Reducing incidence of low-back injuries reduces cost

What Do We Know About Interventions to Prevent Low Back Injury and Pain Among Nurses and Nursing Students? A Scoping Review

STUDY BACKGROUND

Back injuries are common among nurses worldwide with lifetime prevalence of lower back pain ranging from 35% to 80%, making nursing a profession at great risk for back injuries.

PURPOSE

This systematic scoping review explored and mapped existing evidence regarding the prevention of low back injury and pain among nurses and nursing students.

METHODS

Using a scoping review methodology, six databases were searched initially in September 2017 and updated June 2020. Studies investigating interventions designed to reduce back injuries and pain among regulated nurses and student nurses, published in peer-review journals and written in English, were eligible for inclusion in this review. Quantitative, qualitative, and mixed methods studies of regulated nurses, nursing students, and nursing aides were included. Two independent reviewers screened, critically analysed studies using a quality appraisal tool, extracted data, and performed quality appraisals.

RESULTS

Two searches yielded 3,079 abstracts and after title, abstract and screening, our final synthesis was based on 48 research studies.

CONCLUSIONS

Forty years of research has demonstrated improvements in quality over time, the efficacy of interventions to prevent back injury and pain remains unclear, given the lack of high-quality studies. Further research, using multi-dimensional approaches and rigorous study designs, are needed.

Use of Accessible Weight Scales and Examination Tables/Chairs for Patients with Significant Mobility Limitations by Physicians Nationwide

BACKGROUND

Mobility limitations are the most common disability type among the 61 million Americans with disability. Studies of patients with mobility limitations suggest that inaccessible medical diagnostic equipment poses significant barriers to care.

METHODS

The study team surveyed randomly selected US physicians nationwide representing seven specialties about their reported use of accessible weight scales and exam tables/chairs when caring for patients with mobility limitations. A descriptive analysis of responses was performed, and multivariable logistic regression was used to examine associations between accessible equipment and participants' characteristics.

RESULTS

The 714 participants (survey response rate = 61.0%) were primarily male, White, and urban, and had practiced for 20 or more years. Among those reporting routinely recording patients' weights (n = 399), only 22.6% (standard error [SE] = 2.2) reported always or usually using accessible weight scales for patients with significant mobility limitations. To determine weights of patients with mobility limitations, 8.1% always, 24.3% usually, and 40.0% sometimes asked patients. Physicians practicing ≥ 20 years were much less likely than other physicians to use accessible weight scales: odds ratio (OR) = 0.51 (95% confidence interval [CI] = 0.26-0.99). Among participants seeing patients with significant mobility limitations (n = 584), only 40.3% (SE = 2.2) always or usually used accessible exam tables or chairs. Specialists were much more likely than primary care physicians to use accessible exam tables/chairs: OR = 1.96 (95% CI = 1.29-2.99).

CONCLUSION

More than 30 years after enactment of the Americans with Disabilities Act, most physicians surveyed do not use accessible equipment for routine care of patients with chronic significant mobility limitations.

A Taxonomy of the Common Tasks and the Development of a Risk Index for Physical Load Assessment in Nursing Job

Background

Nursing service is a nonroutine work with an excessive physical load and diverse tasks. This study derived representative common tasks based on the frequently occurring tasks with a high physical load in the nursing workers' daily work and developed indicators to evaluate the work risk by reflecting the characteristics of nonroutine work.

Methods

Common tasks were classified through the following stages: literature review, first focus group interview (FGI) with experts, first classification of common tasks, second FGI with hospital health managers, a survey of nursing service workers, and the final classification of common tasks for each task type. To develop an objective risk index for physical load assessment, we investigated the frequency and duration of the derived common tasks via survey.

Results

Nursing common tasks were categorized into six task types and 56 subtasks. To evaluate the risks of various tasks in nonroutine works, three frequencies and three working time levels were defined by examining the task frequency and working hours. Exposure time was defined to reflect the characteristics of a nonroutine job. The final risk assessment was the product of the exposure time level and job intensity level. From this, four risk action levels were derived.

Conclusion

This study has the advantage of solving the problem of focusing on some tasks in evaluating the physical load. It was meaningful in that a new risk assessment index based on exposure time was proposed based on the development of an evaluation scale for frequency and time by reflecting the characteristics of nonroutine work.

Accommodating patients with obesity and mobility difficulties: Observations from physicians

BACKGROUND

Given the growing population of U.S. adults with obesity and mobility disability, physicians will need to accommodate these patients.

OBJECTIVE

To explore attitudes and practices of US physicians related to caring for patients with obesity and mobility disability.

METHODS

Three open-ended, semi-structured, web-based focus group interviews with practicing physicians in selected specialties, which reached data saturation. Interviews were video recorded and transcribed for qualitative, conventional content analysis. Measurements included commonly expressed themes around caring for patients with obesity.

RESULTS

Physicians recognized obesity as a disability that poses challenges to high quality, safe, and efficient patient care. Observations coalesced around four themes: (1) difficulty routinely tracking weight; (2) reluctance to transfer obese patients to exam tables; (3) barriers to diagnostic testing; and (4) weight stigma. Physicians described difficulties accurately assessing weight, performing complete physical examinations, arranging diagnostic imaging, and providing prenatal care for obese patients. Lack of accessible medical diagnostic equipment impeded care for patients with obesity. Other participants did not contest comments of individual participants' that suggested weight stigma.

CONCLUSIONS

Our findings suggest that important gaps may remain in providing equitable access to care for patients with obesity, requiring additional training and accessible medical diagnostic equipment to safely accommodate these patients.

Accessibility of Medical Diagnostic Equipment for Patients With Disability: Observations From Physicians

OBJECTIVE

To explore attitudes and practices of physicians relating to accessible medical diagnostic equipment in serving patients with mobility disability.

DESIGN

Open-ended individual telephone interviews, which reached data saturation. Interview recordings were transcribed verbatim for qualitative conventional content analysis.

SETTING

Massachusetts, the United States, October 2017-January 2018.

PARTICIPANTS

Practicing physicians from 5 clinical specialties (N=20).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Common themes concerning physical accessibility.

RESULTS

Mean ± SD time in practice was 27.5±12.5 years; 14 practices had height-adjustable examination tables; and 7 had wheelchair-accessible weight scales. The analysis identified 6 broad themes: height-adjustable examination tables have advantages; height-adjustable examination tables have drawbacks; transferring patients onto examination tables is challenging; rationale for examining patients in their wheelchairs; perceptions of wheelchair-accessible weight scales; and barriers and facilitators to improving physical accessibility. Major barriers identified by participants included costs of equipment, limited space, and inadequate payment for extra time required to care for persons with disability. Even physicians with accessible examination tables sometimes examined patients seated in their wheelchairs.

CONCLUSIONS

Even if physicians have accessible equipment, they do not always use it in examining patients with disability. Future efforts will need to consider ways to eliminate these access barriers in clinical practice. Given small sample size, results are not generalizable to physicians nationwide and globally.

Outcomes of safe patient handling and mobilization programs: A meta-analysis

BACKGROUND

Variability in patient care settings and the range of patient handling tasks present challenges in developing and evaluating safe patient handling and mobilization (SPHM) programs.

OBJECTIVE

We performed a systematic meta-analysis of SPHM program evaluations.

METHODS

Systematic literature review identified published SPHM program evaluations. Injury Rate Ratios (IRR), pre- to post-intervention, were used to estimate intervention effects and to examine the influence of patient care level, program components, and follow-up time using meta-regression.

RESULTS

27 articles reported evaluations from 44 sites. Combined effect estimate for all SPHM programs was 0.44 (95% CI 0.36, 0.54), reflecting substantial injury reductions after program implementation. While specific program components were not associated with greater effectiveness, longer follow-up duration was associated with greater injury rate reduction (p = 0.01) and intervention effects varied by level of care (p = 0.01), with the greatest effect in intensive care unit interventions (IRR 0.14; 95% CI 0.07, 0.30).

CONCLUSIONS

SPHM programs appear to be highly effective in reducing injuries. More research is needed to identify the most effective interventions for different patient care levels.

Nurses' Perception of Their Work Environment, Health, and Well-Being

The purpose of this analysis was to identify themes nurses expressed in open-ended comments at the end of a working conditions survey related to their work environment, health, and well-being. The nursing shortage, downsizing, and long working hours create challenges for nurses trying to deliver quality client care. In addition, nurses are experiencing high levels of physical injury in their work environments. Injuries on the job have led nurses to leave the workplace. Free form comments offered at the completion of a mailed survey of RNs were analyzed for content. Randomly selected nurses from two U.S. states were surveyed in 1999 and 2000 about their jobs with special reference to neck, shoulder, and back pain and disorders. Of the 1,428 respondents, 309 produced usable comments for this content analysis. Constant comparative analysis was used to identify themes present in these comments. The themes addressed in the nurses' comments included excessive work demands, injustice or unfairness, and nurses' personal solutions to their work environments. Based on the issues raised in the themes, recommendations are provided for improving retention while promoting nurses' health and well-being.

Stakeholders' Perspectives About and Priorities for Economic Evaluation of Health and Safety Programs in Healthcare

This study identified and prioritized resources and outcomes that should be considered in more comprehensive and scientifically rigorous health and safety economic evaluations according to healthcare sector stakeholders. A literature review and stakeholder interviews identified candidate resources and outcomes and then a Delphi panel ranked them. According to the panel, the top five resources were (a) health and safety staff time; (b) training workers; (c) program planning, promotion, and evaluation costs; (d) equipment purchases and upgrades; and (e) administration costs. The top five outcomes were (a) number of injuries, illnesses, and general sickness absences; (b) safety climate; (c) days lost due to injuries, illnesses, and general sickness absences; (d) job satisfaction and engagement; and (e) quality of care and patient safety. These findings emphasize stakeholders' stated priorities and are useful as a benchmark for assessing the quality of health and safety economic evaluations and the comprehensiveness of these findings.

An economic analysis of a safe resident handling program in nursing homes

BACKGROUND

Occupational injuries, especially back problems related to resident handling, are common in nursing home employees and their prevention may require substantial up-front investment. This study evaluated the economics of a safe resident handling program (SRHP), in a large chain of skilled nursing facilities, from the corporation's perspective.

METHODS

The company provided data on program costs, compensation claims, and turnover rates (2003-2009). Workers' compensation and turnover costs before and after the intervention were compared against investment costs using the "net-cost model."

RESULTS

Among 110 centers, the overall benefit-to-cost ratio was 1.7-3.09 and the payback period was 1.98-1.06 year (using alternative turnover cost estimates). The average annualized net savings per bed for the 110 centers (using company based turnover cost estimates) was $143, with a 95% confidence interval of $22-$264. This was very similar to the average annualized net savings per full time equivalent (FTE) staff member, which was $165 (95% confidence interval $22-$308). However, at 49 centers costs exceeded benefits.

CONCLUSIONS

Decreased costs of worker injury compensation claims and turnover appear at least partially attributable to the SRHP. Future research should examine center-specific factors that enhance program success, and improve measures of turnover costs and healthcare productivity.

Continuous assessment of low back loads in long-term care nurses

Considerable effort has been spent evaluating aspects of low back injury risk in nursing yet comprehensive evaluation of all work tasks has been limited. The purpose of this study was to evaluate peak and cumulative lumbar spine loads experienced by personal support workers. A total of 20 female long-term care workers were observed and had trunk posture monitored via an inclinometer throughout their shift. When adjusted for an 8-h workday, workers experienced cumulative loads of 21.3 +/- 4.6 MNs, 1.8 +/- 0.6 MNs and 2.9 +/- 1.4 MNs for compression, lateral and anterior shear, respectively. Patient care, unloaded standing, walking and miscellaneous tasks accounted for almost 80% of cumulative compression, while lifts and transfers accounted for less than 10%. Mechanical lift assists reduced peak loads and contributed minimally to cumulative loading. These findings suggest that both peak and cumulative spine loads should be considered when evaluating injury risk in the nursing profession. STATEMENT OF RELEVANCE: This study has shown that tasks other than patient transfers and lifts are important in the assessment of low back injury risk in nurses. The method developed is a relatively straightforward approach that can be used to estimate peak and cumulative spine load to provide insight to risk of injury in many occupational settings.

Comparison of required operating forces between floor-based and overhead-mounted patient lifting devices

This study investigated the differences in required push, pull and rotating forces for moving fully loaded, floor-based and overhead-mounted full body patient lifting devices with simulated patients of varying weight on a floor of optimal design (i.e. level vinyl tile over concrete). A single person operated the lifting devices for all of the tests. Eighteen male and female volunteer participants, ranging in weight from 51 to 146 kg, acted as patients during the lifting tests. For each test, the simulated patients were pushed and pulled for 3.7 linear metres and were rotated while sitting in the lift slings. Force measurements were acquired using two single axis dynamometers affixed to the lifting devices. Results revealed that, in general, operator input force and torque increased with patient weight category and floor-based lifts required greater force and torque compared to the overhead-mounted lift. Comparison of the required forces with published force limits reveals that the required push and pull force from the various patient lift systems, across all weight categories, were generally acceptable to 90% of the female population. The required forces for these patient transfer tasks, however, could exceed maximum acceptable force limits if the floor surfaces were less than ideal, such as floors composed of carpet, wood, or inclined surfaces. Additional research is needed to assess these conditions.

A Review of the Research Literature on Evidence-Based Healthcare Design

Objective:

This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals.

Background:

It builds on a literature review conducted by researchers in 2004.

Methods:

Research teams conducted a new and more exhaustive search for rigorous empirical studies that link the design of hospital physical environments with healthcare outcomes. The review followed a two-step process, including an extensive search for existing literature and a screening of each identified study for the relevance and quality of evidence.

Results:

This review found a growing body of rigorous studies to guide healthcare design, especially with respect to reducing the frequency of hospital-acquired infections. Results are organized according to three general types of outcomes: patient safety, other patient outcomes, and staff outcomes. The findings further support the importance of improving outcomes for a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms, and improved floor layouts and work settings. Directions for future research are also identified.

Conclusions:

The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work.

Movement-based feedback may reduce spinal moments in male workers during lift and lowering tasks

BACKGROUND AND PURPOSE

To assess if lifting performance can be modified and spine stresses reduced in workers who perform repetitive material-handling jobs in a warehouse environment via a novel real-time, movement-based feedback training protocol.

METHOD

A pre-test/post-test group study design was used with a control group. Data were collected in a warehouse setting and analysed in a university setting. A convenience sample of 22 male warehouse employees was divided equally, based on height and weight, and assigned to either an experimental group or a control group. The experimental group received real-time, performance-based auditory feedback from their calculated moments during lifting or lowering using an electromagnetic tracking system. The electromagnetic tracking system was used to measure the side-bending, flexion and rotation moments during six lifts under four different conditions. A series of repeated-measures analyses of variance (ANOVA) (one between (Group); one within (Time)) was performed on the average maximum moments from six lifting or lowering cycles for all three directions: side-bending, flexion and rotation.

RESULTS

There were significant group x time interactions for the side-bending moment (p < 0.05) and the flexion moment (p < 0.05) but not the rotation moment (p > 0.05). Lower moments were found in the experimental group, which received the training and feedback, compared to the control group.

CONCLUSIONS

Real-time, auditory feedback combined with coaching during lifting or lowering tasks may be effective in the short term (six weeks) in reducing the average maximum side-bending and flexion moments in warehouse workers. Further research is needed to determine the long-term effects of this training protocol on low back injury rates.

Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers

OBJECTIVE

To evaluate the effectiveness of mechanical patient lifts in reducing musculoskeletal symptoms, injuries, lost workday injuries, and workers' compensation costs in workers at a community hospital.

DESIGN

Pre-post intervention study.

SETTING

Three nursing units of a small community hospital. Patients or

SUBJECTS

Nursing personnel.

INTERVENTIONS

Mechanical patient lifts were made available and nursing staff trained in their use between August 2000 and January 2001.

MAIN OUTCOME MEASURES

Workers completed symptom surveys at baseline and six months after lift training. Pre-intervention and post-intervention rates of injuries and lost workday injuries using Occupational Safety and Health Administration logs of the three study units, from the period July 1999 through March 2003 were analyzed. Injuries potentially related to lifting patients were included in the analyses. Using workers' compensation data from the same time period, the compensation paid ($ per full time equivalent [FTE]) due to injuries during the pre-intervention and post-intervention period was calculated.

RESULTS

Sixty one staff members were surveyed pre-intervention; 36 (59%) completed follow up surveys. Statistically significant improvements in musculoskeletal comfort (p<0.05) were reported for all body parts, including shoulders, lower back, and knees. Injury rates decreased post-intervention, with a relative risk (RR) of 0.37 (95% confidence interval (CI) 0.16 to 0.88); decreased injury rates persisted after adjustment for temporal trends in injury rates on non-intervention units of the study hospital (RR = 0.50, 95% CI 0.20 to 1.26). Adjusted lost day injury rates also decreased (RR = 0.35, 95% CI 0.10 to 1.16). Annual workers' compensation costs averaged $484 per FTE pre-intervention and $151 per FTE post-intervention.

CONCLUSION

Reductions were observed in injury rates, lost workday injury rates, workers' compensation costs, and musculoskeletal symptoms after deployment of mechanical patient lifts. Strengths of this study include the community hospital setting and the inclusion of a variety of different outcomes. Limitations include the pre-post study design and the small sample size.

Muscle activity during patient transfers: a preliminary study on the influence of lift assists and experience

The purpose of this study was to examine muscle activity patterns during patient handling during manual transfers, and transfers using floor and ceiling lifts. EMG patterns during transfers from bed to wheelchair and wheelchair to bed as well as patient repositioning in novices and experienced participants were examined. Surface EMG was recorded from the upper and lower erector spinae, latissimus dorsi and trapezius muscles bilaterally. Overall, normalized mean and peak muscle activity were lowest using the ceiling lift, increasing with the floor lift, which were lower than manual transfers (novices: all p < 0.01). Experienced patient handlers demonstrated approximately two times greater trapezius and latissimus dorsi activity than novices, combined with lower mean erector spinae activity (p < 0.05, for most tasks). Integrated EMG for all muscles was directly proportional to the transfer time and was lowest during the manual transfer followed by the ceiling lift, with the floor lift being highest. The difference between the muscle activity patterns between the experienced and novice patient handlers may suggest a learned behaviour to protect the spine by distributing load to the shoulder. Further examination of the muscle activation patterns differences between experience levels could improve training techniques to develop better patient handling strategies.

Risk factors for work-related low back pain in registered nurses, and potential obstacles in using mechanical lifting devices

Back pain disability is a serious and costly problem affecting the nursing profession. The purposes of this study were to determine risk factors for work-related low back pain (WRLBP) in registered nurses and to record the reported use or reasons for nonuse of mechanical lifts. Our hypothesis was that workers who attributed the cause of WRLBP to their own actions would be knowledgeable about back safety, would be more likely to use lifts, and would report less WRLBP. A random sample of 270 registered nurses was selected from two acute care hospitals in central Illinois to identify WRLBP risk factors. This cross-sectional study gathered information on individual, physical workload, psychological, and organizational factors that may present a risk for WRLBP. Information was also collected on the use of safety devices and back pain symptoms. The response rate was 50.4%. Nearly 84% of respondents had WRLBP in the past, and 36.2% had WRLBP in the past year that limited movement or interfered with routine activities. Among the risk factors significantly associated with WRLBP were more years worked in nursing, frequent lifting, and low social support. Only 11% reported that they routinely used mechanical lifting devices, and the primary reason given for failure to use lifting equipment was unavailability of equipment. The reasons for the lack of use of mechanical lifts should be investigated and addressed.