Musculoskeletal disorders are caused by overexertion when lifting excessive loads and by the cumulative effect of repeated high-risk patient handling tasks such as lifting, transferring, and repositioning patients over time. This creates biomechanical stress on a healthcare provider's spine, shoulders, hands, and wrists. The National Institute for Occupational Safety and Health (NIOSH) recommends a weight limit for patient lifting tasks of 35 pounds under ideal conditions (Waters, 2007). The weight limit is decreased if the lifting task is performed in awkward positions, such as, lifting a patient who is on the floor, in a restricted space or when the lifter is fatigued.
Audrey Nelson, Ph.D., R.N., FAAN, a pioneer in SPHM and Department of Veterans Affairs (VA) medical researcher, and her colleagues almost 30 years ago identified common tasks that contributed to musculoskeletal injuries and evaluated ways to redesign tasks or to use alternatives such as mechanical lifts and transfer devices. Nelson and Baptiste (2004) proposed three ergonomic solution types for SPHM: engineering based, administrative, and behavioral. Engineering controls are modifications to the work environment or layout, tools, or equipment used in the workplace to prevent work-related musculoskeletal injuries. This may also include work redesign. Ceiling lifts that allow for the vertical transfer of a patient from bed to chair without manually lifting a patient is another example of an engineering control. Establishment of patient handling procedures, patient assessment protocols, and training to identify, reduce or prevent exposures to ergonomic risk factors are examples of administrative controls. Behavioral or work practice controls involve educating and training care providers in use of safe patient handling equipment, and use of clinical tools for assessment and decision making algorithms.
The clinical case for an SPHM program
Nelson et al. (2006) evaluated the 2001 Veterans Health Administration (VHA) Patient Safety Center project that focused on reducing the number of injuries to nurses engaged in patient handling in 23 high-risk VA patient care units in Tampa, Florida. The hypotheses were that an SPHM program that integrates evidence-based practice, technology, and safety improvement will result in increased: job satisfaction, self-reported unsafe patient handling acts, level of support for the program, staff and patient acceptance, program effectiveness, cost savings, and return on investment. In addition, there would be decreased injury rates and fewer lost or modified work days. A pre/post design without a control group was used. The variables were compared for a 9-month period pre and post intervention. The intervention included six program elements: (a) Ergonomic Assessment Protocol, (b) Patient Handling Assessment Criteria and Decision Algorithms, (c) Peer Leader role, “Back Injury Resource Nurses,” (d) patient handling and moving equipment, (e) After Action Reviews, and (f) a No Manual Lift Policy. The measurement tools used included surveys, injury logs, cost logs, and focus groups. The hypotheses were supported with statistical significance in seven of eight outcomes. Changes in injury rates and self-reported unsafe patient handling and lifting practices were statistically significant. Job satisfaction, perceived support for the program and perceived effectiveness of program elements improved post intervention. Workers' compensation costs and cost of lost productivity decreased post intervention. The injury rate before the intervention was 24.0 per 100 workers per year, and 16.9 per 100 workers per year post intervention. Post intervention, workers compensation costs decreased 74%. There was an 18% improvement in lost workdays or absenteeism. The mean time to recuperate decreased 26%. Lost time costs due to sick leave dropped 22%. There was also improvement in costs of lost productivity due to a 94% improvement in decreased number of days in restricted duty.
One hospital described their SPHM program journey (Cadmus, Brigley, & Pearson, 2011) that included interdisciplinary team SPHM evidence-based education, a hospital-wide assessment of current equipment, historical injury data review, and a staff perception evaluation on SPHM knowledge. Each patient care unit evaluated and determined equipment that best suited their unit and the team developed metrics to measure program outcomes. A SPHM plan included (a) committee roles and responsibilities, (b) patient rights, (c) procedures for equipment, (d) equipment storage, (e) infection control recommendations, (f) laundering procedures, (g) compliance expectations, (h) remediation procedures, (i) documentation requirements, and (j) reporting mechanisms of injuries/incidents. Transfer mobility coaches and RN staff super users were identified on each unit. Lift equipment was purchased and education, competency validation tools, and ongoing support were provided. The effectiveness of the program was measured using workplace injury data, reduction in lost days, employee satisfaction, and use of lift equipment over time. Over a 2-year period, there was a 90.5% reduction in lost days, and a 57.1% reduction in workplace injuries. RN satisfaction improved 6%. The authors concluded that it wasn't the quantity or purchase of lift equipment but commitment by everyone to a comprehensive plan that moves an organization to a culture of SPHM.
Lift team model—an alternative
Given the U.S. nursing turnover rate average of 14%, the 6-week average amount of time it takes to orient a new RN, and the time that incumbent RNs spend in annual clinical education and training (KPMG Healthcare & Pharmaceutical Institute, 2011), organizations may consider alternative SPHM models such as lift teams. An organization can maintain high-level proficiency with a focused lift team with lower training costs than training all patient care providers. A lift team or patient transfer team is defined (Meittunen, Matzke, McCormack, & Sobczak, 1999) as two physically fit people that are competent in lifting techniques and work together to perform high-risk patient transfers.
Lift team studies (Charney, 1997, 2003; Donaldson, 2000 & Shea & Short, 2011) describe the importance of specially trained lift teams. Their foundation is that lifting is a specialized skill for focused, trained lift team technicians and that physical characteristics, abilities, fatigue levels, stress levels, training, compliance and attitudes of hundreds of patient care providers are too many variables to control. Post-lift team implementation data showed between 55% and 62% reduction in patient handling back injuries, double-digit percentage decreases in work injury costs associated with the injuries and a reduction in lost work days. A survey study (Bentas, Bossman, Docken, Hefti, & Schaefer, 2003) indicated that 64% of patient caregivers felt the lift team significantly reduced the amount of required patient lifting and 73% indicated that the lift team enhanced their job satisfaction. Common themes in the studies were organizational support, lift team leadership, proper lift team practices that include use of ergonomic equipment (e.g., mechanical lifts) and methods with skill check off competencies, patient care staff educated and trained to the role and accountability of the lift team, and metrics to measure and evaluate the effectiveness of the lift team.
Physical therapists, occupational therapists and rehabilitation
SPHM literature has focused on nurses as they make up the largest percentage of caregivers and spend the most time with patients. Fewer SPHM studies have looked at other professionals such as physical and occupational therapists (PT and OT).
Darragh, Huddleston, and King (2009) summarized research indicating that OTs and PTs are at risk for musculoskeletal injuries during patient handling. They found the annual injury incidence rate of OTs was 16.5 injuries and PTs 16.9 injuries per 100 full-time workers. In addition, they found therapists to be poor self-reporters of injuries and while they recognize early signs and symptoms of musculoskeletal injury, therapists will self-treat rather than seek treatment. The study found that therapists may perceive injury as a negative reflection on their part when they are viewed as experts, role models and educators in physical mobility and patient handling. The fact that PTs and OTs consider changing their patient care focus to working with patient populations that are less medically acute and physically challenging was also identified. This has the potential to create future therapist imbalances or shortages in the workforce in areas such as acute rehabilitation units and hospitals.
Campo, Weiser, Koenig, and Nordin (2008) found the 1-year incidence rate of PT work-related musculoskeletal disorders was 20.7% among a nationally randomly selected sample of 882 PTs. Repetitive patient transfers, repositioning patients, soft tissue or joint mobilization while in awkward bent or twisted postures, and job strain were factors found to increase the risk of work-related musculoskeletal disorders.
The underreporting and altruistic behavior on the part of therapists suggest that PTs and OTs are at risk for work-related musculoskeletal injuries and must integrate SPHM devices into the treatment plan.
Comprehensive and acute rehabilitation services of rehabilitation nursing, physical therapy, occupational therapy and speech therapy assist patients in achieving their highest possible level of function and ideally to return to their prior living arrangement. Therapists and nurses on rehabilitation units facilitate patient mobility (for example, moving around in bed, moving from sitting to standing, walking), and functional independence in activities of daily living (for example, bathing, dressing, feeding and toileting). This therapeutic model encourages patients to do as much of the functional activity as they can for themselves, so it has been a challenge for rehabilitation clinicians to accept the use of mechanical lift equipment to move patients from one surface to another.
Campo, Shiyko, Margulis, and Darragh (2013) conducted the first study that evaluates the effect of an SPHM program on functional mobility outcomes across a full range of rehabilitation diagnoses. It was a retrospective cohort study of rehabilitation patient outcomes before and after implementation of an SPHM program. Data collected over a 1-year period, looked at several facilities with a total of 507 patients without an SPHM program and 784 patients with an SPHM program. One Massachusetts rehabilitation unit SPHM program included administrative policies and advanced handling technologies that utilized floor and ceiling mounted lifts, sit to stand assists, ambulation aides, friction-reducing devices, motorized hospital beds and shower chairs, and multihandled gait belts. Mobility monitors of the (FIM™) Functional Independence Measures (Centers for Medicare & Medicaid Services, 2004) were used to measure outcome. There were significant results with patients with a 15.1 or higher FIM initial evaluation mobility score. Controlled for initial mobility, FIM score, age, length of stay and diagnosis, the analyses showed that these patients performed better with the SPHM program. The authors concluded that SPHM programs do not appear to inhibit recovery and therapists' fears that the use of equipment would lead to dependence were not supported. Perceptions that SPHM technologies promoted only passive participation in transfers or mobility were disproved. Instead, therapists noted advantages of using SPHM equipment, including increased participation of patients in their therapeutic activities and earlier opportunities to begin the rehabilitation process of mobilizing bariatric and medically complex patients. A finding that comparable functional outcomes for the SPHM group may have been achieved in a shorter length of hospital stay was unanticipated and the researchers believe that more research should be conducted to evaluate the potential impact of SPHM programs on length of stay. This study has positive implications for rehabilitation clinical practice and rehabilitation patient outcome.
Advances in SPHM
Equipment advancements and state safety regulations contribute to increased acceptance of SPHM programs. Improvements in design of motorized lift equipment (Morse et al., 2008) make it easier for care providers to use and more comfortable to the patient. Equipment options include: vertical and horizontal transfer lifts for moving patients from sitting to standing or from a bed to a gurney, ceiling mounted lifts to move patients throughout the room on the ceiling tracks, and equipment that allows a nurse or PT to support a patient as they walk.
Washington was one of the first states to pass an SPHM law. Results from a 2011 study found that patient handling injuries decreased more than 33% (Silverstein & Schurke, 2011) after the law went into effect. SPHM legislation has passed in 11 states, but unfortunately, lack of funding provision, penalties or consequences have made compliance difficult. (Monaghan, 2012).
Current SPHM work
The American Nurses Association formed a multidisciplinary working group of SPHM experts to develop national interdisciplinary safe patient handling and mobility standards that are evidence-based and outcomes-focused (American Nurses Association, 2012a,b). The Safe Patient Handling and Mobility Interprofessional National Standards were released on June 25, 2013 (American Nurses Association, 2013).
Congress appropriated funds to the VHA for a 4-year safe patient handling national initiative in 2008. This research was discussed at the 12th Annual Safe Patient Handling Conference (Powell-Cope, 2012). Positive SPHM program outcomes resulted from: deployment of ceiling lifts, effective SPHM leaders, linking an SPHM facility champion with an organization's safety committee, annual staff SPHM competencies completion, the amount of peer leader training, and including SPHM education in new employee orientation. VHA programs adopted SPHM policies, procedures, and protocols that match evidence-based VHA program elements.