Recognizing Trends in Preventing Caregiver Injury, Promoting Patient Safety, and Caring for the Larger, Heavier Patient

| March 6, 2009 | 0 Comments

by Susan Gallagher Camden, RN, MSN, MA, WOCN, CBN, PhD

Dr Gallagher is a certified bariatric nurse, licensed healthcare risk manager, and wound ostomy continence nurse.

Safety initiatives seem to transcend every aspect of healthcare. The Surgical Review Corporation Centers of Excellence (COE) efforts have integrated safe patient handling either directly or indirectly into at least three of the 10 requirements for status as a COE. Safety standards have affected not only care of larger patients, but patients of all sizes.

From the Joint Commission on the Accreditation of Healthcare Organizations (JCAHCO) mandates, such as the 2008 National Patient Safety Goals, to Senate bills, such as the MEDiC Act of 2005, to individual hospital and clinic policies, there is a growing awareness of the risks of injury inherent in healthcare. Safe patient handling is one aspect of patient safety that concerns many clinicians involved with caring for larger, heavier patients.[1] Literature suggests, and most clinicians would agree, safe patient handling must be a consideration in all practice settings along the continuum of care, whether addressing needs of obese patients in a physician’s waiting area, critical care, rehabilitation gym, parking lot, or the morgue. This article examines a comprehensive safe patient handling strategy that addresses the needs of larger, heavier patients—a strategy comprising assessment, administrative support, an on-unit safe patient handling mentor, specialized equipment, training, policies, and procedures—all with the aim of using new ideas to transform a culture of sacrifice to a culture of safety.

The problem
A team of researchers at the Institute for Work and Health discovered that, on average, clinicians performed 38 patient lifts or transfers in their previous eight-hour shifts. Further, the cumulative weight a nurse may have to lift within that same period of time is equivalent to 1.8 tons.[2] This research was not conducted in a weight loss surgery center; therefore, the cumulative weight or number of lifts or transfers may be greater among clinicians who work on bariatric units. Regardless, the risk inherent with this repeated stress is the undetected wear and tear that occurs on caregivers’ bodies, which can go unnoticed for a long period of time because there are so few nerve endings within the spinal discs and other joints. Damage to the back, neck, and shoulders is then largely undetected until the injury is extensive, causing severe, lifelong, and disabling pain. This likely explains why patient lifting, transferring, and repositioning tasks over time are thought to be the leading cause of back, neck, and shoulder damage.

Data calculated in the private sector of US healthcare workers indicate that back injuries result in more lost work days than other injuries or illness.[3] For example, in 2005, healthcare workers sustained nearly 38,000 musculoskeletal (MSD) injuries, which totaled 10 percent of all MSD injuries in the US labor force.[4] Yet, this estimation is probably low as researchers suggest many injuries are unreported. In fact, as many as 50 percent may go unreported.[5] Data from more than 80 studies show that every year, 40 to 50 percent of nurses experience back injuries. At any point in time, 17 percent of nurses are injured.[6]

Who is at risk?
Although it may be difficult to identify who is truly at risk for caregiver injury, researchers suggest that risk factors might include age, shift and hours worked, and gender. More specifically, older female nurses having worked longer evening or night shifts are thought to be at greater risk for injury. Tasks that create more risk are likely those associated with greater effort required to move the patient. Additionally, awkward positions of the patient or the position of the patient’s center of gravity in relation to the caregiver providing the transfer or lift can lead to greater risk, as well as the number of transfers, turns, and lifts on a daily basis or the ability of the patient to help with transfers. When both caregiver and patient are obese the threat to safe patient handling is considerably greater. And finally, the greatest concern is the mistaken assumption that exposure to occupational injury is simply an acceptable risk associated with patient care. This barrier to meaningful safe patient handling blocks efforts to improve working conditions in the patient care environment.[7] Each of these risks further leads to cost consequences.

Costs of injury
The risks and threats of injury further contribute to an already serious nursing shortage as an estimated 47 percent of hospital nurses report that they have considered leaving patient care because of their jobs’ physical demands. Among those nurses already injured, 59 percent have considered quitting.[8] From a cost perspective, nurses’ back injuries cost an estimated $16 billion annually in workers’ compensation benefits. Medical treatment, lost work days, “light-duty,” and employee turnover cost the industry an additional $10 billion.[9] Nursing personnel have the highest workers’ compensation claim rates of any occupation or industry.

Efforts to connect work environment safety and caregiver injury with quality of patient care and patient care-related cost control have created interest from a different angle. For example, patient safety efforts have long been a driving force in cost outcome strategies; however, little emphasis has been given to improving care or controlling cost outcomes by improving the work environment for clinicians. This correlational research is just recently forthcoming. De Castro[10] noted that using equipment during handling activities is a more secure process for patients, and, therefore, patients were subjected to awkward or forceful handling fewer times, they experienced less anxiety, patient autonomy was increased, and a higher level of dignity was maintained.

Others have recognized use of lifting equipment with a decrease in combative behavior.[11] Use of friction-reducing devices for lateral transfers are not only helpful in preventing neck and shoulder injuries among caregivers, but are known to reduce shearing injury in patients, which lead to skin damage and exacerbate pressure ulcers. Nelson et al[12] recently reported a link between safe patient handling and patient outcomes in long-term care, citing a reduction in falls and other adverse events.

Are there solutions?
Hospitals and healthcare organizations are seeking strategies to address the issues of caregiver safety, but are faced more and more often with the fact that a new way of thinking about safety is the only answer. For instance, caregivers, including nurses, continue to be trained on methods of manual lifts and transfers, despite the fact that body mechanics training in proper lifting techniques has been discredited by 35 years of research.[13] More recently, the concept of mechanical handling devices has come under scrutiny, and never more seriously than with the larger, heavier patients. For example, consider dragging heavy or cumbersome bariatric equipment across carpeted inclines or placing a sling under a morbidly obese patient using a log roll technique. These tasks are thought to support a safe patient handling philosophy—but do they really? The challenge is recognizing practices that truly support a safe environment. The new paradigm is more than equipment; a safe environment comprises assessment, administrative support, an on-unit mentor, policies and procedures, and sustained enthusiasm for change.

Realistic changes
The essence of a successful transformation is administrative support. This will likely occur on two fronts: individual states passing safe handling legislation and the federal government passing a national bill. In the interim, cost control will drive interest. The hospitals that have instituted successful safe patient handling programs have found significant cost saving in terms of human and economic costs. For example, one study indicated workers’ compensation costs decreased by 61 to 95 percent, insurance premiums dropped 50 percent, medical and indemnity costs decreased by 92 percent, lost work days decreased by 66 to 100 percent, and restricted work days decreased by 38 percent.[14, 15] Several cost-benefit analyses show initial investment in Figure 1 and training can be recovered in 2 to 3 years through reductions in workers’ compensation benefits.[16] Each of these studies serve to advance administrative interest and support.

Introduction of equipment is an important next step. Equipment must meet the realistic needs of the patient, caregiver, and facility. Because bariatric equipment is larger, heavier, and wider, it can be more cumbersome to move and use. Practical considerations to bariatric equipment include ergonomic qualities (e.g., ease of use) and patient-specific qualities (e.g., width and weight limit). Specially designed wheels, steering systems, and powered units are safety features integrated into not only bariatric patient care equipment, but also clinical and nonclinical equipment that require physical exertion.

Equipment selection is the task of those closest to the patient. When renting equipment, consider delivery time, set up, training, and cost. When purchasing equipment, ask questions such as the following: Is there an option for a service agreement? What is the cost? Who will maintain, store, or set up the equipment? Staff members who evaluate equipment should report on ease of use, effectiveness, storage, patient comfort, and patient and staff member safety. Implementation plans should include staff training in the safe and effective utilization of new patient handling equipment. Ideally, the training would include thorough demonstrations for the staff on techniques and propert equipment usage, with opportunities for the staff to perform demonstrations that show competency (i.e., train-the-trainer programs). Identify, in a discreet fashion, weight limits of bariatric equipment to ensure maximum safety for patients who use the equipement. For example, a simple number or colored sticker placed in the same place on each piece of equipment might serve this purpose.

Title III of the Americans with Disabilities Act requires reasonable accommodation in public spaces, which can be interpreted to mean in the general areas of public and private hospitals and clinics. Wider, heavy-duty chairs with adequate weight capacity in patient rooms and waiting areas are essential, especially in a facility that provides a medical or surgical weight management services. Patient and visitor bathrooms should provide floor-mounted toilets and sinks as there is some question as to the actual weight limit of many wall- mounted structures when force is added to weight. Specially designed rooms furnished and equipped to meet the needs of the larger, heavier patient on a unit with trained staff members have been a successful safety strategy in some facilities. Appropriately sized furniture, gowns, blood pressure cuffs, patient handling equipment, and resuscitation equipment should be located in or near the patient rooms for easy, discreet access.[11]

Policies and procedures that guide processes for moving and lifting larger, heavier patients and explain use of equipment are an important part of the safety equation. Consider the work done by the Patient Safety Center, Tampa Florida, where the Safe Bariatric Patient Handling Toolkit has been developed and is available online for use.[17] The goal of the toolkit is to promote safety for both patients and caregivers by providing just-in-time training for staff members, which is training delivered specific to a particular situation and as needed, and is designed to foster dignified, comfortable, and safe care for bariatric patients. The toolkit includes clinical tools, resources, policies, safety tips, and training ideas.

Training is an important component of success. However, in years past, the most common training approach included body mechanics classes, of which recent evidence suggests is not an effective strategy in safe handling.[18] The new training paradigm incorporates on-unit mentoring as compared to an approach using an annual safety day that reviews body mechanics and other safety ideas during an all-day program, which attendees are expected to recall in the event they are faced later with a safety challenge. An on-unit mentor or back injury resource clinical specialist is more involved with the day-to-day safety issues, with responsibilities such as providing expertise in patient-handling assessment, offering techniques on use of equipment, evaluating on-unit hazards, training program elements, leading safety huddles (after-action reviews), identify reasons and solutions for ongoing injuries, support minimal lift philosophy, and sustain enthusiasm in patient and caregiver safety.[19] The value of the on-unit mentor is the practical nature of real-time training pertaining to an actual safety need.

Practical tips for safety
Clinicians are often faced with awkward patient transfer situations, such obese patients who are in pain, uncooperative, afraid, or simply hesitant—all of which increase the risk of injury. For example, in one study, nurses spent on average 1.6 hours per shift in a stooped posture.[20] Clinicians must recognize and understand certain risks and learn to control those risks. The spine provides the basic form of movement and support for the human body; it is constantly in use and therefore suffers cumulative injuries caused by these situations and positions, aggravated by heavy lifting.

From a practical perspective, consider ideas to promote patient independence, such as grab rails and toilet seat risers in the bathroom and adjustable shower benches or chairs designed for bathtub use. An oversized walker or heavy-duty shower chair will promote independence of patient in the shower. Plan activity to reduce the number of transfers needed as each transfer or lift places the patient and clinician at risk. Occasionally an unforeseen lift or transfer may be necessary. Take advantage of proper training in positioning and ergonomic lifting procedures. To reduce chances of injury when assisting an otherwise independent patient, caregivers should consider some of these real-life ideas: Make sure that feet are stable, knees are bent, face the patient as close as possible, hold in the abdominals, and keep the back straight as this adds strength from legs and arms. However, always consider lift and transfer equipment and encourage the patient to participate whenever possible.

When turning a patient from back to side, distribute weight equally between feet and try to avoid extended forward bending movements as much as possible. Caregivers who find themselves providing frequent lateral turning for the dependent patient should consider a full-body lateral rotation surface to provide mechanical rotation or use a turning band attached to a ceiling lift. When possible, alleviate awkward body positions while bathing or providing personal care or hygiene. A bariatric bed that can be lowered from 48 inches to 39 inches or less is one strategy to allow the patient adequate room when the bed is expanded, yet allows the clinician opportunity to easily reach the patient when the bed is narrowed to 39 inches.

Avoid twisting, bending, and stooping positions in order to alleviate strain not only on the spine, but also on muscles and joints. A ceiling lift with bands for turning, lifting, or repositioning the larger, heavier patient allows for basic care without placing undue physical stress on the clinician. Clinical staff members who have access to an on-unit mentor can integrate this resource into the everyday routine of caring for patients who otherwise may pose a safety challenge.

Putting it all together
Safe patient handling and the obese patient need to be considered in all areas of patient contact.[21] Wider wheelchairs are necessary to move the patient from one department to another. Wider, heavy-duty, reclining, stretcher chairs are essential for patients with obesity hypoventilation syndrome or other conditions that require reclined positioning when transferring. Lateral transfer products are important to move the patient from the gurney to bed or diagnostic table. Fixed ceiling-mounted lifts, portable ceiling lifts, and floor lifts work together to provide a cost alternative and flexible solution to lift and transfer needs and should be tailored to the needs of the specific service line. Along the same line, a number of lifting bands, slings, and litters (lift baskets) are available, again designed to match the specific task to be accomplished. Take the opportunity to learn what vendors offer and make suggestions when there is an unmet need.

The bariatric task force best serves the needs of caregiver safety and patient outcomes by investigating every area of patient care and determining what hazards of care exist in each.[22] Frontline workers—those in direct contact with the patient—are the most valuable as these individuals can relate the real risks of specific care area. An example of a risk is a bed that is wide enough for the patient but too wide for the clinician to provide proper care without caregiver injury; likewise, a bed that is a manageable size for the caregiver may be too narrow for the patient.

Safe lifting techniques should be integrated into every aspect of clinical and nonclinical care in order to maintain the safety, not only of the patient, but the caregiver. A caregiver who finds that the physical strain of providing care becomes too difficult may place the patient at risk for injury. Knowing when to ask for help and not being hesitant to do so may prevent accidents and injuries. Caregivers must assess daily assignments and plan their day to avoid excess numbers of transfers and utilize resources and equipment. Encourage patients to participate in their care whenever clinically appropriate. Keep in mind, England, the Netherlands, Switzerland, Australia, Finland, Ireland, and Canada already prohibit manual patient handling and require mechanical handling devices. An array of equipment and devices is commercially available to help move even the largest, fully immobile patients. However, equipment should never be a substitute for proper safe patient handling assessment, administrative support, on-unit mentoring, policies and procedures, and meaningful training.

1.    Gallagher S. Issues of caregiver injury: addressing needs of a changing population. Bariatric Times. 2005;2(1): 3–7.
2.    Tuohy-Main K. Why manual handling should be eliminated for resident and caregiver safety. Geriaction. 1997;15:10–14.
3.    Nelson A. Patient Safety Center of Inquiry: Veterans Health Administration and Department of Defense, Patient Care Ergonomics Resource Guide. November 2003.
4.    Bureau of Labor Statistics, Department of Labor, Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work, 2005. November 2006.
5.    Nelson A, Matz M, Chen F, Siddharthan K , Lloyd J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. International Journal of Nursing Studies. 2006;43(6):717–733.
6.    Hignett S, Work-related back pain in nurses, Journal of Advanced Nursing. 1996; 23(6):1238–1246.
7.    Nelson A, Collins J, Siddharthan K, Matz M, Waters T. Link between safe patient handling and patient outcomes in long term care. Rehab Nurs. 2008;33(1):33-43.
8.    Peter D. Safe Patient Handling: A Report. Hart Research Associates: March 2006.
9.    Edlich RF, Winters KL, Hudson A, Britt LD, Long WB. Prevention of disabling back injuries in nurses by the use of mechanical patient lift systems. Journal of Long-Term Effects of Medical Implants, 2004;14(6):521–533.
10.    De Castro B. Handle with care: The American Nurses Association’s campaign to address work related musculoskeletal disorders. Online Journal of Issues in Nursing. 2004;19(3): Manuscript 2.
11.    Collins, J.W., L. Wolf, J. Bell, B. Evanoff, An evaluation of a ‘best practices’ musculoskeletal injury prevention program in nursing homes. Injury Prevention, 2004; 10:206–211.
12.    Nelson A, Collins J, Siddharthan K, Matz M , Waters T. Rehab Nurs. 2008;33(1):33–43.
13.    ANA Handle With Care Factsheet, handlewithcare/factsheet.htm. Nelson, Audrey, Ed., Patient Safety Center of Inquiry (Tampa, FL) Veterans Health Administration and Department of Defense, Patient Care Ergonomics Resource Guide, November 2003
14.    Collins JW, Wolf L, Bell J, Evanoff B. An evaluation of a ‘best practices’ musculoskeletal injury prevention program in nursing homes. Injury Prevention, 2004; 10:206–211.
15.    Nelson A, Matz M, Chen F, Siddharthan K , Lloyd J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. International Journal of Nursing Studies. 2006;43(6):717–733.
16.    National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention, Department of Health and Human Services, Safe Lifting and Movement of Nursing Home Residents, February 2006.
17.    Safe Bariatric Patient Handling Toolkit. Accessed January 2, 2009 at:
18.    Nelson A, Baptiste A. Evidenced-based practices for safe patient handling and movement. Online Journal of Issues in Nursing. 2004;19(3): Manuscript 3.
19.    Department of Veterans Affairs VHA. Patient Ergonomic Program September 8, 2005. Accessed January 2, 2009 at:
20.    Stubbs DA, Buckle PW, Hudson MP, Rivers PM, Worringham CJ. Back pain in the nursing profession. Epidemiology and pilot methodology. Ergonomics. 1983;26:755–766.
21.    Gallagher S. The challenges of bariatric care: strategies to maximize patient health and caregiver safety. ECPN. 2005;101(6):18–25.
22.    Camden SG. Obesity, organizational policy and education. Bariatrics Today. 2005;3:60–63.

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