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My Aching Back! The goal of nursing is healing the sick, so it's ironic that nursing as a profession sees some of the highest rates of musculoskeletal injuries. The impact of such injuries is far-reaching, report industry observers, and can adversely affect everything from staffing to budget to patient care. Realizing the detrimental effects of work-related musculoskeletal disorders, medical facilities are taking steps to reduce injuries among nurses and other staff through the acquisition of assistive equipment, increased education, and other initiatives. Common complaint Back injuries are the most common and costly musculoskeletal injuries among nurses, but frequent injuries also occur in the neck, shoulders, elbows, wrists and knees, notes Audrey Nelson, RN, PhD, FAAN, director of the Patient Safety Center at James A. Haley VA Hospital in Tampa, Fla. "Nurses change the way they perform tasks in subtle ways to protect their lower back or whatever is bothering them, shifting risk from one body part to the other," says Nelson, who has done extensive research into nursing-related musculoskeletal injuries. "As a result, they get achy and tired and end up having pain pretty much all over." A 2004 follow-up survey by NurseWeek Publishing and the National Organization of Nurse Executives revealed that nearly one-third (31%) of the 1,738 RN respondents had experienced back or musculoskeletal injuries on the job during the previous year. This was comparable to the 34% who reported such injuries in the original survey, conducted in 2002. The study, "How RNs View the Work Environment: Results of a National Survey of Registered Nurses," was published in the September 2005 edition of JONA, the Journal of Nursing Administration. Serious impact The American Nurses Association addressed the problem of work-related injuries in 2003 with the launch of its "Handle With Care" ergonomics campaign. "Studies of back-related workers' compensation claims reveal that nursing personnel have the highest claim rates of any occupation or industry," says ANA President Barbara A. Blakeney, MS, APRN, BC, ANP. "In addition, other estimates report that 12% of nurses leave the profession annually as result of back injuries, and more than 52% complain of chronic back pain. These alarming statistics tell us two things: that poor ergonomics hurts nurses, who are choosing to leave the profession rather than suffer unnecessarily, and that poor ergonomics hurts patients, whose safe nursing care is already threatened by the nation's escalating nursing shortage." A musculoskeletal injury might disrupt a nurse's career, agrees Nelson. "Many nurses fear a career-ending injury," she says. "There are many examples of nurses who love direct patient care but have been forced to either leave nursing or leave the type of nursing they enjoy because of injury." Injuries also can strain working relationships. Nurses often are not supportive of their peers who get hurt, Nelson says. "When one person reports an injury, rarely does the institution replace that worker. As a result, the workload falls on smaller and smaller numbers, which brings out the worst in people," she says. "There is often resentment toward coworkers who report injuries because it puts more work on the others, who are also experiencing musculoskeletal pain. There is pressure not to report the injury, and then to return to work faster, which is not a good thing." A study by Bernice Owen, RN, PhD, former professor at the University of Wisconsin-Madison School of Nursing, shows that as many as one-third of nurses who experience work-related back injuries do not report them. Risk in moving patients A variety of factors contribute to work-related musculoskeletal disorders, says Anna L. Alderuccio, (right) RN, MSN, director of nursing at St. Mary Medical Center, Langhorne, Pa. Prominent among them are increasing number of obese patients and the aging nursing population. "It's the gut feeling of our nursing staff that patients are definitely getting heavier," Alderuccio says. "Not necessarily just the bariatric population, but patients in general seem to be getting larger. And with our maturing nursing population, those two things can increase the risk of injury to staff and patients [when a patient must be moved]." Christine Collins, APN, director of employee health at Christiana Care Health System, Wilmington, Del., agrees. "We're seeing many more obese patients," Collins says. "I don't know specifically what the average weight of a patient is today, but back in the early '90s it was about 185 pounds. I would imagine that today it's around 220 pounds." Sedated or unconscious patients, regardless of size, also pose a problem when nurses must move them, Collins adds. Because the patient cannot assist, the nurse must bear the patient's entire weight. Adding to the problem is the myth that there are correct ways to manually lift a patient. Nelson points to a study by Owen showing that 85% of U.S. nursing schools teach manual-lifting techniques. "That is so outdated," Nelson says. "Many students going to school today are learning practices that are not evidence-based." Preventive initiatives Pennsylvania-based Genesis Healthcare Corp., which owns more than 200 nursing homes and assisted care facilities in 10 states, created a "no manual lift" policy as part of its Safe Resident Handling Program, says Mark Santoleri, corporate director of safety and loss control. "The majority of injuries to caregivers in nursing homes are caused by lifting, transferring, or repositioning residents," Santoleri says. "What we did was develop a program that reduces the most common risk factors, such as excessive force, awkward posture, and repetitive motion. Our program establishes a hierarchy of interventions using equipment as a primary means for lifting, transferring, and repositioning residents." The Safe Resident Handling Program has shown promise in the centers where it has been implemented. After one year in the program, 12 centers reported a 90% reduction in the frequency of resident-handling claims and a 94% reduction in cost, Santoleri says. The quality of resident care also has been improved by the program, Santoleri says. "Our initiative was not just for the protection of our staff, it's an integrated clinical and occupational health initiative that has had a tremendous impact on the protection of residents in the areas of skin tear, fractures, abrasions and falls related to manual lifting or transferring," he says. There are other benefits as well. The routine use of assistive equipment has allowed residents to be assisted to the toilet more easily, which has resulted in fewer urinary tract infections. Bedbound residents are being repositioned on schedule more often, which has dramatically reduced the number of nursing home-acquired skin ulcers. Fewer injuries Christiana Care Health System has created its own program to reduce musculoskeletal injuries among staff members. The PEEPS program - an acronym for patient, environment, equipment, posture, and safety, the components of safe-lifting technique - has reduced work-related injuries and time lost due to injury. Since its inception in 2000, the average days lost per injury have plummeted from 45.75 days to 13 days systemwide, company officials report. "The program is extremely comprehensive," Collins says. "It helps assess a patient's mobility needs and how to safely facilitate those needs. The training is extensive and we continually reinforce the safe use of the equipment. It's hardwired into nursing orientation." Christiana Care has invested in a wide array of assistive equipment, including partial standing lifts and horizontal air-transfer mattresses that bears most of the load when transferring a patient from stretcher to bed or stretcher to x-ray table. "We also are installing permanently mounted ceiling lifts that will eventually be available in all patient rooms," Collins says. "We're identifying the highest-risk units and patient care areas first. The staff is very excited about them. The lifts are very cutting edge." The drop in staff injuries pleases nurses as well as hospital officials at Christiana Care. "It has reduced costs associated with workers' compensation and improved both productivity and our nurses' work lives," Collins says. "When we were presenting to the budget committee for expanding our ceiling-lift program, the nurses came in and noted the fact that they no longer went home in pain every night." Partnering with technology At St. Mary Medical Center, staff members have a new directive - no solo lifts. They are required to seek assistance from others and take advantage of assistive devices whenever a patient must be moved, transferred, or repositioned, Alderuccio says. The hospital originally considered a "no manual lift" policy but found it impractical. "No matter what you do for a patient, you have to lift, even when transferring them onto the assistive equipment," Alderuccio says. "So we took a few steps back, looked at the literature, saw what others were doing, and settled on a no solo lift policy." Ease of use and standardization were key in selecting the most effective assistive equipment, Alderuccio says. After meeting with a variety of vendors, the hospital chose the E-Z Lift, the E-Z Lift Assist, and the SLIPP Patient Mover. It is currently looking into purchasing several air transfer mattresses, which will make moving patient even easier and safer. "We provided training for all of the equipment that we acquired, and with some we'll add it to our nurses' yearly competency to make sure they are using it correctly," Alderuccio says. "When we roll out the official 'no solo lift' policy, we'll be doing a hospitalwide initiative to go with it." But the efforts won't end there, she says. "Back-injury prevention and patient safety are issues that we'll continually address in the future."
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