1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References


This study evaluated the effectiveness of a safe patient handling program (STEPS) at an inpatient rehabilitation unit in reducing injury due to patient transfers. Our objectives were to compare number of staff injuries during the 1.5-year period post training to pre training (baseline) and to determine whether reduction in injuries was sustained long term during a 2.5-year post training period.


All nursing and therapy staff as well as new hires received STEPS training. Periodic retraining was not provided.


The number of injuries was significantly reduced at post training compared to baseline (p = 0.01). However, the reductions in injuries were not sustained long term.


We estimated a cost benefit of $3.71 for every dollar invested in retraining based on injury reduction realized during the post training period.

Clinical Relevance

Retraining is likely to have a positive cost benefit when it results in maintaining reduction in staff injuries.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Low back injuries as well as other injuries related to patient handling are prevalent in health care (Barnes, 2007; D'Arcy, Sasai, & Stearns, 2011; Ogg, 2011; Pompeii, Lipscomb, Schoenfisch, & Dement, 2009; Sikiru & Shmaila, 2009; Trossman, 2009). Staff injury rates as well as costs related to lost work and restricted work days have supported the growth of safe patient handling programs with specific lifting policies and increased use of equipment (Edlich, Winters, Hudson, Britt & Long, 2004; Barnes, 2007; American Nurses Association, 2008; Tullar et al., 2010). Although there have been several studies reporting the incidence of injuries through manual lifting, rehabilitation professionals have resisted successful implementation of safe handling policies due to the supposition that rehabilitation is meant to foster increased independence and use of lifting equipment may limit or decrease functional gains (Durham, 2007; Nelson, Harwood, Tracey & Dunn, 2008). Additionally, there is a belief that knowledge and practice of proper body mechanics will prevent injuries; however, studies have demonstrated that repetitive lifting even with proper body dynamics results in injury.

The acute inpatient rehabilitation unit at our facility admits people with stroke, spinal cord injury, brain injury, as well as those requiring comprehensive, intensive therapy post surgery such as hip replacements and spinal fusions. In response to a high level of staff injuries related to patient transfers, our facility implemented a safe patient handling policy that included a hands-on training class called, Safe Transfers Every Person Succeeds (STEPS). Both nursing and therapy staff participated in a research study from October 2004 through June 2005. During the study period, staff participated in education about the safe patient handling policy and was evaluated on knowledge and performance of patient transfers. Staff scoring below 80% on the competency pretest was identified as benefiting from further training and attended the STEPS training class. Trained staff did not receive refresher courses on safe patient handling.

The objectives of the study, to evaluate our facility's STEPS program, were to identify whether (1) reduction in staff injuries due to patient transfers was realized during the 1.5-year period post training and implementation of the safe patient handling policy and (2) reduction in staff injuries due to patient transfers was sustained during a 2.5-year period following the post training period. We chose to focus on injury due to transfers rather than on all aspects of patient handling (e.g., boosting, turning, gait training) for two reasons: (1) our facility had experienced a large number of injuries due to patient transfers, which motivated the creation of the STEPS program, and (2) we could better control the effects of our intervention on a single dependent variable by focusing on transfers versus all aspects of patient handling. Garg & Kapellusch (2012) described long-term success of a multisite safe patient handling program supported by a comprehensive ergonomics program over a 3- to 5-year period. To our knowledge, there are no other studies that evaluate long-term effects of implementation of a safe patient handling program on injury in the absence of a comprehensive program for retraining, monitoring, and reinforcement (Black, Shah, Busch, Metcalfe, & Lim, 2011).


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Participants were required to sign informed consent to participate in this study. Of 56 possible participants, 55 (98.2%) agreed to participate. As training was mandatory, the single individual who did not participate did receive evaluation and training, but those data were not used for analysis of outcomes. The study was approved by the Institutional Review Board of our health system.

STEPS training program

STEPS Program

STEPS, an 8-hour hands-on training class developed by our facility, covers the following: (1) general overview of purpose of class including incidence of staff injury through patient handling, (2) understanding normal body movement, (3) definition of seven transfer techniques used on our rehabilitation unit, (4) hands-on practice of transfer techniques, (5) procedures for safe patient handling assessment and movement, (6) problem solving difficult situations (e.g., transferring when someone is fatigued or has urgency related to toileting), (7) mock scenarios for safe patient handling, (8) return demonstration of seven transfers, and (9) post competency check-off of transfers. Staff scoring below 80% on the competency pretest was identified as needing further training and attended STEPS from October 2004 through June 2005.


As we prepared to implement our program, our healthcare system initiated a systemwide lifting policy of a 32-pound lifting limit. Although guidelines at the time of the study were 35-pound lifting limit (Waters, Putz-Anderson, Garg & Fine, 1994), we chose to decrease that limit by ~10%, given that our staff members are almost entirely female, which is consistent with the subsequent recommendation of Waters (2007) where he suggests that a lower weight limit would be appropriate for nurses and therapists due to decreased muscle and intervertebral strength in women. As a part of this process, our facility installed ceiling lifts in all of our 22 patient rooms above each patient's hospital bed for a total of 37 patient beds. We also had portable full-body sling lifts and standing assist lifts available for use on our unit when needed (e.g., if a ceiling lift were not working or if a patient was not in a location where the ceiling track could be used). Each hospital room had transfer boards for lateral and sit pivot transfers when indicated. Our rehabilitation therapy clinic did not have ceiling lift access, but it had access to portable full-body sling lifts and standing assist lifts and we now have installed ceiling track lifts for standing and walking since the completion of this study.

Evaluation and Selection

Prior to implementing STEPS, we set up a plan for assessing competency of both nursing and therapy staff on the seven types of transfers performed on our unit. Three trainers worked together to score staff members consistently on the following: verbalization of the transfer definitions, verbalization of preparation of patient for transfer, as well as repositioning of patient after transfer, verbalization of steps of transfer, and return demonstration of transfer (e.g., safe performance, skill, and technique). Based on scores in each area, staff was assigned a total grade for the transfers. Staff with scores equal to or above 80% was categorized as competent, while those with scores below were categorized as needing further training. Of those tested, the occupations represented were the following: registered nurses, licensed practical nurses, nursing assistants, occupational therapists, occupational therapy assistants, physical therapists, physical therapy assistants, and therapeutic recreational specialists. Thirty-three of 55 (60.0%) did not pass their competency pretest and were required to attend the 8-hour STEPS training program. The competency checklist is shown in Figure 1. Participants were reevaluated using the same checklist. Fifteen percent of those reevaluated required additional training. At the time of the study, we had not developed a plan for additional training. Staff needing additional training were provided access to the trainers to continue practicing skills while working.


Figure 1. Staff Patient Transfer Pre Competency Check-Off List.

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An assessment form based on the Safe Patient Handling Form provided a detailed checklist to be used for clinical reasoning when assessing a patient's safe patient transfer needs. Examples of items on the assessment form included whether the patient could support weight through his/her legs during transferring, patient's level of cooperation, specific medical considerations (e.g., joint replacement, fractures, history of falls, hypotension, and pressure ulcers), and the recommended safe handling technique.

A transfer selection guideline was developed to provide a complete description for each of the transfer methods and patient appropriateness for the method (see Figure 2).


Figure 2. Transfer Selection Guideline.

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Patient characteristic comparisons between time periods

Three time periods were defined as: (1) Baseline: 1/1/2002–9/31/2004, (2) Post Training: 7/1/2005–12/31/2006, and (3) Long Term: 1/1/2007–6/30/2009. To control for the potential of change in patient characteristics over the study time period confounding effects on staff injuries, we analyzed the Functional Independence Measure (FIM) scores. FIM scores related to transfer, as well as total motor score and age were compared using one-way analysis of variance. Chi-square was used to compare gender distributions. A two-sided p-value < .5 was required for significance. Effect size applied to difference of means was used to evaluate the significance of the between-period differences in FIM scores. We considered an effect size <0.40 as no difference.

Analysis of injury events due to patient transfers

Baseline provided the injury rate prior to delivering STEPS and was used as the basis for evaluating outcomes of the intervention at Post Training and Long Term. The objective of long-term analysis was to evaluate whether reduction in injuries was retained longterm in the absence of retraining those care providers who had received training during the training period October 2004 through June 2005.


Expected number of injuries: Expected number of injuries is based on the baseline injury rate of 32 per 26,480 patient days. A Poisson distribution for number of injuries is assumed, given the rarity and randomness of events. Number of injuries for both Post Training and Long Term periods were compared with the expected number of injuries calculated from the baseline injury rate.

Estimated cost benefit for providing additional training

Restricted and lost days were both treated as nonpatient care days. Providers were hired on a temporary basis to fill in for these days, while injured staff continued to be paid. The cost of injury in lost days (8 hours) was calculated based on the salary per hour associated with the job title at our institution for 2010. Cost of retraining was based on a 4-hour session for 60 staff members using the same average rates of pay and a distribution of job titles equal to the original training group. The benefit per dollar of training cost was calculated as the difference between post and long-term injury costs normalized to 1 year divided by the cost of training per year. This estimate of benefit is conservative because it does not add in other costs such as those attributable to hiring substitute care providers, worker's compensation payment, or retraining those who have sustained injuries.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

The age and gender of the populations during each of the time periods are described in Table 1 and admission FIM scores relevant to transferring patients are described in Table 2. Average FIM scores for transfers as well as total motor score among the three periods are significantly different (p < .001). However, all effect sizes for time period comparisons are less than 0.35, meeting our criteria for no difference in FIM scores between time periods as an effect size <0.40.

Table 1. Demographics
 Baseline (N = 2248)Post (N = 1112)Long Term (N = 2053)p-value
Age: (years) (mean, SD)62.7 (16.4)62.6 (16.4)63.2 (16.3).47
Gender n(%)
Male1103 (49.1%)562 (50.5%)1032 (50.3%).64
Female1145 (51.9%)550 (49.5%)1021 (49.7%) 
Table 2. FIM admission scores relevant to patient transfer
 1) Baseline2) Post3) Long Term  
(N = 2248)(N = 1112)(N = 2053)p-valueEffect Sizesa Times-1:2, 2:3, 1:3
  1. a

    Effect sizes <0.35 are considered small; statistical significance is due to the large sample sizes.

Bed Transfer3.3 (1.4)3.5 (1.4)3.2 (1.5)<.0010.14, 0.20, 0.07
Toilet Transfer3.4 (1.4)3.6 (1.4)3.3 (1.5)<.0010.17, 0.08, 0.07
Tub Transfer2.7 (2.0)2.4 (2.1)2.1 (2.2)<.0010.16, 0.12, 0.27
Comprehension5.6 (1.5)5.3 (1.6)5.1 (1.5)<.0010.21, 0.15, 0.37
Expression5.7 (1.7)5.3 (1.8)5.1 (1.8)<.0010.19, 0.34, 0.15
Total motor44.2 (13.9)44.1 (13.9)40.4 (13.7)<.0010.007, 0.27, 0.28
Total cognitive26.7 (6.9)26.2 (6.8)25.0 (6.9)<.0010.07, 0.18, 0.25

Occurrence of injuries

The number of injuries was significantly reduced at post training compared with baseline (p = .01). However, in the long term, the number of injuries was not significantly different from that of the baseline (p = .21) (Table 3).

Table 3. Number of injuries
PeriodPatient DaysNumber of InjuriesExpected Based on Prep-valueUnique Providers
Baseline26,480 32 NANA25
Long Term24,74425300.2122

A description of days lost and days restricted based on OSHA criteria by time period is given in Table 4. In each of the time periods, majority of injuries occurred for RNs. For the long-term period, 76% of injuries were for RNs compared with 40.6% and 37.5% at baseline and post training periods, respectively.

Table 4. Lost and restricted days by job title for each of the time periods
PeriodPositionOSHA Days LostOSHA Days RestrictedNo. of Cases%Total Cases
BaselineAssistant Head Nurse 0 65 1 3.13
LPN (Licensed Practical Nurse)23 444 825.00
Nursing Assistant41 316 825.00
Occupational Therapist 0 0 1 3.13
Occupational Therapy Assistant-Certified 0 14 1 3.13
RN (Registered Nurse) 0 2781340.63
PostLPN 0 0 112.50
Nursing Assistant 0 0 112.50
Occupational Therapy Assistant-Certified0 0 112.50
Physical Therapist 2 19 112.50
Physical Therapist-Lead 0 8 112.50
RN 1 182 337.50
TOTAL 3 209 8 
Long TermLPN 0 20 14.00
Nursing Assistant 2 6 416.00
Physical Therapist33 8 1 4.00
RN14 2911976.00
TOTAL49 32525 

At our institution, all new personnel are trained using the STEPS program. Formal retraining of staff already trained was not a part of the protocol during the time period of this study. The estimated cost benefit of retraining is estimated as shown in Table 5. The number of injuries increased during the long-term period and was not significantly different from that at the baseline. The difference in cost in lost or restricted days from long term to post was $30,495. The cost to deliver a 4-hour refresher training course to 60 staff members is estimated to be $8,214. The cost/benefit for every dollar invested in retraining is estimated to be $3.71, given the assumption that retraining is a key factor in reducing injuries.

Table 5. Estimated cost benefit of retraining
PeriodTotal CostaMonthsTotal Cost/year
  1. a

    Total cost based on average salary for the job title 2010 = (lost+restricted days)*pay rate/hr*8.

  2. b

    Retraining ½ day for 60 employees distributed by job function as in the original training – cost: $8,214/year.

  3. c

    Difference in cost of injury long term compared with post/cost of training.

Long Term$109,632.4018$73,088.27
Cost/Benefit Analysis
Trainingb  $8,214
Difference: Post to Long Term  $30,495.04
Cost/Benefitc   $3.71


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

We have shown that training in safe patient handling and establishment of a safe patient handling policy was effective in reducing staff injuries at our facility by more than 50% during the 1.5-year post training period, from an expected number of 17 injuries to only 8. Our results are similar to those of Sedlak, Doheny, Jones, & Lavelle (2009) who reported that training in conjunction with a safe handling policy and procedures does have a positive impact on reduction in staff injuries. Our results further support other studies that report and propose significant reduction in staff injuries through hands-on training incorporating a multifactorial intervention/program (Krill, Raven, & Staffileno, 2012; Morgan & Chow, 2007; Nelson et al., 2008). During the 1.5-year post training period, it is possible that staff injuries at our institution were reduced compared with the baseline period pre training due to the training as well as an ongoing emphasis on safe patient handling and reinforcement of the safe patient handling policy.

In the absence of retraining in safe patient handling, the number of injuries due to patient handling long term was not different from that at baseline. To our knowledge, there are few studies that evaluate long-term outcomes in the absence of retraining (Black et al., 2011; Garg & Kapellusch, 2012; Wardell, 2007). Garg & Kapellusch (2012) demonstrated significant reductions in injury rates at seven institutions where data were collected post intervention for 36–60 months. In this study, the observation period was not divided into post intervention and long term, and therefore we cannot compare the impact of time from date of implementation on incidence of injury. We considered other factors that may have impacted the long-term outcome: (1) FIM measures for bed, toilet, and tub transfers as well as total motor score (including other aspects of burden of care measures such as toileting, bathing, lower body dressing) were shown to be similar between time periods; (2) training of newly hired care providers using STEPS continued, demonstrating management's commitment to safe patient handling; (3) staffing ratios remained constant over the study period; (4) equipment and supplies for safe patient handling at our institution were strictly maintained and available; and (5) consequences of violating safe patient handling policy remained constant where management discussed the incident and may have suggested additional training. The factor that most likely impacted long-term outcome was adherence to safe handling policy (Garg & Kapellusch, 2012; Schoenfisch, Pompeii, Myers, Yeung, Frickas, et al. 2011). Staff was more frequently reminded about following procedures through spot checks and communication of findings during the post time period. In addition to our program not including ongoing retraining, we did not include formal peer coaching and mentoring, which have been shown to improve support of safe patient handling practices (Alamgir et al., 2011).We know from observation and discussions with staff that they do not always use the equipment provided in large part due to the amount of additional time required as well as wanting to provide opportunities for patients to progress toward increased physical independence. We hypothesize that retraining can directly affect behavior in adhering to safe patient handling policy and positive culture. We further hypothesize that monitoring accompanied by significant consequences of not adhering to this policy will help increase adherence and reduce staff injuries. Garg & Kapellusch (2012) provided evidence of decreased injury at seven nursing facilities over a 3- to 5-year period when training in safe patient handling was supported through positive safe patient handling culture including the following: a comprehensive ergonomic program that included management commitment and participation; empowerment of nursing personnel in equipment selection and program implementation; evaluation of patients' transferring needs by nursing personnel; laminated cards to specify patient handling devices and technique in patients' rooms; additional patient handling devices to limit downtime or inaccessibility of equipment; hands-on training of all personnel; monitoring of use of patient handling devices supported with monthly meetings to address and resolve problems or concerns; feedback by key nursing personnel to those staff who needed help; and team approach to address patient/family concerns regarding patient handling devices.

We have shown that retraining in safe patient handling, assuming that the outcome, maintenance of injury reduction as demonstrated in the post training period, is attributable in large part to further training, would result in a positive cost benefit of $3.71 for every dollar invested in retraining. This finding is supported by Pelczarski (2012); however, further studies are needed to test this assumption and to identify the most efficient timing for retraining. These studies should include evaluation of competencies as well as quantification of adherence to policy over the long term.

Our study found that injury rates were higher in nursing staff compared with therapy staff. This may be due to the fact that (1) nursing staff is larger than the therapy staff, and therefore in a typical 24-hour day, nurses perform more transfers than therapy staff; (2) therapy staff may have greater opportunity to control the environment for transferring patients than nursing staff. For example, therapy staff can modify and control conditions for a transfer by raising or lowering a surface such as a firm therapy mat, while nursing staff may not be able to do this because they are dealing with conditions that are less modifiable like toilets and hospital beds; and (3) therapy staff are typically involved with only one patient from their case load at a time, while nursing staff are responsible for several patients which limits the time they can spend in using safe transfer methods resulting in increased risk of injury.

In response to having learned that injury rates returned to baseline rates during the long-term training period, our facility is planning a refresher course addressing safe handling during transfers. The safe handling literature suggests that one of the biggest barriers to implementing and adhering to a safe patient handling policy is the absence of a safe patient handling culture (Cadmus, Brigley, & Pearson, 2011; Durham, 2007; Johnson & Hall, 2005; Tideiksaar, 2008). Facilities with a high safety culture as well as strong adherence to safe handling have the lowest incidence of injuries (Cornish & Jones, 2010; Hignett & Crumpton, 2007; Schoenfisch, Myers, et al., 2011). It is possible that although our intervention addressed how to select the safest option for transferring a patient as well as providing a variety of transfer methods, we also needed to address and improve the safety culture at our facility (Cornish & Jones, 2010; Schoenfisch, Pompeii et al., 2011). Our staff have used both portable lifts and ceiling lifts more frequently, but they rarely use lifting equipment for tasks such as boosting, turning, or even facilitating standing and walking. When asked why staff is not using positioning slings, a frequent response is that it is time consuming and disruptive to patients' sleep and skin integrity. It is also possible that staff has not been integrated sufficiently into the selection process for these devices and therefore does not have full appreciation of their benefits in avoiding injury (Garg & Kapellusch, 2012; Kim & Lee, 2010; Mutch, 2004). Furthermore, staff may need to be trained to incorporate patients and family members in selection and use of these devices to create a culture that is more accepting of safe handling equipment (Cadmus et al., 2011; Garg & Kapellusch, 2012; Pellatt, 2005).


STEPS training focused on safe patient transfers and therefore we included only injuries due to transfers in analyzing our results. Boosting and turning patients are another source of injury we are addressing with a new initiative.

There was natural turnover of staff during the baseline, post, and long-term periods. Although new hires receive STEPS training at orientation, they practice with staff who have not been retrained and who may have adopted poor patient handling practices. This environment can negate safe practices learned during training. This situation supports the need for ongoing training.

The novelty of new equipment installed for safe patient handling may have impacted adherence in the post training period. As the novelty wore off, attitudes with regard to using it may have changed (Cadmus et al., 2011). If this is true, then ongoing training to strengthen the culture of safe patient handling may be necessary.

Key Practice Points
  • Safe patient handling continues to be affected by several factors including the importance of continued retraining as well as ongoing efforts to maintain positive cultural support of staff and administration regarding safe patient handling in a rehabilitation setting.
  • Although many studies support reduction in staff injuries with safe patient handling programs, this study highlights the challenges with maintaining the reduction long-term (i.e. greater than 1.5 years)
  • Although ongoing retraining of staff involves a cost, the cost benefit of retraining leading to potential long term positive effects of sustained reduction in staff injuries across disciplines outweighs the costs of staff injuries and ongoing use of safe patient handling equipment.
  • Hands on training of safe patient handling through multiple strategies including training and competency assessment across nurses and therapists can reduce staff injuries.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

We have shown that implementing a safe handling policy and hands-on training reduced staff injuries on a rehabilitation unit. We have also shown that in the absence of retraining, injury rates may return to baseline. Retraining is likely to have a positive cost benefit when it results in maintaining reductions in staff injuries. Ongoing training has the additional benefit of establishing a rehabilitation culture that embraces use of equipment to aid in patient handling. Future studies should look at the effects of providing ongoing refresher courses in safe patient handling on staff injury rates over time. These studies should evaluate not only the effects of retraining, but also how frequently retraining is necessary to maintain significant reduction in injury rates due to patient handling.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
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