Safety and Quality across Practice Settings: The Emerging Role of Safe Patient Handling and Mobility
In the United States, healthcare workers practice in a culture of sacrifice irrespective of discipline, setting, or specialty. For two centuries blame has been placed on, and typically accepted by, the healthcare worker when injury occurs, despite dangerous working conditions. Just recently, science has helped healthcare workers and other stakeholders recognize the consequences of these unsafe practices. Poor design, unsafe technology, and outdated education and training have all contributed to hazardous conditions and injury. Manual handling and movement have been at the heart of the dangers inherent in the daily activity of healthcare workers.
Experts estimate that the nursing shortage in the United States will increase to a level of 30% shortage by the year 2020. Therapy shortages are documented as well. According to the Bureau of Labor Statistics (BLS, 2012), the demand for physical therapists is expected to grow 27% between 2006 and 2016, and the need for occupational therapists will grow 30% in 2013. The American Physical Therapy Association recently conducted a study citing BLS data (2011) showing that between 13% and 18% of physical therapy jobs were open. Some suggest that the shortages among healthcare occupations are linked to occupational hazards. Research into the impact of musculoskeletal disorders (MSD) on nurses has revealed that 52% of nurses surveyed complain of chronic back pain, while 12% state that they have left nursing because of back pain. A survey conducted by the American Nurses Association (ANA) revealed that one of nurses’ top concerns was injury on the job (work-related injury). Many healthcare workers, including nurses and therapists, have high rates of back and shoulder injuries. BLS data reported in 2012 are unchanged from data reported in 2009, which suggest that more than 23,000 lost-time cases of work-related pain are reported each year in the Healthcare and Social Assistance (HCSA) sector; of these, more than 44% were among healthcare support occupations such as aides and assistants (BLS, 2011, 2008).
Nursing aides, orderlies, registered nurses, and licensed practical nurses suffered the highest prevalence (16.6%) of and reported the most annual cases (n = 3,620) of work-related back pain involving days away from work in the
HCSA sector. Unfortunately, the culture has accepted this as the new norm. For example, consider the following quotes from the website of Work Injured Nurses Group USA (WING USA, 2013): “If you’re in nursing 10 or 15 years, you’ll be hurt. It’s a hazard of the trade”; “When the CNA wanted the two of us to pull the 300-pound patient up in bed, I said I’m not doing it. I care about my back and I thought we needed more help. But she said ‘I’ll do it myself,’ and she did.” These are simply two examples that illustrate the ongoing acceptance of dangers inherent in the current culture of sacrifice.
HCSA sector. Unfortunately, the culture has accepted this as the new norm. For example, consider the following quotes from the website of Work Injured Nurses Group USA (WING USA, 2013): “If you’re in nursing 10 or 15 years, you’ll be hurt. It’s a hazard of the trade”; “When the CNA wanted the two of us to pull the 300-pound patient up in bed, I said I’m not doing it. I care about my back and I thought we needed more help. But she said ‘I’ll do it myself,’ and she did.” These are simply two examples that illustrate the ongoing acceptance of dangers inherent in the current culture of sacrifice.
Overexertion incidents are the leading source of worker’s compensation claims and costs in healthcare settings, with MSDs as the primary outcome associated with such incidents. The single greatest risk factor for MSDs in healthcare workers is manual handling of healthcare recipients. Also contributing to the negative outcomes associated with manual handling is the shortage of nurses. Peter Buerhaus (Buerhaus, Auerbach, & Staiger, 2009), a researcher at Vanderbilt University Medical Center, confirms that in the United States by the year 2025, there will be a shortage of 250,000 nurses. During his career, the late Dr. William Charney (2005, 2011, 2012) argued that without intervention, this problem has endless circularity in that the shortage of healthcare workers leads to increased risk of injury, as described earlier. Workers who experience discomfort, fatigue, overexertion, or pain may work in pain, work while medicated, or simply fail to present to work, thus completing the circle of working shorthanded (absenteeism or presenteeism) and placing other healthcare workers at risk for injury.
Fortunately, solutions do exist. A number of facilities across the United States have begun to integrate the principles of safe patient handling and mobility (SPHM) into their safety initiatives. However, a common and widespread misconception is that SPHM technology by itself is sufficient to protect the healthcare worker. Although technology is an important component, technology alone does not support the essence of safety for the healthcare worker and healthcare recipient.
SPHM and Healthcare Workers: An Historical Perspective
In 2000, Audrey Nelson and the teams at the Department of Veterans Affair (VA) Hospital in Tampa, the Tampa Patient Safety Center of Inquiry, and the University of South Florida introduced the First Annual Safe Patient Handling and Movement Conference in Clearwater, Florida. A handful of healthcare workers from a variety of backgrounds attended. Therapists, nurses, dieticians, ergonomists, human factors researchers, insurance stakeholders, and others
came together. The value of this interdisciplinary approach was the ability of healthcare workers to discuss, share, and learn from a variety of disciplines. For the first time, many healthcare workers began to understand the limits of body mechanics as a strategy to prevent injury. Further, a number of healthcare workers who previously viewed ergonomics simply as a department within an organization were introduced to the true meaning of ergonomics, and a culture of safety as an essential part of their workday. At that time, few healthcare workers understood that ergonomics is not a new specialty. For example, a good deal of evidence suggests that Greek civilization in the 5th century BCE used ergonomic principles in the design of tools, jobs, and the workplace.
came together. The value of this interdisciplinary approach was the ability of healthcare workers to discuss, share, and learn from a variety of disciplines. For the first time, many healthcare workers began to understand the limits of body mechanics as a strategy to prevent injury. Further, a number of healthcare workers who previously viewed ergonomics simply as a department within an organization were introduced to the true meaning of ergonomics, and a culture of safety as an essential part of their workday. At that time, few healthcare workers understood that ergonomics is not a new specialty. For example, a good deal of evidence suggests that Greek civilization in the 5th century BCE used ergonomic principles in the design of tools, jobs, and the workplace.
In the healthcare setting, an example of this can be found in the description Hippocrates gave of how a surgeon’s workplace should be designed and how surgical tools should be arranged. Later, in Notes on Nursing, Nightingale (1860) recognized injury as a risk to the nurse while performing an altruistic but dangerous manual handling task. In those first days of recognizing the challenges inherent in lifting, turning, and repositioning patients, conference attendees learned the special needs of certain patient populations, such as the larger, heavier healthcare recipient. Certain clinical areas, such as the emergency department, surgical services, radiology, maternal health, and others, were identified as high-risk settings and further subsequent discussion provided better understanding of the risks. Additionally, focus on unique clinical tasks, such as hygiene, catheterization, lateral transfers, and others, offered opportunities for conference participants to better address the hazards of caring for the healthcare recipient. To that extent, the emerging Safe Patient Handling and Movement Conference, and increasing awareness of the challenges in creating an evidence-based culture of safety that is designed to improve patient safety outcomes and reduce the frequency and severity of injury among healthcare workers, lent momentum to the overall SPHM efforts.
On June 17, 2005, the State of Texas passed into law TX Senate Bill 1525, the first state legislation requiring hospitals and nursing homes to implement a safe patient handling and movement program. The Texas Nurses Association was instrumental in getting this important legislation passed; it took on effect January 1, 2006. With Texas as the first state to successfully pass such legislation, a number of other states began working toward legislative protection of healthcare workers against preventable injury from manual patient lifting. Since then, nine additional states have passed some level of legislation or resolution, although the laws are inconsistent in content. These states are Ohio, New
York, Washington, Rhode Island, Minnesota, Maryland, New Jersey, Hawaii, and California. H.R. 2480, the “Nurse and Health Care Worker Protection Act of 2013,” was introduced to Congress in June 2013. Its aim is to “[d]irect the Secretary of Labor to issue an occupational safety and health standard to reduce injuries to patients, nurses, and all other health care workers by establishing a safe patient handling, mobility, and injury prevention standard,” and the text of the proposed bill aligns with Safe Patient Handling and Mobility: Interprofessional National Standards (ANA, 2013b).
York, Washington, Rhode Island, Minnesota, Maryland, New Jersey, Hawaii, and California. H.R. 2480, the “Nurse and Health Care Worker Protection Act of 2013,” was introduced to Congress in June 2013. Its aim is to “[d]irect the Secretary of Labor to issue an occupational safety and health standard to reduce injuries to patients, nurses, and all other health care workers by establishing a safe patient handling, mobility, and injury prevention standard,” and the text of the proposed bill aligns with Safe Patient Handling and Mobility: Interprofessional National Standards (ANA, 2013b).
Although state legislation has focused on the acute, general, and long-term care settings, the healthcare worker of the future will likely work in a number of other settings. For example, today only 20% of physical therapists work in acute care hospitals, whereas 72% of physical therapy assistants and 27% of occupational therapists are employed in acute care. Nearly 30% of nursing jobs are found in acute, general, and long-term care hospitals. However, because of administrative cost cutting, increased workload, and rapid growth of postacute services, much of the healthcare worker/healthcare recipient experience will occur outside the settings and criteria set forth by many states’ legislation or resolutions. Legislative mandates are a great first step, but stakeholders are recognizing the impact of failure to provide adequate methods for safe patient handling and mobility that do not differentiate between practice setting and healthcare workers, and this includes workers in clinics, post-acute care settings, and the home care environment.
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