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SPECIAL REPORT:Preventing Patient-Handling Injuries in Nurses

This supplement was funded by anunrestricted educational grant from SageProducts. Content of this supplementwas developed independently of thesponsor and all articles have undergonepeer review according to AmericanNurse Today standards.

38 American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com

Hazards associated with manual pa-tient handling continue to compro-mise the health and safety of nurs-

es. Among nurses who responded to theAmerican Nurses Association’s (ANA’s)Health Risk Appraisal: • 42% believe they are at risk at workfrom lifting or repositioning patients

• 13% have had a debilitating muscu-loskeletal injury

• 75% have access to safe patient han-dling and mobility (SPHM) technology,but only half use it consistently.We must take a closer look at this

problem and ask critical questions: Whydo only half of the nurses who could useSPHM technology actually use it? Is theequipment relatively inaccessible? Is itheavy or difficult to use? Is enough SPHMtechnology available to meet patients’needs? Have nursing staff received the education they need to use it properly? But even if every nurse had access to

SPHM technology, equipment alone isn’tthe answer. Comprehensive SPHM pro-grams are necessary to eliminate manualpatient handling. ANA’s Safe Patient Han-dling and Mobility: Interprofessional Na-tional Standards and the correspondingimplementation guide provide a frame-work for developing effective and sustain-able SPHM programs. Important programelements include:• maintaining a commitment to a cultureof safety

• choosing appropriate SPHM technology• ensuring SPHM technology is accessible• conducting ongoing training to maintaincompetency

• conducting ongoing program evaluationand remediation. This special report gives you the infor-

mation you need to help you or your em-ployer develop and implement an SPHMprogram or enhance an established one.The report details risk factors for patienthandling injuries, describes a multifactorialapproach to preventing these injuries, dis-

cusses the importance of a culture of safe-ty and commitment to SPHM, and pro-vides strategies that help prevent injuries.A graphic on the last page summarizeskey points of the report. Additional infor-mation is available in the article “Fivestrategies to help prevent nurses’ patient-handling injuries” at www.AmericanNurseToday.com/?=23251. Debilitating musculoskeletal injuries have

ended too many nurses’ careers. We can nolonger allow the health and safety of thenursing workforce to be compromised. We’re all on this journey to a safer

workplace together. We all need to doour part. •

Ruth Francis is a senior policy advisor and Jaime M. Dawson isa program director in the Nursing Practice and Work Environ-ment Department at ANA.

Selected referencesExecutive Summary: American Nurses AssociationHealth Risk Appraisal (HRA). Preliminary FindingsOctober 2013-October 2014. nursingworld.org/HRA-Executive-Summary.

American Nurses Association. Safe Patient Handlingand Mobility: Interprofessional National Standards.Silver Spring, MD: American Nurses Association;2013.

SPECIALREPORT: Preventing Patient-Handling Injuries in Nurses Safe patient handling and

mobility: The journey continuesBy Ruth Francis, MPH, MCHES, and Jaime M. Dawson, MPH

Ruth Francis

Jaime M. Dawson

www.AmericanNurseToday.com May 2016 American Nurse Today 39

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On June 18-19, 2015, a panel of leadingexperts in safe patient handling andmobility met to better define the prob-

lem, clarify risk factors, and identify strategiesfor reducing risk for patient-handling injuriesand improving patient safety. Panel membersincluded:

Guy Fragala, PhD, PE, CSP, CSPHPSenior Advisor for ErgonomicsPatient Safety Center of InquiryTampa, Florida

Teresa Boynton, MS, OTR, CSPHPOccupational TherapistPreviously an Ergonomics and Injury Preven-tion Specialist and

Workers Compensation ConsultantBanner Health, Western RegionGreeley, Colorado

Marlyn T. Conti, BSN, RN, MM, CPHQ Patient Safety Initiatives ManagerIntermountain HealthcareSalt Lake City, Utah

Lee Cyr, CPCU, ARMDirector, Insurance ServicesSynernet, Inc. Portland, Maine

Lynda Enos, BSN, MS, RN, COHN-S, CPECertified Professional ErgonomistErgonomics and Human Factors ConsultantHumanFit, LLCPortland, Oregon

Devon Kelly, MS, OTR/L Injury Prevention Project Manager Safety Department OSF Saint Francis Medical Center Peoria, Illinois

Nancy McGann, PT, CSPHPSystem Manager of Ergonomics and Safe Pa-tient Handling

SCL HealthColorado, Kansas, Montana

Kathleen Mullen, BSN, RN, CNOR, CSPHASafe Patient Handling CoordinatorCoxHealthSpringfield, Missouri

Susan Salsbury, BS, OTR/L CDMSSystem Lead for Safe Patient Handling and Mobility

OhioHealthAssociate Health and WellnessColumbus, Ohio

Kathleen Vollman, MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist/ConsultantAdvancing Nursing, LLCNorthville, Michigan

The panel discussed the persistent and cost-ly problem of injuries experienced by nursesand other healthcare professionals in acute-caresettings. While many occupational injuries canstem from acute or traumatic events, the panelconcurred that injuries also develop throughthe progressive accumulation of body stressorscaused by the physical demands of routinenursing activities. They agreed that healthcareprofessionals must be informed about the risksassociated with routine patient-care activitiesand strategies to design, implement, and main-tain safe patient handling and mobility pro-grams, which are essential to reduce the con-tinued risk of patient-handling injuries.The three primary meeting objectives were to:

• review the current evidence and identifygaps in the existing evidence base regardingthe burden of healthcare worker injuries

• consider activities performed in acute-caresettings associated with an increased risk ofinjuries while gaining a better understandingof contributing risk factors

• develop terminology to better describehealthcare worker injuries caused by the cu-mulative impact of physical stressors and de-mands of routine patient-care activities.

The panel, convened by Sage Products, ad-hered to a consensus-building process to achievethese objectives, working collectively and insmall groups to refine their understanding of thekey issues. A literature review on the topic ofpatient-handling injuries had been completed byan independent consultant before the meeting,and the panel reviewed and considered the in-formation during the course of its discussion. •

Safe patient handling and mobility panel: Members, process,and objectives

40 American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com

For more than 40 years, nurs-es have had the highest job-related injury rates of all

healthcare personnel. In a 2011survey conducted by the AmericanNurses Association:• 62% of nurses expressed con-cerns about experiencing a dis-abling musculoskeletal injury

• 56% reported musculoskeletalpain caused or exacerbated bytheir work

• 42% reported being injured atwork at least once during a 12-month period

• 52% reported chronic back pain• 38% said they’d had to taketime off work due to occupa-tion-related back pain

• 20% said they’d changed theirunit, position, or employmentsetting due to lower back pain.The costly and seemingly in-

tractable problem of work-relatedinjuries among nurses and otherhealthcare professionals promptedSage Products to convene a June2015 meeting with leading expertsin safe patient handling and mobili-ty (SPHM) to better define theproblem, clarify risk factors, andidentify risk-reduction strategies.Panel members reached a consen-sus that the term patient handlinginjury (PHI) is an accurate, well-

Patient-handling injuries: Risk factorsand risk-reduction strategiesLearn about a multifaceted approach to safe patient handlingand mobility programs. By Guy Fragala, PhD, PE, CSP, CSPHP; Teresa Boynton, MS, OTR, CSPHP; Marlyn T. Conti, BSN, RN, MM, CPHQ; Lee Cyr,CPCU, ARM; Lynda Enos, BSN, MS, RN, COHN-S, CPE; Devon Kelly, MS, OTR/L; Nancy McGann, PT, CSPHP; Kathleen Mullen,BSN, RN, CNOR, CSPHA; Susan Salsbury, BS, OTR/L, CDMS; and Kathleen Vollman, MSN, RN, CCNS, FCCM, FAAN

SPECIALREPORT: Preventing Patient-Handling Injuries in Nurses

www.AmericanNurseToday.com May 2016 American Nurse Today 41

recognized term for identifying nurses’ in-juries stemming from direct patient care.This term promotes awareness andknowledge about specific causes of in-juries, establishes a shared understandingof the problem’s magnitude, and helpsidentify solutions to enhance nurse andpatient safety. The overarching goal of SPHM pro-

grams is to support nurses’ efforts to pro-vide the right care for the right patient atthe right time. Nurses must be aware ofPHI risk factors and participate fully inefforts to ensure their patients’ and theirown safety through consistent use ofSPHM practices. This article examinesleading risk factors for PHIs and reviewsstrategies for designing and implement-ing effective SPHM programs at health-care facilities.

Risk factors The following factors contribute to PHIsin nurses:• prolonged work hours• longer shift duration• longer duration of exposure during ashift

• more consecutive days worked• preexisting health conditions• excessive sleepiness• social and familial disruptions• psychological disorders• an older nurse workforce• greater use of complex technologicalinnovations

• increasing numbers of critically ill pa-tients. Certain organizational factors also con-

tribute to high PHI rates—inadequatestaff education in SPHM, failure to com-mit resources to technology to supportsafety, and limitations of systems thatpromote and reinforce SPHM.Based on a literature review and pro-

fessional experience, Sage’s expert panelidentified four major risk factors linkedspecifically to patient handling that in-crease nurses’ PHI risk. (See Risk factorsfor patient handling injuries.)

Multifaceted approach to injurypreventionMultifaceted SPHM programs are more ef-fective than any single intervention in re-

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Risk factors for patient handling injuriesFour major risk factors for patient handling injuries (PHIs) in nurses areexertion, frequency, posture, and duration of exposure. Combinations ofthese factors, such as high exertion while in an awkward posture (for ex-ample, holding a patient’s leg while bent over and twisted), unpre-dictable patient movements, and extended reaching intensify the risk.

ExertionThe amount of exertion (force or effort required to lift, move, or handle apatient) depends on such patient factors as size, need for physical assis-tance to perform mobility activities, cognitive status, and physical abilityand willingness to actively participate in the move. Forces exerted onthe nurse’s musculoskeletal structure during manual lifting or handlingor when moving heavy, dependent, or nonparticipatory patients com-monly exceed levels that the body can safely tolerate. Nurses exertthemselves more for patients who:

• are obese or overweight

• are more dependent

• have cognitive impairments

• are unable or unwilling to actively participate and promote their ownmovement.

PHI risk increases as the degree of exertion intensifies.

FrequencyFrequency refers to the number of times a nurse performs patient-han-dling tasks during a shift. Repeated performance of such activities aspulling up or boosting a patient in bed, turning a patient from side toside, performing a lateral transfer, and lifting a patient after a fall in-creases PHI risk.

PosturePosture refers to the nurse’s body position when performing patient-handling activities. During patient care, nurses commonly reach acrossbeds or around medical equipment or other obstacles. Extended reach-ing away from the trunk can lead to undesirable postures, especiallywhen weight or load is added. The farther the load is from the nurse’sbody during lifting, the greater the force imposed on the musculoskele-tal structure. Bending (with or without a load) places considerable forceon the musculoskeletal structure, especially the lower back and lumbarspine, increasing PHI risk. Twisting the back while bending also signifi-cantly increases risk.

When working in a confined space, nurses frequently assume awk-ward postures. Holding patients in a stationary position or maintainingtheir own back or arms in a fixed position for a prolonged time placesnurses in a static posture, which increases stress, strain, and PHI risk. Dy-namic or repetitive movements in specific postures also increase risk.

Duration of exposureDuration of exposure to risk encompasses the cumulative effects of ex-ertion, frequency, and position. Many PHIs stem from cumulative orrepetitive risk exposure. Frequent episodes of excessive exertion withheavy loads or undesirable and awkward postures while providing pa-tient care over extended periods can stress, weaken, and damage themusculoskeletal structure, causing cumulative trauma disorders.

42 American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com

ducing or preventing PHIs; researchshows such programs reduce PHI risk. A comprehensive effort to achieve sus-tained PHI reductions and improve pa-tient safety hinges on multimodal strate-gies that take into account availablehuman and equipment resources, as wellas how these resources interact with worksystems in diverse healthcare settings(such as perioperative, long-term care,and critical care and other acute-care en-vironments). Successful SPHM programsmust encompass appropriate technologyalong with worker education, a culture ofsafety, commitment from the top down,and routine periodic program evaluation.

TechnologyTechnological advances and assistive de-vices aid the critically important work ofpromoting patient movement and mobili-ty while reducing or eliminating PHI riskfactors. Proper use of assistive devices tolift, move, reposition, and transport pa-tients is the foundation of a successfulSPHM program. Assistive devices includemobile mechanical patient lifts, ceiling-mounted lifts, friction-reducing devices,lateral transfer aids, in-bed turning andrepositioning devices, and height-ad-justable electric beds. Ideally, this equip-ment should be located at or near thebedside of all patients. All staff involved in patient handling

activities must embrace and endorse inte-gration of tools and technology into the

care delivery process. Where nurses haveeasy access to appropriate equipment,evidence-based SPHM programs are cru-cial—but these alone are insufficient toguarantee program success (for instance,some nurses may choose not to useSPHM equipment). What’s more, SPHMprograms may reduce injuries initially,but if nurses eventually revert to old, fa-miliar patient-handling behaviors, injuryreductions may not be sustained. Also, assistive devices must match pa-

tients’ physical, cognitive, and clinicalneeds; nursing tasks to be performed;workplace design; and nurse characteris-tics. Furthermore, nurses must workwithin the structure of their organizationto be effective agents of change forSPHM. An organizational investment inSPHM equipment and integration of thisequipment into daily patient care is vitalto a successful program.

EducationCompetency-based employee educationon use of SPHM devices and associatedwork practices is crucial. Both new hiresand permanent staff involved in patienthandling should receive education on anongoing basis to promote, sustain, andincrease their proficiency.

CultureSuccessful design and implementation ofSPHM programs requires meaningful,sustained changes in the workplace cul-ture. Establishing a culture of safety atthe individual, group, and organizationallevels rests on understanding the com-plexity of healthcare delivery systemswith tightly interwoven and constantlychanging work processes. The organiza-tion’s current culture and SPHM programdesign must be evaluated from a systemsperspective to ensure that the programhas a sustained favorable impact on PHIrates.In an organizational culture of safety:

• nurses feel a sense of responsibilityand are willing to report adverseevents, injuries, and near misses

• administrators respond to these reportsconsistently and effectively

• everyone involved is treated fairly,with the cause of the event viewed

SPECIALREPORT: Preventing Patient-Handling Injuries in Nurses

Activities that promote a culture ofsafetyActivities that foster a culture of safety in healthcare organizations include:

• open communication using daily in-house or unit-based huddles

• presenting safety messages or topics at the start of all meetings

• visible safety boards and messaging

• rounding by senior leadership

• coaching programs

• promoting the message that errors provide opportunities to learnand improve safe patient handling and mobility (SPHM) skills.

These activities promote cultural changes at both the organizationaland staff levels, leading to a participatory approach that creates a sustain-able SPHM program.

www.AmericanNurseToday.com May 2016 American Nurse Today 43

from a systems perspective rather thanassigning blame to individuals. (SeeActivities that promote a culture ofsafety.)

CommitmentTo build and sustain a successful SPHMprogram, leaders, managers, and clinicalstaff must demonstrate a consistent com-mitment and nurse and patient safetymust be integrated into clinical and busi-ness goals. Frontline nursing staff mustbe actively engaged and participate inplanning, implementing, and evaluatingthe program. Visible active support of allprogram elements by senior leaders, mid -level managers, and engineering andconstruction staff can overcome barriersand promote changes in ways that front-line staff may be unable to achieve. Also,a well-designed and supported SPHMmentoring or coaching program at theunit or department level continuously re-inforces SPHM principles and use of ap-propriate equipment, which are crucial tomaintaining cultural changes.

EvaluationSPHM program outcomes and processesmust be evaluated objectively on a rou-tine basis. Relevant outcome measuresinclude decreased PHI rates, improvedpatient safety, reduced direct costs (in-cluding medical costs for injury treatmentand rehabilitation, as well as compensa-tion to injured workers), fewer days oflost work, increased employee satisfac-tion, and ongoing identification of op-portunities for refining SPHM processesand policies. Outcome metrics at the sys-tem and unit levels can be disseminatedthrough the facility’s intranet or “dash-boards” that display safety data in realtime. Employees should be encouragedto share stories of safety events with fulltransparency.

Thoughts, words, and actionsAn industry-wide effort to prevent PHIsthrough SPHM programs requires part-nerships and coalitions, staff education,increased access to and use of assistivedevices, and ongoing education—all supported by federal and state SPHM ini-tiatives in development. Numerous re-

sources are available to assist organiza-tions on their journey to SPHM.Organizational change to support and

promote SPHM occurs only when all or-ganization members focus on three keyquestions: What are we are doing? Whyare we doing it? What’s my role? Full en-gagement and cultural transformation canoccur only when everyone responds ef-fectively to these questions in thoughts,words, and actions. •

Guy Fragala is a senior advisor for ergonomics at the PatientSafety Center of Inquiry in Tampa, Florida. Teresa Boynton,an occupational therapist, previously served as an ergonom-ics and injury prevention specialist and workers’ compensa-tion consultant at Banner Health, Western Region, in Gree-ley, Colorado. Marlyn T. Conti is a patient safety initiativesmanager at Intermountain Healthcare in Salt Lake City,Utah. Lee Cyr is director of insurance services with Synernet,Inc. in Portland, Maine. Lynda Enos is a certified professionalergonomist and ergonomics/human factors consultant withHumanFit, LLC, in Portland, Oregon. Devon Kelly is an injuryprevention project manager in the safety department at OSFSaint Francis Medical Center in Peoria, Illinois. Nancy Mc-Gann is system manager of ergonomics and safe patienthandling for SCL Health in Colorado, Kansas, and Montana.Kathleen Mullen is the safe patient handling coordinator forCoxHealth in Springfield, Missouri. Susan Salsbury is systemlead for safe patient handling and mobility at OhioHealthand Associate Health and Wellness in Columbus, Ohio. Kath-leen Vollman is a clinical nurse specialist/consultant for Ad-vancing Nursing, LLC, in Northville, Michigan.

Visit www.AmericanNurseToday.com/?p=23251 for alist of selected references.

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44 American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com

SPECIALREPORT: Preventing Patient-Handling Injuries in Nurses Reduce patient handling injuries NOW!

It’s time for nurses and administrators to do their part to reducepatient handling injuries (PHIs) in nurses—and patients—resulting from mobility missteps.

Seek out resources Safe Patient Handling and Mobility @ nursingworld.org/handlewithcare. This ANAwebsite features many valuable resources. Also check out these ANA publications:1. Safe Patient Handling and Mobility: Interprofessional National Standards Across

the Care Continuum (2013)2. Implementation Guide to the Safe Patient Handling and Mobility Interprofession-

al National Standards (2013)Association of periOperative Nurses (AORN). Safe patient handling toolkit. (In-cludes resources specific to the perioperative environment.) https://www.aorn.org/guidelines/clinical-resources/tool-kits/safe-patient-handling-tool-kitMinnesota Hospital Association. Safe patient handling. (Offers a tool kit for imple-menting a safe patient handling program, plus other resources.)mnhospitals.org/patient-safety/current-safety-quality-initiatives/patient-handling

Occupational Health & Safety Administration. Safe patient handling equipment.(Includes links to such tools as “Beyond Getting Started: A Resource Guide for Implementing a Safe Patient Handling Program in the Acute Care Setting.”) osha.gov/dsg/hospitals/patient_handling_equipment.htmlVA Sunshine Healthcare Network. Safe patient handling and movement. (Offersalgorithms, toolkits, and other resources.) www.visn8.va.gov/patientsafetycenter/safepthandling/Agency for Healthcare Research and Quality. The Falls Management Program: AQuality Improvement Initiative for Nursing Facilities. (A good resource for long-term care facilities.)ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/index.html

From “Special Report: Preventing Patient-Handling Injuries in Nurses.” American Nurse Today, May 2016.

Know the factsIn a survey of nurses conducted bythe American Nurses Association(ANA):

• 56% reported musculoskeletalpain caused or exacerbated bytheir work

• 42% reported being injured atwork at least once during a 12-month period

• 52% reported chronic back pain.

Understand therisk factors• Exertion

• Frequency

• Posture

• Duration of exposure

Promote a culture of safety• Foster open communication by using

daily in-house or unit-based huddles.

• Convey safety messages or topics at thestart of all meetings.

• Use visible safety boards and messaging.

• Conduct rounding by senior leadership.

• Establish coaching programs.

• Promote the message that errors are op-portunities to learn and improve patienthandling and mobility skills.

• Address safe patient handling and mo-bility in orientation and competencyprograms.

Track metrics• Monitor outcomes

measures, such asPHI rates.

• Be transparent bysharing data.

• Make changes asneeded.

Use technology as a resource• Involve staff in choosing

assistive devices.

• Make sure assistive devicesare readily at hand.

• Match the assistive device tothe situation.

• Use assistive devicescorrectly.

Watch a video on safe patient handling and

mobility at nursingworld.org/

SafePatientHandling-Video

Support safe patient handling and mobility legislation atrnaction.org/site/PageNavigator/nstat__take_action_sph_113.html

Focus on threebig questions:• What are we are doing?

• Why are we doing it?

• What’s my role?