Minimizing Musculoskeletal Injuries
Written by Gail Powell-Cope
MMT 2012 Volume: 16 Issue: 1 (February)
Injuries due to patient lifting and transferring are the leading cause of musculoskeletal injuries among nurses, resulting in lost work days, pain and suffering, loss of nurses to the profession, and cost to the Veterans Health Administration (VHA). Ergonomics-based safe patient handling programs (SPH) have evolved over the past 15 years to reduce the incidence and severity of musculoskeletal injuries in direct care providers. The VHA is a recognized leader in SPH through years of sustained work. Evidence of the success of this VHA-wide program is becoming clear. The number and standardized rates of VHA incidents (defined as injury per 10,000 full-time workers) related to lifting and repositioning of patients has declined, coinciding with program implementation:
- From 2006 to 2011 the rate of patient handling injuries across all nursing occupations has decreased 34 percent.
- Among nursing occupation categories, the rate has decreased the most in licensed practical nurses: 45 percent.
Data analysis is ongoing and will allow us to examine the conditions and predictors of reduced injuries. For example, is the number of ceiling lifts associated with a decrease in injuries? How do the activities of facility champions and unit peer leaders contribute to program implementation and the decreased injury rates? The purpose of this article is to tell the story of how SPH evolved and identify best practices and reasons for successes based on a 15-year history in the VHA.
The Beginnings
In 1996, with a new Ph.D. in hand, Dr. Audrey Nelson asked leaders at the Tampa VA Hospital what she could do for them. The director at the time, Richard Silver, said, “Fix the back injury problem in nurses.” She thought that if she conducted a literature review she could find the answer and fix the problem. However, she found that nursing injuries continued despite the usual practice of sending injured nurses to back classes to be instructed on body mechanics. Because the answers were not in the literature, she then went to the loading dock at the hospital to observe how workers moved heavy loads. With Silver’s charge, a literature review that yielded no evidence for preventing musculoskeletal injuries in nursing, and her observation of the loading dock, Dr. Nelson consulted with the few researchers in the field, ergonomic experts and launched a program of research in safe patient handling. Three key features of program implementation that propelled its success will be described: building on successes and learning from failures, nurturing partnerships to increase spread, and cultivating a “sales force.”
Building on successes and learning from failures: Dr. Nelson did not get funding agencies interested in the research until she renamed it from “back injuries in nursing” to “safe patient handling,” giving it a patient focus. In Dr. Nelson’s first study, funded by VA Health Services Research and Development, she redesigned basic nursing skills to reduce harmful forces on the joints and back through the use of equipment. She garnered more funding and was able to demonstrate the usefulness of ceiling mounted lifts at a time these lifts were almost non-existent in the United States. The next step was a regional implementation project focusing on high risk units, nursing homes and spinal cord injury. This step was important because it not only allowed us to demonstrate positive outcomes, but it also helped us to hone program components, develop training materials, and become more systematic in our approach.
Nurturing partnerships to increase spread: The program initially was focused on musculoskeletal injuries in nursing, and partnerships were developed with the American Nurses Association, the Orthopedic Nursing Association, the Association of Rehabilitation Nurses, and others. In 2003, the American Nurses Association launched their Handle with Care Campaign to advocate for policies and legislation to eliminate manual patient handling and to promote national and federal legislation toward this end. The ANA’s successes are many (www.anasafepatienthandling.org) and have helped to propel advances in SPH. At early conferences, physical therapists were not fully supportive of the program because some believed that using equipment to move patients was contrary to rehabilitation goals of increasing strength and promoting independence. In a tactical move, Dr. Nelson invited the American Physical Therapy Association (APTA) to the table. Their first endeavor was a position paper that was dually written by the APTA and the Association of Rehabilitation Nurses. Over the years, therapists have become great advocates in SPH because they realize its potential to be used therapeutically to foster independence during rehabilitation.
Other partnerships were formed to increase the spread of implementation, including the National Institute for Occupational Safety and Health and branches of the military that resulted in significant gains. For example, the ANA, NIOSH and the VISN 8 Patient Safety Center developed and pilot tested a curriculum for baccalaureate nursing education. In 2006, under the leadership of Dr. Michael Hodgson, chief consultant for the VHA Occupational Health Strategic Health Care Group, the VA launched a multimillion initiative to implement SPH VA-wide. As a result of this program, every VA medical center hired a clinical champion and funds were provided to all facilities to purchase ceiling lifts, transfer devices and other safe patient handling technologies. Partnerships with multiple organizations facilitated the growth of two annual evidence-based conferences in SPH, now in their 12th year. Conferences have grown from the first held in Tampa with only a few VA employees from Florida to last year, when conferences drew over 1,500 attendees from the VA, private sector, and other government agencies, and from countries around the world. A highlight of the program for many is the extensive vendor area that allows participants hands-on experiences with a variety of SPH technologies. The vendors also have the opportunity to listen to health care workers’ concerns and needs and modify their designs and develop new ones as needed to move the industry forward.
Cultivating a sales force: While the lifting and transfer equipment is the tangible and indispensable part of the program, VHA Central Office Staff, facility champions and unit peer leaders make up the VHA sales force that has tirelessly worked to communicate the benefits of SPH to stakeholders, persuade others to support the program, and encourage use of the equipment and tools at the bedside. The role of Dr. Hodgson in Central Office has been to garner resources (e.g., funding for equipment and facility champion positions) by communicating to the VHA leadership the importance of ergonomics-based safe patient handling in decreasing musculoskeletal injuries in the VHA workforce and how decreased injuries translate in cost saving through decreased lost work time, decreased light duty days, reduced turnover of staff, lower worker compensation costs and a positive view of the VA as an employer of choice for prospective employees. Cost analysis provided important information to VA leadership about why they should support the program. At the same time, Dr. Hodgson and his staff have been instrumental in working with regional VHA offices and the facility champions to work through barriers of purchasing and installing equipment. His presence and involvement at the SPH conferences gives a strong message to facility champions and front line staff of the VHA commitment to worker and patient safety.
In 2006, the funding from the VHA provided for a facility champion in every VA medical center to implement SPH. The main function of this cadre of dedicated individuals is to provide leadership at the local level, bridging across levels of the organization including VHA Central Office, medical center administration, mid-level managers, unit peer leaders and direct care staff. They also work across hospital services to ensure smooth implementation, such as fiscal for securing funding, purchasing for buying the right type and amount of equipment, engineering and facilities management for proper equipment installation, and education to ensure that staff are well trained and competent in use of equipment. From our observations, the most effective facility champions are clinicians who understand direct patient care, leaders who know how to motivate and persuade others, and managers who can effectively work in complex environments and who have a systems perspective on change and safety.
Unit peer leaders are the specially trained workers on the front line who work with clinical champions and coworkers to insure program implementation. Unit peer leaders come from many backgrounds, including registered and licensed practical nurses, certified nursing assistants, therapists, therapy aids and health technicians. From our perspective, the most effective unit peer leaders are enthusiastic, hold strong beliefs in the benefits of the SPH, and are viewed by coworkers as knowledgeable and competent. Often they are natural leaders who volunteer for opportunities to improve the work environment and patient care. Logistically, unit peer leaders formally train staff and provide informal training as opportunities arise in the work setting. Some assume other leadership responsibilities, such as one who developed unit-based manuals for his and other hospital units, and another who responds to request for just-in-time training on other units.
Over the years, numerous implementation tools have been developed by the VHA, professional organizations and industry. Implementation tools that the sales force use include but are not limited to: videos to explain SPH to hospital administrators, health care workers; patients and families, algorithms to facilitate clinical decision making; toolkits for implementation including a technology toolkit and a bariatrics toolkits; and guidelines for conducting unitbased hazard assessments. Many toolkits are housed online and available without charge. Most recently a journal has come online specific to SPH, The American Journal of Safe Patient Handling and Movement.
In summary, the vision of Dr. Audrey Nelson, her championship, the numerous people and groups who have carried her vision forward and the leadership of the VHA have all worked together over a 15-year period to propel SPH forward. In doing so, health care is safer for both workers and patients within the VHA and in the private sector as well. While much progress has been made, continued leadership and effort is needed to overcome threats such as budget constraints, policy, and other forces that loom large. I look forward to the day when safe patient handling is taken for granted as a part of routine patient care. ♦
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Public Health, Occupational Health. The contents do not represent the views of the Department of Veterans Affairs or the United States government.
Gail Powell-Cope, ANRP, PhD, FAAN, is chief, Nursing Research and Acting Director, HSR&D/RR&D Center of Excellence Tampa VA Hospital.