements (Review Large Patient Handling Guidelines):
Task# of Staff Members
RequiredType of Equipment
Required
Bed Boost
Bed Turn
Side to Side Movement in Bed
Bed to Stretcher Transfer
Bed to Chair/Commode Transfer Transport Within the Hospital
Comments:
Fig. 8. Large patient assessment checklist (for nursing care plan). (Courtesy of the Health Sciences Centre and the
Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; with permission.)
234 MUIR et al
Respiratory status. The patient required intuba-tion, resulting in a tracheostomy and ventilation.Elevation of the head of the head of the bed wasrecommended to facilitate breathing compro-
mised by the weight of the chest wall, andimpingement of the thoracic cavity by the largeabdomen and fat deposits in the intercostals and
diaphragm [7,19]. Lowering of the head of the bedwas limited to short intervals during turns and re-positioning, as the patient could tolerate the flat
position for only 5 to 10 minutes.
Central nervous system. There were times whenthe patient was semicomatose and confused be-
cause of sepsis. At times he was not able to assist,follow directions, or assist with repositioning.
Gastrointestinal and genital urinary. The patient’snutritional needs were met with tube feeds formost of his admission in the ICU. His weight
reduced from 697 lb to 550 lb during 13.5 weeks ofhis stay in the ICU. Because of tube feeds, thepatient had frequent diarrhea. He was incontinent
of urine and spent time in renal failure. A Foleycatheter and Bardex rectal tube were in place toassist in monitoring output and assist in prevent-
ing further skin breakdown.
Immune system. Isolation was required because ofpoor immune response, partly from pancytopenia.
A private room was provided.
Musculoskeletal. The patient had severe weaknessand poor strength in arms and legs. He was ableto assist with upper body strength during turns
using the overhead trapeze bar when he wasconscious. His legs were weak and he was unableto move them independently or turn his body
from side to side.
Skin integrity. Skin integrity was compromised
from the excessive skin folds and poor nutritionalstatus, including diabetes. He had a pressure ulceron the coccyx and thigh and leg ulcers. A low air-
loss pressure reduction mattress and friction-reducing devices during turns, with close attentionto skin integrity, were required.
Psychosocial. The patient was grieving the recentdeath of his father. He had some family members
and co-workers visit during his admission butoften was too ill for social visits. Despite hissituation and isolation, he did not demonstratea depressed mood often. He always was thankful
for his care.
All of these medical conditions are not un-common for bariatric patients and are welldocumented in the bariatric literature [7,14,19].
The critical care unit
The critical care area in this case study islocated at the HSC. The unit is a 10-bed care unit
specializing in care for critically ill patients andalso houses a 6-bed unit for intensive coronarycare. Most nursing personnel follow a 12-hourshift rotation.
Annual training refresher courses and newemployee orientation are provided on patienthandling techniques to the medical ICU nursing
personnel. Friction-reducing devices (slider) use isencouraged for turning the patients on a bed,boosting patients up in bed, and during lateral
transfers. Mechanical patient lift devices are pro-vided for bed-to-chair transfers. In the case of thisbariatric admission, further assistance was re-
quired with hands-on teaching in the unit.
Patient handling equipment provided
The following equipment was provided for thepatient; some was available on site, and others
had to be rented:
� Bariatric bed with rated weight to 1000 lb and
a 48 inch sleep surface� Three double-width bariatric slide sheets (fric-tion-reducing devices)
� Mechanical lift with scale and capacity tomanage up to 1000 lb� Custom bariatric sling
� Wedge pillow, to maintain turning postures� Pressure-reduction, low-air-loss mattress� Stretcher chair
� Standing tilt table� Overhead repositioning trapeze bar� Step stool or bench for nursing personnel tostand on
Patient handling tasks
Table 1 reviews the patient handling tasks, thetechnique, equipment used, and the number ofpeople required. The desired outcomes from the
patient handling tasks included maintenance ofskin integrity to prevent further breakdown; facil-itating circulation to the heart, lungs, and extrem-
ities; monitoring the patient’s weight; meetinghygiene care needs; preventing infections; provid-ing a safe patient handling environment, thus
235BARIATRIC PATIENT CARE: LESSONS LEARNED
preventing injuries to health care nursing person-nel and to patients; maintaining or encouraging
patient strength in extremities; and providinga dignified respectful environment during allinteractions.
A daily patient handling care plan schedule forrepositioning was designed and posted. During therepositioning procedure, several other activities,
such as hygiene care, wound care, and pericare, alsowere provided. This included deflation and reinfla-tion of the Bardex tube, during each turn,
assessment and adjustment of the Foley catheter,treatment of skin excoriations in creases, and treat-
ment of any wounds. Most tasks required 6 to 8nursing personnel. Six nursing personnel were inposition to perform the maneuver using sliders;
the other two nurses provided the necessary treat-ments. Every other day, the procedure also in-cluded weighing the patient using a mechanical
lift. Changing of bed linens and insertion and re-moval of the bariatric sling were required at thistime. On two occasions, the patient was lifted
Table 1
Patient handling tasks
Patient handling task
Number of
nursing staff
Equipment
required Algorithm Technique
Repositioning in bed 8 Two double-width
sliders
Overhead trapeze
bar
#3 Slider insertion
with head-to-toe unraveling
Changing bed linens 8 Completed during
turns using sliders.
Also done when
up in lift
N/A
Weighing patient 6 Lift (Titan 1000 lb)
with
scale and sling
N/A Sling insertion
between two sliders
technique
Transferring patient
to stretcher chair
8 Three double-width
sliders
#2 Lateral transfer technique
Transferring patient
to alternate bed
8 Mechanical lift
(rated to 1000 lb)
with sling
#2 Sling application
using slider insertion
method
Lifting patient
with mechanical lift
device and suspending
in air while
bed switching occurs
Transfer patient
to standing tilt table
8 Three double-width
sliders
#2 Lateral transfer
with sliders
Chairing patient
in cardiac chair position
1 Bed with
cardiac chair
feature
N/A Using bed technology controls
Hygiene care
to abdominal groin Area
4 Long sheet
fan folded
#5 One nursing
personnel stands on each
side of bed facing
patient’s feet; the sheet
is fan folded,
placed against the abdomen,
and used to lift
the abdomen during
hygiene care
Accessing patient
(lines, tracheostomy,
and so forth)
1 Platform to stand
on to elevate
nurse to proper
height
N/A Teaching nurses
to not over
reach during care
236 MUIR et al
with the mechanical lift to facilitate a well-coordinated bed transfer (removal of one bed andprovision of another). When a lateral transfer wasperformed, six people performed the maneuver
while one observed the patient and another ob-served the patient lines (IV central lines, intubationequipment, Foley bags, and Bardex).
Lessons learned
The technology of bariatric equipment hasimproved greatly during the past 5 years withnew and emerging equipment designed that ac-
commodates these patients. Although equipmentmay be rated for increased weight, it often is notdesigned properly to accommodate the increased
size of patients (Table 2). The purchasing facilityshould put more emphasis on patient assessmentand equipment fit, instead of weight capacity.This applies to wheelchairs, commodes, stretchers,
walkers, and beds. Companies that manufactureequipment need to solicit more feedback relatedto equipment design needs from facilities’ front-
line health care nursing personnel.
Lift choices
A lift from another facility was borrowed, as
that in the HSC were weight rated to only 600 lb.A floor lift was used but found difficult to maneu-ver under the load during bed transfers. A ceiling
lift would have been easier to use under the cir-cumstances as the space and exertion require-ments would have been less.
Sling design
A sling should not bind or cut into a patient’sthighs nor should it constrict the shoulders. It
should provide good support and not be uncom-fortable. Currently, there is a limited choice inbariatric sling sizes. Regular lift slings are provided
in a range of six sizes for patients weighing from 35lb to 500 lb; however, it is common to find that onlyone sling is provided for patients spanning 500 lb to1000 lb. A patient’s individual body type, height,
and individual physical characteristics complicatea sling’s fit further. A custom sling needed to beordered for this patient at his initial 750-lb weight,
although the ones provided with the lift could beused when his weight decreased to 500 lb. In anideal situation, a facility should have a range of at
least four bariatric size slings tomeet different bodytypes. Additionally, extra slings are needed toenable the slings to be sent for frequent laundering.
Bed design
The bed manufacturers have improved selec-tion and the ability to accommodate bariatricpatients by providing beds that can expand and
adjust to several sizes. When fitting a bed toa patient, ensure that the bed is the right size. Asleep surface that is too small limits the patienthandling maneuver; conversely, too wide a bed
surface causes the health care nursing personnel toover-reach. Bariatric beds need to lower beyonda regular bed capacity. A patient’s body thickness,
increased air mattress thickness, and the need tohave the head of the bed elevated puts a patientout of reach of health care workers almost
constantly. The need to access a patient throughover-reaching resulted in a shoulder injury to oneof the nurses. Also, the authors have foundinstances when a patient could not reach the floor
to stand, as the bed was too high. The bed must beeasy to set up and transport in a quick and easyfashion, between units. A bed that can be reduced
to 39 inches will fit through most facility door-ways and then be expanded to the necessary widthto accommodate patient size once in the room is
optimal. The facility experienced many difficultieswhen transferring the patient’s bed betweenthe units. The patient could not be transported
in the bed because of a width of 48 inches. Thus,the patient had to be removed and the beddisassembled and reassembled manually at thedestination. Some newer bed designs have a power
transport feature, preventing worker exertion.Additionally, equipment tuggers to move thebeds are another option.
Bed mattress
The facility bed comes with a regular foam
mattress. In this case, it was not effective inpreventing skin breakdown to the patient. A lowair-loss mattress was rented rated for 1000 lb. The
mattress available for rent was only 39 in wide, sobolsters were placed on either side, to fill theremaining space. The bolsters were problematicwhen the patient was dangling, as they separated
from the mattress and needed extra reinforcementwith duct tape. Although the mattress did not fillthe entire bed space, it worked well to facilitate
skin integrity. The mattress did not inflate underload and the patient needed to be removed fromthe mattress to reinflate it. The variable pressure
oscillation on the mattress was a great feature. Itrotated pressure relief to varying parts of thebody using cyclical timed intervals.
237BARIATRIC PATIENT CARE: LESSONS LEARNED
Table 2
Problems and solutions associated with patient handling tasks
Problems Action taken Future recommendations
Recruiting enough nursing
personnel to assist with
repositioning, especially
scheduled turns.
Unit manager and director
arranged with other
managers to send staff
to assist at designated times
(every 3 hours).
Light refreshments were provided
as a gesture of appreciation for
those that attended.
Have a designated scheduled time, with
people identified to attend from other
units.
Provision of snacks as a goodwill
gesture of thanks.
Knowledge on techniques varied
between staff and shift changes.
Hands on and reinforcement of
techniques needed frequently.
Trainers consulted 2–3 times per
day initially. This decreased
to once daily and then on
request only.
Trainers needed to be available
to problem solve for
unexpected events. Otherwise
trainer’s attendance was
scheduled.
A draft manual with techniques,
protocols and algorithms
was provided as a resource
and kept on front of the chart.
Designated trainers in critical care units
need to be identified, trained, and
supported to problem solve and be
available more readily to their own
staff for when admissions occur.
Algorithms and safe work procedures
should be posted in room for easy
reference.
Transfer of knowledge and skills
when patient transferred to
another ward limited.
Critical care manager arranged
for critical care staff to attend
the unit on several occasions to
ensure transfer of knowledge.
Experienced unit needs to communicate
and visit receiving ward to pass on
information (unit transition
planning)
Bed needed repairs.
Patient had to be transferred
into a rented bed. The bed
available for rent was too
small for the patients needs.
Rush on bed repair ordered
Instruction booklet left at
bedside
Patient instructed in bed use
so he also could direct staff
Post instructions on bed use at bedside
to prevent further breakage
Sling fit inadequate and
compromised skin integrity
on thighs.
Custom sling ordered Several size bariatric slings should be
available.
Weight rating on tilt table in
question.
Call to company confirmed
that tilt table capacity
reduced from 600 to 500 lb.
Discontinued use of tilt table.
Other means of maintaining and exer-
cising of legs needs to be explored.
Purchase higher rated tilt table.
Stretcher chair worked poorly
under load and was inadequate
in size to fit patient size.
(Although rated for 800 lb,
it was a poor fit for patient
at 550 lb.)
Only used as stretcher for
transport as patient had to
remain side lying.
Recommend purchase of larger chair
with hydraulic capacity and electrical
functions for operation. Communi-
cation to company redesign is
recommended.
Difficulty maintaining patient
on side lying (to prevent
pressure sores and promote
circulation and so forth)
as he would crush positioning
pillows flat.
Wedge cushions to maintain
patient side lying were designed.
Patient found them
uncomfortable
Cushions need to be covered and
padded.
Repositioning mattress may be a useful
tool.
(continued on next page)
238 MUIR et al
Patient transport
Transporting a patient who weights 710 lb andhas a girth greater than 70 inches on a 39-inchstretcher is a difficult task. A patient of this sizedoes not fit on a 39-inch stretcher comfortably
even if it is rated for 1000 lb. The stretcher-chairwas found too narrow for the patient at 32 in,even when his weight was 550 lb. Also, bariatric
patients require the head of the bed to be elevated,and the head elevation feature worked poorlyunder load. One option is to have a patient to
remain side lying and if the girth hangs over thestretcher, then abdominal binding may berecommended.
Space planning
During this admission to the critical care unit,the space required was beyond a normal cubicalsize. Initially, this need was met by using a two-patient bed space for the one bariatric patient;
once he was admitted to an isolation room, thespace was adequate to accommodate all theequipment and nursing staff.
Diagnostic imaging
The CT scanner entrance was only 39 incheswide with a table rated at 350 lb. Therefore, noCT scan could be done. No facility could provide
imaging equipment, such as CT scanner or MRI,that would accommodate the size of this patient
Other facility issues
Identification of pathways and department
capabilities to accommodate bariatric patientsalso must be planned. Operating room tables,elevators, and morgues may pose problems.
Worker education
Training and written resource guidelines canprovide general information. The ability of nurs-ing personnel to become proficient in caring forthese patients can be affected by the frequency and
time intervals between admissions. Providing re-freshers and ready access to the resources forsupport and training are required under these
circumstances.
Emotional supports
Nursing personnel often have an emotionalreaction to this type of patient admission, includingfear of injury, disgust, or anger that can have
a negative impact on patient care. As discovered inthe case history literature reviewed, this is notuncommon. It is important that employers identify
and communicate, as part of training, the expecta-tions for appropriate conduct of workers. Thecritical care nursing personnel filed several injury
reports initially on receiving the patient. As thenursing personnel were able to feel confident intheir techniques and became aware of the patient asan individual, they became more sensitive to the
patient, and there were no further reports filed. TheICU staff needed other patient care programs inthe facility to provide manpower and consultation.
The provision of these supports assisted the staff infeeling supported.
Summary
Prevention of admissions to critical care unitsmight be mitigated by providing improved pri-mary health care access. Currently, bariatric
patients avoid accessing medical treatment untilthey are in a serious health crisis. Unfortunately,there is a high mortality rate for these patients
Table 2 (continued )
Problems Action taken Future recommendations
Mattress inadequate for
patient care.(Bed came with
regular mattress and patient
experienced significant skin
breakdown.)
A low air loss mattress was rented.
The size available was a bit small.
Bolsters were provided to assist in
fitting the mattress to the bed.
Recommend purchase of our
own low air loss mattress, to
ensure availability and immediate
use,
and to reduce costs
Worker injury reported due to over-
reaching. Bed height did not lower
adequately for safe worker
ergonomics.
Platform provided at the bedside to
enable shorter nursing personnel to
reach over patient.
Straps attached to sliders for lateral
transfers.
Future bed purchase criteria requires
that bed have ability to lower to a
minimum of 15 in or less from the
floor.
239BARIATRIC PATIENT CARE: LESSONS LEARNED
because of this delay in accessing treatment. Thismay help explain why critical care units receivea large proportion of the bariatric admissions.
This case study reviews the techniques, equip-ment, and difficulties associated with a bariatricadmission to a critical care unit as it relates to thepatient handling perspective. The techniques dis-
cussed are limited to patient handling, not toclinical nursing issues. The practices discussed arelimited to this unit and do not review the type of
equipment, techniques, struggles, and solutionsthat are experienced on a regular or rehabilitationunit.
As technology advances and the stream ofbariatric patient admissions increases, nurses needto communicate their experiences to their peers sothat others can learn from each other’s experiences.
References
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