FEATURE
Prevention of Work-related Musculoskeletal Injuries in Rehabilitation Nursing Rozina Bhimani1,2, PhD, DNP, RN, CNP, CNE 1 Doctor of Nursing Practice Program, Department of Nursing, St. Catherine University, Saint Paul, MN, USA 2 Courage Kenny Rehabilitation Institute, Minneapolis, MN, USA
Keywords
Abstract
Injury prevention; nursing; rehabilitation. Correspondence Rozina Bhimani, Doctor of Nursing Practice Program, Department of Nursing, St. Catherine University, Whitby Hall G9C, Saint Paul, MN 55105. [email protected] Accepted July 29, 2014. doi: 10.1002/rnj.185
Purpose: Work-related musculoskeletal injuries remain a concern for the nursing profession. The purpose of this study was to reduce work-related musculoskeletal nursing injuries by 10% on the rehabilitation unit in a Midwestern hospital. Design: Using a quality improvement and evidence-based practice lens, one group time-series design was employed. Methods: Shift reports, interdisciplinary collaboration, self-study educational packets, and journal club sessions were implemented. Findings: Results, although not statistically significant, indicated over a 50% reduction in work-related musculoskeletal nursing injuries. Self-engagement and the Hawthorne effect are thought to have contributed to this decline in injury rates. Conclusions: A cost-benefit analysis indicates an estimated savings of $90,000 over 4 months. A yearly practice-based education program and improvement in electronic health records is advocated to sustain this decrease in nursing injury rates. Clinical Relevance: Context-specific interventions, communication, algorithm approach to patient transfers, and research knowledge are needed to decrease rehabilitation work-related musculoskeletal nursing injuries.
Introduction Nursing is a practice profession that requires nurses to engage in patient-related physical tasks. Caring for patients requires nurses to ambulate, lift, transfer, slide, reposition, and transport many times during the day, which can result in nursing personnel incurring musculoskeletal injuries. The nursing profession has been consistently classified as sixth of the top ten occupations for sustaining work-related musculoskeletal disorders (American Nurses Association [ANA], 2011; Bureau of Labor Statistics, 2013). According to the National Institute for Occupational Safety and Health (NIOSH), (2009), “The healthcare patient was the most frequent cause of injury at a rate of 47.5 cases per 10,000 workers. Given that the average workers’ compensation cost for back pain is $10,689 per case, back © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
injury alone represents a significant health and economic burden” (p. xii). Literature Review Approximately 12% of nurses consider a job change to reduce their risk of injury and 12–18% nurses leave the profession due to chronic back pain (Nelson & Baptiste, 2006). Eighty eight percent of nurses reported that health and safety concerns predisposed their decision to remain in nursing and the kind of nursing work they chose to perform (Byrns, Reeder, Jin, & Pachis, 2004; NIOSH, 2009). The American Association of Occupational Health Nurses research priorities call for strategies that minimize adverse work-related health outcomes. The NIOSH recommends a 35-pound maximum weight restriction in
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patient handling tasks (Waters, 2007). Furthermore, “there is still more to learn about how work system interactions between environment, technology, organization, task requirements, and individual factors can lead to MSDs (musculoskeletal disorders) and to further improve interventions at all of these levels” (NIOSH, 2009, p. xii). Safe Patient Handling Safe patient handling, focusing on reducing clinicians’ work-related musculoskeletal injuries became more prominent in 2000 and beyond (ANA, 2013; Occupational Safety & Health Administration [OSHA], 2011). In 2006, NIOSH proposed a safe patient handling curriculum for nursing schools to adopt to prevent back injuries. The OSHA (2011) identified organizational support, allocation of time and money, team formation, context-based needs assessment and literature reviewm, ergonomic revisions, staff education, and change in policy and procedures as key strategies in developing safe patient handling programs. In a comprehensive review of the literature, Nelson and Baptiste (2006) identify three primary categories of (engineering, administrative, and behavioral or work practice controls) interventions that are widely supported as being effective in mitigating staff musculoskeletal injury. A review of the literature supports appropriate use of lifting equipment, lift team, and algorithm approach for safe patient transfers, policies, and procedure for safe patient handling as evidence-based (Nelson, 2006; Mayeda-Letourneau, 2013). Organization support and allocation of resources are central to success for safe patient handling program implementation (Krill, Raven, & Staffileno, 2012; Missar, MetCalfe, & Gilmore, 2012). Therefore, evidence-based practice using evidence from research, clinical context, practice guidelines/expert opinions, and stakeholder preferences provide directions for clinical practice (Melnyk & Fineout-Overholt, 2011). Theoretical Underpinning Self-efficacy is people’s ability to navigate events based on how one feels, thinks, and believes (Bandura, 1994; Resnick, 2009). This belief produces diverse effects through cognitive, motivational, affective, and selection processes, which influence daily lives. Strong self-efficacy is essential not only in navigating individuals’ lives but is also crucial when dealing with professional practice issues. Therefore, Bandura’s self-efficacy theory provides the theoretical
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underpinning for this study. Self-efficacy is also seen to foster confidence and self-engagement, which can be developed (Resnick, 2009; Robb, 2012). Key Issues in Safe Patient Handling There are many safe patient handling program recommendations; however, evidence suggests that there are issues embedded in implementation. Barriers Knowledge Lack of knowledge about safe patient handling is a barrier. The literature indicates that manual lifting techniques are not evidence-based and may potentially injure nurses and patients (ANA, 2013; Nelson & Baptiste, 2006). To reduce work-related musculoskeletal injuries, organizations have purchased mechanical equipment and mounted ceiling lifts; however, staff education on proper use is lacking (Collins, Wolf, Bell, & Evanoff, 2004; Pompeii, Lipscomb, Schoenfisch, & Dement, 2009). Since basic back care education on reducing back injuries alone is not supported by the evidence, ongoing staff education is needed to identify correct transfer techniques based on transfers algorithms and correct use of ergonomic equipment (Lee et al., 2009; Nelson & Baptiste, 2006; Rockefellar, 2008; Waters, 2007). Lack of Time and Space Time and space required to use equipment and mechanical lifts are potential barriers in practice. Maneuvering equipment in space requires time, which may hinder quick access to equipment and needed supplies (Li, Wolf, & Evanoff, 2004; Nelson & Baptiste, 2006; Nelson, Harwood, Tracey, & Dunn, 2008). In addition, nurses may not report an injury due to lack of time or awareness of an injury until after the event; bureaucracy associated with the reporting process, perceived lack of support from peers, or fear of reprimand from superiors (Nelson & Baptiste, 2006; Nelson et al., 2008). Facilitators Ergonomics/Mechanical Lift Considerable research evidence exists on ergonomics, use of mechanical lifts, and zero lift policy (Li et al., 2004; Nelson et al., 2008; Rockefellar, 2008; Silverwood & Haddock, 2006; Weinel, 2008). With the advancement of technology, many safe patient lift products, such as ceil© 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
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ing lifts, are available in the nursing work environment. When used consistently, these ergonomics measures are helpful in reducing injuries; however, there is a perception in the rehabilitation setting that the patient’s functional retraining is hindered by utilizing ergonomics equipment because it does not allow patients to utilize their functional movements (Campo, Shiyko, Margulis, & Darragh, 2013; Nelson et al., 2008). Communication Ongoing communication through shift report is a vital part of nursing practice. It becomes crucial in the inpatient setting where multiple clinical staff interact to care for an individual patient. Continuity of care requires clear lines of communication and multidisciplinary engagement for safe patient care. Literature supports bedside shift report and change in shift report in patients’ EMR, so all team members can access the same information without wasting time and effort (Athwal, Fields, & Wagnell, 2009; Crabtree, Howard, & El-Mallack, 2009; Staggers & Jennings, 2009).
Prevention of Work-related Musculoskeletal Injuries
Problem Statement This study occurred in an acute inpatient rehabilitation unit in a large Midwestern hospital. The staffing pattern was one registered nurse (RN) to four patients. In addition, two nursing assistants (NAs) were assigned to the entire unit, with a census of 38 patients. The nursing council addressed practice issues through monthly meetings which were attended by the unit nurse manager who oversaw both RNs and NAs. One of the nursing council concerns was the high rate of musculoskeletal injuries, where one nursing personnel was injured every month. Staff transfer and turnover rates were high with approximately 60% of nursing staff having worked on the unit for 5 years or less (see Table 1). During orientation new nurses received 8 hours of handson training on Safe Transfer Every Person Succeeds; however, this training once provided was never reinforced. The rehabilitation unit also had ceiling and other transfer lifts available with a policy of 32-pound lift restrictions for patient handling tasks. Method
Gaps in Knowledge
Research Purpose
Patient handling tasks are repetitious in nature and require bending, twisting, and flexing in awkward positions (Collins et al., 2004; Knibbe, Knibbe, & Crist, 2008). Current evidence suggests that these repetitious movements exert more strain on muscles and the spine than a static load; therefore, the NIOSH recommended guideline of 35 pounds is in question because it based on a static load while nursing activities are dynamic in nature. (Nelson, Fragala, & Menzel, 2003; Theis & Finkelstein, 2014). Therefore, better guidelines are required to accommodate repetitious movements in daily nursing practice. A review of the literature indicates that nursing injuries seem to be the dynamic interplay of complex factors such as knowledge deficit, attitudes toward injury, ergonomics, and inappropriate lift products (McCoskey, 2007; Nelson & Baptiste, 2006; Rockefellar, 2008). As Nelson and Baptiste note, “there is no one solution or ‘fix’ likely to be successful across all units in a facility” (p. 368). Although a couple of articles have used a rehabilitation unit as an example, investigators have not delineated this specialty from other nursing work environments (Nelson et al., 2008; Weinel, 2008). Therefore, evidence-based practice inputs are essential for implementation of safe patient handling programs.
The purpose of this evidence-based project was to reduce the average monthly musculoskeletal injury rates for rehabilitation nursing personnel by 10% in 2010 (March–June) compared to 2009 (March–June) based on the Institutional Occupational Health and Safety (IOHS) data.
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Study Implementation A needs assessment survey conducted before this evidencebased research implementation identified six themes: lack Table 1 Demographics of participants Years at Institution 1–5 6–10 11–15 16–20 21–25 26–30 Did not report Job title CNA/LPN RN Total responses Number of responses Percent responses
Percentage of Participants 34.1 31.6 11.6 5.8 5.8 0 8.6 11.4 88.6 38 61.3
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of time and help, patient acuity, ergonomics, body movement issues, knowledge deficit, and communication. Based on the results, two priority areas, communication and knowledge, were implemented. Communication (variable) was operationalized by instituting a shift report system for CNAs, and by inviting the supervisor of the Physical Therapy (PT) department to the Nursing Council meetings to initiate interdisciplinary communication. Knowledge (variable) was operationalized by providing a one-time selfstudy educational packet to all nursing personnel and by initiating a journal club with a focus on issues related to ergonomics and mechanical lifts. Research Question In a rehabilitation unit, how do interventions focusing on communication (shift report, interdisciplinary communication) and knowledge (self-study packet, journal club) affect work-related musculoskeletal injury rates for nursing personnel? An additional research question explored how nurses perceive helpfulness of quality improvement interventions. Design This evidence-based research used one group time-series design. Because the purpose was to improve practice and reduce injuries, the quality improvement “process” of PDSA (plan, do, study, act) aided the implementation protocol. Population The unit of analysis for this research was the population, as results were available at the aggregate level from all nursing personnel on the unit, with no assumption that the same individuals would provide data at all points. Based on the nature of this research study, the survey input and the interventions were aimed at all nursing personnel on the unit; therefore, a comparison group was not available. Sample Sixty-two nursing personnel participated in this study from August 19, 2009, through June 30, 2010. Initially over 93% of participants responded to the needs assessment survey. Based on their feedback, four interventions
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were selected. In summative evaluations, 61% (38) of participants responded. The participant profile is provided in Table 1. The a priori power analysis of 0.8 with medium effect size of 0.5 was achieved for communication and knowledge variables. Procedures Institutional Review Board approved the study. Survey data were anonymous and de-identified. A mass e-mail was sent to the nursing personnel via their work e-mail to alert them when the new report process was being initiated for a 6-week duration. The supervisor of the PT department was invited to nursing council meetings. Posted flyers on the unit announced the place, time, and date of the journal club meetings. A similar process was used to alert nurses once the self-study educational packet became available. After all the interventions were implemented and completed, a general survey was sent out to nurses to elicit feedback about these interventions. Copies of the survey were available at the nursing station and in the report room. Once completed, participants dropped off the survey in a sealed envelope in a specified box located in the nursing report room. Data Sources Two data sources were available; the first source of data was nursing injury rates collected monthly by the IOHS. This included the de-identified aggregate data total number for types, and rates of injury for each unit. The researcher collected the second source of data from a survey using categorical responses to understand the effectiveness of the interventions provided. In addition, each question had an additional comment box to elaborate their responses. Data Analysis Data analysis used descriptive, post hoc statistics and analyzed graph patterns. The alpha level of significance was assumed to be 0.05. The comments were analyzed using content analysis. Lincoln and Guba’s (1994) framework was used to ensure data rigor. The organizational data was analyzed using chi-squared analysis to determine whether changes in the injury pattern were statistically significant after the interventions were implemented.
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Quality Improvement Interventions Shift Report In February 2010, conversations to implement the shift report began. The nursing council determined that electronic health records (EHR) would be an optimum place to start. As the nurses began the process of “pulling out elements of reports” from the EHR system, they encountered two major barriers: (a) the NAs did not have access to the patient kardex, and (b) no aggregate view of basic information on all patients was available, leading to inefficient use of time to view individual patient status. These barriers resulted in a process where all RNs individually informed each NA on their patient’s mobility/transfer status, with the printout report from EHR as a guide. Self-Study Education Packet The self-study education packet was provided to all nursing personnel. The content of the self-study packet attempted to dispel myths about nursing injuries and provided some factual information. In addition, a couple of different algorithms were referenced for patient transfers based on work by Nelson, Lloyd, Menzel, and Gross (2003), and Nelson and Baptiste (2006). Journal Club Three journal club sessions were provided during nursing council meetings. They were open to all nursing personnel regardless of educational background. For the first journal club session only, the researcher provided a 20-minute presentation on the basics of reading research articles for evidence followed by a review of an original research article.
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helpful to have all patient transfer information on one sheet. Communication helpful with 1:1 BR transfer and fall risk”; “More communication meant more knowledge”; and “Communication helpful with transfer of specific patients.” Rare comments indicated that communication was still not seen as an issue. “Issue is not communication, need more CNAs.” Other qualitative feedback indicated that the RN to CNA report was inconsistent. Some RNs were using a written report format to provide information but did not connect with the CNAs face to face. Other RNs reported face-to-face meetings with CNAs where writing down information was left up to the CNA. Few RNs provided both written and verbal reports. Participants stated, “Face-to-face report not happening”; “NAs now ask for paper report, verbal still an issue. Report was very basic”; “Less time finding NA to communicate, fewer incorrect transfers”; and “CNA hard to track.” The quantitative results supported the qualitative findings. Initiation of the shift report was seen as the most helpful intervention of the study (see Table 2). The mean score of 2.60 on Likert categorical scale indicates that most of the participants found shift report to be “somewhat helpful” or “most of the time helpful.” Standard deviation of less than 1 indicates responses were closely related and opinions varied little. Table 2 Descriptive statistics for all the interventions N Communication
35
Education
35
Journal club
35
Overall QI impression
35
Results Shift Report Overall nursing personnel found implementation of the shift report helpful. More felt informed, while others found it helpful in performing patient-related tasks, as noted by their comments: “I forget to update the white board in room, so report was a good way of remembering to update patient transfer status”; “My NA told me that new sheet is very useful”; “NAR/LPN felt informed during report”; “Communication was the positive thing, seems
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Grading Scores 1 = Not all 2 = Sometimes 3 = Most of the time 4 = All the time 1 = Not all 2 = Sometimes 3 = Most of the time 4 = All the time 1 = Comfort decreased 2 = No change 3 = Comfort increased 1 = Not all 2 = Sometimes 3 = Most of the time 4 = All the time
Mean
Standard Deviation
2.60
0.85
2.29
0.93
2.20
0.41
2.22
0.74
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From the survey feedback, it is apparent that implementation of shift report was inconsistent. Face-to-face shift communication with paper report was a new process for nursing personnel. Participants reported difficulties in creating and implementing the shift report. The qualitative data indicate that this intervention was not implemented successfully given EHR constraints; however, CNAs’ expectations and awareness changed as they often initiated request for shift report. Although face-to-face verbal reports did not occur consistently, nursing personnel indicated that a face-to-face verbal shift report was desired and expected. Self-Study Education Packet Nursing personnel found the education packet to be helpful. Some found better ways to transfer patients; others reported the knowledge refresher was helpful. The mean score of 2.29 indicates the intervention was slightly better than the “somewhat helpful” category but was not found to be “most helpful.” The standard deviation of .92 indicates that responses varied little. The post hoc analysis for self-study education becomes statistically significant (p = .03), where nurses with less than 2 years of affiliation found this intervention very helpful (see Table 3). The participants stated, “Education provided helpful reminders”; “Need practice with education material”; “Using proper body mechanics”; “Appreciate review of transfer techniques”; “Education was helpful as I became more aware of my own body/movement”; “Integrate education in real work situation”; “Enjoyed reading educational material”; and “Discovered a new technique of using ceiling lift slings to help position.” One common criticism noted was the unavailability of the hands-on experience. Journal Club Primarily, the nursing council members attended this intervention. Eight participants, including one nursing Table 3 Post hoc analysis for self-study education packet intervention
Self-study Education Packet All nursing personnel .05), which resulted in estimated $90,000 savings. The data were
Practice improvements require specific evidence for implementation. The literature indicates that information available to the Bureau of Labor Statistics is received from a worker’s compensation report as aggregated numbers, and therefore, obscures unit setting-specific issues and trends. As OSHA points out, it collects only small amount of private sector data, which may not represent
Figure 1 Actual injury data are plotted with four critical time periods; implications are noted. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
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Key Practice Points
Safe Patient Handling
Multidimensional context-specific interventions are needed to reduce musculoskeletal nurse injuries on a rehabilitation unit.
Patient handling tasks are not mindless activities and therefore require due attention when tasks are performed. Even though there is enough evidence that poor body mechanics, back and transfer belts by themselves do not prevent injuries, the myths about manual lifting are persistent (ANA, 2013; Campo et al., 2013). As literature identifies, the evidence-based approach to safe patient handling does require appropriate ergonomic equipment in conjunction with algorithm transfer approaches (Mayeda-Letourneau, 2013; Rockefellar, 2008; Theis & Finkelstein, 2014; Waters, 2007).
Safe patient handling tasks are not mindless activities; therefore, an algorithm approach is advocated. Nurses must build capacity in understanding basic research knowledge and infuse evidence into practice.
all organizations and general conclusions should not be drawn (United States Department of Labor, 2010). In addition, the Bureau of Labor Statistics data do not reflect injuries that occur but are not reported by the nurses. Therefore, empowering nurses in decision-making based on their setting is important in reducing nursing injury rates (Krill, Staffileno & Raven, 2012; Krill, Raven, et al., 2012). Communication The rehabilitation nurses in this study recognize the lack of communication and interdisciplinary collaboration as determinants for work-related musculoskeletal injuries, a result not reported in the literature. The call for interdisciplinary collaboration is quite clear in the Institute of Medicine report (2010). Communication is a dynamic determinant that can affect care at multiple levels. It is logically conceivable that this determinant plays a role in nursing injuries; however, a systematic evaluation of nursing opinion about work-related musculoskeletal injuries is missing from the literature. Self-Engagement and Education The phenomenon of the Hawthorne effect is well known in research but its implication in work-related musculoskeletal injury has not been reported in the literature. It is clear that nursing injury rates dropped before quality improvement interventions were put in place (Figure 1). This brings up an important issue about the impact of self-engagement and education. As Missar et al. (2012) point out, safe handling programs with a quality improvement lens provide nurses an opportunity to selfengage and educate themselves about this issue. This study finding is similar to Theis and Finkelstein (2014) findings that periodic hands-on education about safe patient handling is needed.
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Research Knowledge Evidence-based practice requires understanding of research concepts (Melnyk & Fineout-Overholt, 2011). Implementation of a journal club where the majority of nurses were associate degree RNs who had no exposure to the research concepts was a daunting task. Findings are consistent with Purkis, Jackson, Hundt, and Stockman (2008) and Jones, Crookes, and Johnson (2011) that nurses are often unfamiliar with research terminology and found reading articles to be a tedious process. Other barriers included lack of preparation for journal club discussion; most nurses did not read the article even though it was provided ahead of time. Nurses expressed concerns that this is new for them; however, they were willing to participate. Most nurses acknowledged that this was an important activity for professional practice. Conclusion There are multiple ways of addressing nursing injuries. These results suggest that self-engagement and education play an important role in reducing work-related musculoskeletal injury. The interactional nature of communication and interdisciplinary collaboration require further scrutiny to understand their role in the prevention of work-related musculoskeletal nursing injuries. The continuous quality improvement method could decrease nursing injuries. Pragmatism in clinical practice requires an evidence-based team approach with support from nurses, leadership, and other stakeholders who are the ultimate beneficiaries.
Acknowledgment The author wishes to acknowledge and thank the nurses who supported and participated in this project. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
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Knibbe, N.E., Knibbe, H.J., & Crist, J. (2008). Special approaches for safe handling of disabled children in Netherland. Rehabilitation Nursing, 33(1), 18–21. Krill, C., Raven, C., & Staffileno, B.A. (2012). Moving from a clinical question to research: The implementation of a safe patient handling program. MedSurg Nursing, 21, 104–116. Krill, C., Staffileno, B.A., & Raven, C. (2012). Empowering staff nurses to use research to change practice for safe patient handling. Nursing Outlook, 60, 157–162. Lee, J., Kim, S., Jung, H., Koo, J., Woo, K., & Kim, M. (2009). Participatory action oriented training for hospital nurses (PAOTHN) program to prevent musculoskeletal disorder. Journal of Occupational Health Nursing, 10, 370–376. Li, J., Wolf, L., & Evanoff, B. (2004). Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries in healthcare workers. Injury Prevention, 10, 212– 216. Lincoln, Y.S., & Guba, E.G. (1994). Naturalistic Inquiry. Beverly Hills, CA: Sage. Mayeda-Letourneau, J. (2014). Safe patient handling and movement: A literature review. Rehabilitation Nursing, 39 (3), 123–9. doi:10.1002/rnj.133 McCoskey, K.L. (2007). Ergonomics and patient handling. American Association of Occupational Health Nursing, 55(11), 454–462. Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing and Health Care: A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Williams. Missar, V.J., MetCalfe, D., & Gilmore, G. (2012). Transforming a hospital safety and ergonomics program: A four year journey of change. Work, 41, 5912–5916. National Institute for Occupational Safety and Health. (2009). State of the Sector/Healthcare and Social Assistance: Identification of Research Opportunities for the Next Decade of NORA. Retrieved from http://www.cdc.gov/niosh/ docs/2009-139/pdfs/2009-139.pdf. Nelson, A., & Baptiste, A. (2006). Evidence-based practices for safe patient handling and movement. Orthopaedic Nursing, 25(6), 366–379. Nelson, A., Fragala, G., & Menzel, N. (2003). Myths and facts about back injuries in nursing. American Journal of Nursing, 103, 32–40. Nelson, A., Harwood, K.J., Tracey, C.A., & Dunn, K.L. (2008). Myths and facts about safe patient handling in rehabilitation. Rehabilitation Nursing, 33(1), 10–17. Nelson, A., Lloyd, J., Menzel, N., & Gross, C. (2003). Preventing nursing back injuries redesigning patient handling tasks. American Association of Occupational Health Nursing Journal, 51, 126–134. Nelson, A., Matz, M., Chen, F., Siddharthan, K., Lloyd, J., & Fragala, G. (2006). Development and evaluation of a
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Rockefellar, K. (2008). Using technology to promote safe patient handling and rehabilitation. Rehabilitation Nursing, 33(1), 3–9. Silverwood, S., & Haddock, M. (2006). Reduction of musculoskeletal injuries in intensive care nurses using ceiling-mounted patient lifts. Dynamics, 17, 19–21. Staggers, N., & Jennings, B.M. (2009). The content and context of change of shift report on medical and surgical units. The Journal of Nursing Administration, 39, 393–398. Theis, J.L., & Finkelstein, M. (2014). Long-term effects of safe patient handling program on staff injuries. Rehabilitation Nursing, 39, 26–35. United States Department of Labor. (2010). Occupational Safety & Health Administration (OSHA). Retrieved from http://www.osha.gov/pls/odi/establishment_search.html Waters, T.R. (2007). When is it safe to manually lift a patient? American Journal of Nursing, 107(8), 53–59. Weinel, D. (2008). Successful implementation of ceilingmounted lift systems. Rehabilitation Nursing, 33, 63–66.
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Prevention of Work-related Musculoskeletal Injuries in Rehabilitation Nursing Rozina Bhimani1,2, PhD, DNP, RN, CNP, CNE 1 Doctor of Nursing Practice Program, Department of Nursing, St. Catherine University, Saint Paul, MN, USA 2 Courage Kenny Rehabilitation Institute, Minneapolis, MN, USA
Keywords
Abstract
Injury prevention; nursing; rehabilitation. Correspondence Rozina Bhimani, Doctor of Nursing Practice Program, Department of Nursing, St. Catherine University, Whitby Hall G9C, Saint Paul, MN 55105. [email protected] Accepted July 29, 2014. doi: 10.1002/rnj.185
Purpose: Work-related musculoskeletal injuries remain a concern for the nursing profession. The purpose of this study was to reduce work-related musculoskeletal nursing injuries by 10% on the rehabilitation unit in a Midwestern hospital. Design: Using a quality improvement and evidence-based practice lens, one group time-series design was employed. Methods: Shift reports, interdisciplinary collaboration, self-study educational packets, and journal club sessions were implemented. Findings: Results, although not statistically significant, indicated over a 50% reduction in work-related musculoskeletal nursing injuries. Self-engagement and the Hawthorne effect are thought to have contributed to this decline in injury rates. Conclusions: A cost-benefit analysis indicates an estimated savings of $90,000 over 4 months. A yearly practice-based education program and improvement in electronic health records is advocated to sustain this decrease in nursing injury rates. Clinical Relevance: Context-specific interventions, communication, algorithm approach to patient transfers, and research knowledge are needed to decrease rehabilitation work-related musculoskeletal nursing injuries.
Introduction Nursing is a practice profession that requires nurses to engage in patient-related physical tasks. Caring for patients requires nurses to ambulate, lift, transfer, slide, reposition, and transport many times during the day, which can result in nursing personnel incurring musculoskeletal injuries. The nursing profession has been consistently classified as sixth of the top ten occupations for sustaining work-related musculoskeletal disorders (American Nurses Association [ANA], 2011; Bureau of Labor Statistics, 2013). According to the National Institute for Occupational Safety and Health (NIOSH), (2009), “The healthcare patient was the most frequent cause of injury at a rate of 47.5 cases per 10,000 workers. Given that the average workers’ compensation cost for back pain is $10,689 per case, back © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
injury alone represents a significant health and economic burden” (p. xii). Literature Review Approximately 12% of nurses consider a job change to reduce their risk of injury and 12–18% nurses leave the profession due to chronic back pain (Nelson & Baptiste, 2006). Eighty eight percent of nurses reported that health and safety concerns predisposed their decision to remain in nursing and the kind of nursing work they chose to perform (Byrns, Reeder, Jin, & Pachis, 2004; NIOSH, 2009). The American Association of Occupational Health Nurses research priorities call for strategies that minimize adverse work-related health outcomes. The NIOSH recommends a 35-pound maximum weight restriction in
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patient handling tasks (Waters, 2007). Furthermore, “there is still more to learn about how work system interactions between environment, technology, organization, task requirements, and individual factors can lead to MSDs (musculoskeletal disorders) and to further improve interventions at all of these levels” (NIOSH, 2009, p. xii). Safe Patient Handling Safe patient handling, focusing on reducing clinicians’ work-related musculoskeletal injuries became more prominent in 2000 and beyond (ANA, 2013; Occupational Safety & Health Administration [OSHA], 2011). In 2006, NIOSH proposed a safe patient handling curriculum for nursing schools to adopt to prevent back injuries. The OSHA (2011) identified organizational support, allocation of time and money, team formation, context-based needs assessment and literature reviewm, ergonomic revisions, staff education, and change in policy and procedures as key strategies in developing safe patient handling programs. In a comprehensive review of the literature, Nelson and Baptiste (2006) identify three primary categories of (engineering, administrative, and behavioral or work practice controls) interventions that are widely supported as being effective in mitigating staff musculoskeletal injury. A review of the literature supports appropriate use of lifting equipment, lift team, and algorithm approach for safe patient transfers, policies, and procedure for safe patient handling as evidence-based (Nelson, 2006; Mayeda-Letourneau, 2013). Organization support and allocation of resources are central to success for safe patient handling program implementation (Krill, Raven, & Staffileno, 2012; Missar, MetCalfe, & Gilmore, 2012). Therefore, evidence-based practice using evidence from research, clinical context, practice guidelines/expert opinions, and stakeholder preferences provide directions for clinical practice (Melnyk & Fineout-Overholt, 2011). Theoretical Underpinning Self-efficacy is people’s ability to navigate events based on how one feels, thinks, and believes (Bandura, 1994; Resnick, 2009). This belief produces diverse effects through cognitive, motivational, affective, and selection processes, which influence daily lives. Strong self-efficacy is essential not only in navigating individuals’ lives but is also crucial when dealing with professional practice issues. Therefore, Bandura’s self-efficacy theory provides the theoretical
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underpinning for this study. Self-efficacy is also seen to foster confidence and self-engagement, which can be developed (Resnick, 2009; Robb, 2012). Key Issues in Safe Patient Handling There are many safe patient handling program recommendations; however, evidence suggests that there are issues embedded in implementation. Barriers Knowledge Lack of knowledge about safe patient handling is a barrier. The literature indicates that manual lifting techniques are not evidence-based and may potentially injure nurses and patients (ANA, 2013; Nelson & Baptiste, 2006). To reduce work-related musculoskeletal injuries, organizations have purchased mechanical equipment and mounted ceiling lifts; however, staff education on proper use is lacking (Collins, Wolf, Bell, & Evanoff, 2004; Pompeii, Lipscomb, Schoenfisch, & Dement, 2009). Since basic back care education on reducing back injuries alone is not supported by the evidence, ongoing staff education is needed to identify correct transfer techniques based on transfers algorithms and correct use of ergonomic equipment (Lee et al., 2009; Nelson & Baptiste, 2006; Rockefellar, 2008; Waters, 2007). Lack of Time and Space Time and space required to use equipment and mechanical lifts are potential barriers in practice. Maneuvering equipment in space requires time, which may hinder quick access to equipment and needed supplies (Li, Wolf, & Evanoff, 2004; Nelson & Baptiste, 2006; Nelson, Harwood, Tracey, & Dunn, 2008). In addition, nurses may not report an injury due to lack of time or awareness of an injury until after the event; bureaucracy associated with the reporting process, perceived lack of support from peers, or fear of reprimand from superiors (Nelson & Baptiste, 2006; Nelson et al., 2008). Facilitators Ergonomics/Mechanical Lift Considerable research evidence exists on ergonomics, use of mechanical lifts, and zero lift policy (Li et al., 2004; Nelson et al., 2008; Rockefellar, 2008; Silverwood & Haddock, 2006; Weinel, 2008). With the advancement of technology, many safe patient lift products, such as ceil© 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
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ing lifts, are available in the nursing work environment. When used consistently, these ergonomics measures are helpful in reducing injuries; however, there is a perception in the rehabilitation setting that the patient’s functional retraining is hindered by utilizing ergonomics equipment because it does not allow patients to utilize their functional movements (Campo, Shiyko, Margulis, & Darragh, 2013; Nelson et al., 2008). Communication Ongoing communication through shift report is a vital part of nursing practice. It becomes crucial in the inpatient setting where multiple clinical staff interact to care for an individual patient. Continuity of care requires clear lines of communication and multidisciplinary engagement for safe patient care. Literature supports bedside shift report and change in shift report in patients’ EMR, so all team members can access the same information without wasting time and effort (Athwal, Fields, & Wagnell, 2009; Crabtree, Howard, & El-Mallack, 2009; Staggers & Jennings, 2009).
Prevention of Work-related Musculoskeletal Injuries
Problem Statement This study occurred in an acute inpatient rehabilitation unit in a large Midwestern hospital. The staffing pattern was one registered nurse (RN) to four patients. In addition, two nursing assistants (NAs) were assigned to the entire unit, with a census of 38 patients. The nursing council addressed practice issues through monthly meetings which were attended by the unit nurse manager who oversaw both RNs and NAs. One of the nursing council concerns was the high rate of musculoskeletal injuries, where one nursing personnel was injured every month. Staff transfer and turnover rates were high with approximately 60% of nursing staff having worked on the unit for 5 years or less (see Table 1). During orientation new nurses received 8 hours of handson training on Safe Transfer Every Person Succeeds; however, this training once provided was never reinforced. The rehabilitation unit also had ceiling and other transfer lifts available with a policy of 32-pound lift restrictions for patient handling tasks. Method
Gaps in Knowledge
Research Purpose
Patient handling tasks are repetitious in nature and require bending, twisting, and flexing in awkward positions (Collins et al., 2004; Knibbe, Knibbe, & Crist, 2008). Current evidence suggests that these repetitious movements exert more strain on muscles and the spine than a static load; therefore, the NIOSH recommended guideline of 35 pounds is in question because it based on a static load while nursing activities are dynamic in nature. (Nelson, Fragala, & Menzel, 2003; Theis & Finkelstein, 2014). Therefore, better guidelines are required to accommodate repetitious movements in daily nursing practice. A review of the literature indicates that nursing injuries seem to be the dynamic interplay of complex factors such as knowledge deficit, attitudes toward injury, ergonomics, and inappropriate lift products (McCoskey, 2007; Nelson & Baptiste, 2006; Rockefellar, 2008). As Nelson and Baptiste note, “there is no one solution or ‘fix’ likely to be successful across all units in a facility” (p. 368). Although a couple of articles have used a rehabilitation unit as an example, investigators have not delineated this specialty from other nursing work environments (Nelson et al., 2008; Weinel, 2008). Therefore, evidence-based practice inputs are essential for implementation of safe patient handling programs.
The purpose of this evidence-based project was to reduce the average monthly musculoskeletal injury rates for rehabilitation nursing personnel by 10% in 2010 (March–June) compared to 2009 (March–June) based on the Institutional Occupational Health and Safety (IOHS) data.
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Study Implementation A needs assessment survey conducted before this evidencebased research implementation identified six themes: lack Table 1 Demographics of participants Years at Institution 1–5 6–10 11–15 16–20 21–25 26–30 Did not report Job title CNA/LPN RN Total responses Number of responses Percent responses
Percentage of Participants 34.1 31.6 11.6 5.8 5.8 0 8.6 11.4 88.6 38 61.3
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of time and help, patient acuity, ergonomics, body movement issues, knowledge deficit, and communication. Based on the results, two priority areas, communication and knowledge, were implemented. Communication (variable) was operationalized by instituting a shift report system for CNAs, and by inviting the supervisor of the Physical Therapy (PT) department to the Nursing Council meetings to initiate interdisciplinary communication. Knowledge (variable) was operationalized by providing a one-time selfstudy educational packet to all nursing personnel and by initiating a journal club with a focus on issues related to ergonomics and mechanical lifts. Research Question In a rehabilitation unit, how do interventions focusing on communication (shift report, interdisciplinary communication) and knowledge (self-study packet, journal club) affect work-related musculoskeletal injury rates for nursing personnel? An additional research question explored how nurses perceive helpfulness of quality improvement interventions. Design This evidence-based research used one group time-series design. Because the purpose was to improve practice and reduce injuries, the quality improvement “process” of PDSA (plan, do, study, act) aided the implementation protocol. Population The unit of analysis for this research was the population, as results were available at the aggregate level from all nursing personnel on the unit, with no assumption that the same individuals would provide data at all points. Based on the nature of this research study, the survey input and the interventions were aimed at all nursing personnel on the unit; therefore, a comparison group was not available. Sample Sixty-two nursing personnel participated in this study from August 19, 2009, through June 30, 2010. Initially over 93% of participants responded to the needs assessment survey. Based on their feedback, four interventions
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were selected. In summative evaluations, 61% (38) of participants responded. The participant profile is provided in Table 1. The a priori power analysis of 0.8 with medium effect size of 0.5 was achieved for communication and knowledge variables. Procedures Institutional Review Board approved the study. Survey data were anonymous and de-identified. A mass e-mail was sent to the nursing personnel via their work e-mail to alert them when the new report process was being initiated for a 6-week duration. The supervisor of the PT department was invited to nursing council meetings. Posted flyers on the unit announced the place, time, and date of the journal club meetings. A similar process was used to alert nurses once the self-study educational packet became available. After all the interventions were implemented and completed, a general survey was sent out to nurses to elicit feedback about these interventions. Copies of the survey were available at the nursing station and in the report room. Once completed, participants dropped off the survey in a sealed envelope in a specified box located in the nursing report room. Data Sources Two data sources were available; the first source of data was nursing injury rates collected monthly by the IOHS. This included the de-identified aggregate data total number for types, and rates of injury for each unit. The researcher collected the second source of data from a survey using categorical responses to understand the effectiveness of the interventions provided. In addition, each question had an additional comment box to elaborate their responses. Data Analysis Data analysis used descriptive, post hoc statistics and analyzed graph patterns. The alpha level of significance was assumed to be 0.05. The comments were analyzed using content analysis. Lincoln and Guba’s (1994) framework was used to ensure data rigor. The organizational data was analyzed using chi-squared analysis to determine whether changes in the injury pattern were statistically significant after the interventions were implemented.
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Quality Improvement Interventions Shift Report In February 2010, conversations to implement the shift report began. The nursing council determined that electronic health records (EHR) would be an optimum place to start. As the nurses began the process of “pulling out elements of reports” from the EHR system, they encountered two major barriers: (a) the NAs did not have access to the patient kardex, and (b) no aggregate view of basic information on all patients was available, leading to inefficient use of time to view individual patient status. These barriers resulted in a process where all RNs individually informed each NA on their patient’s mobility/transfer status, with the printout report from EHR as a guide. Self-Study Education Packet The self-study education packet was provided to all nursing personnel. The content of the self-study packet attempted to dispel myths about nursing injuries and provided some factual information. In addition, a couple of different algorithms were referenced for patient transfers based on work by Nelson, Lloyd, Menzel, and Gross (2003), and Nelson and Baptiste (2006). Journal Club Three journal club sessions were provided during nursing council meetings. They were open to all nursing personnel regardless of educational background. For the first journal club session only, the researcher provided a 20-minute presentation on the basics of reading research articles for evidence followed by a review of an original research article.
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helpful to have all patient transfer information on one sheet. Communication helpful with 1:1 BR transfer and fall risk”; “More communication meant more knowledge”; and “Communication helpful with transfer of specific patients.” Rare comments indicated that communication was still not seen as an issue. “Issue is not communication, need more CNAs.” Other qualitative feedback indicated that the RN to CNA report was inconsistent. Some RNs were using a written report format to provide information but did not connect with the CNAs face to face. Other RNs reported face-to-face meetings with CNAs where writing down information was left up to the CNA. Few RNs provided both written and verbal reports. Participants stated, “Face-to-face report not happening”; “NAs now ask for paper report, verbal still an issue. Report was very basic”; “Less time finding NA to communicate, fewer incorrect transfers”; and “CNA hard to track.” The quantitative results supported the qualitative findings. Initiation of the shift report was seen as the most helpful intervention of the study (see Table 2). The mean score of 2.60 on Likert categorical scale indicates that most of the participants found shift report to be “somewhat helpful” or “most of the time helpful.” Standard deviation of less than 1 indicates responses were closely related and opinions varied little. Table 2 Descriptive statistics for all the interventions N Communication
35
Education
35
Journal club
35
Overall QI impression
35
Results Shift Report Overall nursing personnel found implementation of the shift report helpful. More felt informed, while others found it helpful in performing patient-related tasks, as noted by their comments: “I forget to update the white board in room, so report was a good way of remembering to update patient transfer status”; “My NA told me that new sheet is very useful”; “NAR/LPN felt informed during report”; “Communication was the positive thing, seems
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Grading Scores 1 = Not all 2 = Sometimes 3 = Most of the time 4 = All the time 1 = Not all 2 = Sometimes 3 = Most of the time 4 = All the time 1 = Comfort decreased 2 = No change 3 = Comfort increased 1 = Not all 2 = Sometimes 3 = Most of the time 4 = All the time
Mean
Standard Deviation
2.60
0.85
2.29
0.93
2.20
0.41
2.22
0.74
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From the survey feedback, it is apparent that implementation of shift report was inconsistent. Face-to-face shift communication with paper report was a new process for nursing personnel. Participants reported difficulties in creating and implementing the shift report. The qualitative data indicate that this intervention was not implemented successfully given EHR constraints; however, CNAs’ expectations and awareness changed as they often initiated request for shift report. Although face-to-face verbal reports did not occur consistently, nursing personnel indicated that a face-to-face verbal shift report was desired and expected. Self-Study Education Packet Nursing personnel found the education packet to be helpful. Some found better ways to transfer patients; others reported the knowledge refresher was helpful. The mean score of 2.29 indicates the intervention was slightly better than the “somewhat helpful” category but was not found to be “most helpful.” The standard deviation of .92 indicates that responses varied little. The post hoc analysis for self-study education becomes statistically significant (p = .03), where nurses with less than 2 years of affiliation found this intervention very helpful (see Table 3). The participants stated, “Education provided helpful reminders”; “Need practice with education material”; “Using proper body mechanics”; “Appreciate review of transfer techniques”; “Education was helpful as I became more aware of my own body/movement”; “Integrate education in real work situation”; “Enjoyed reading educational material”; and “Discovered a new technique of using ceiling lift slings to help position.” One common criticism noted was the unavailability of the hands-on experience. Journal Club Primarily, the nursing council members attended this intervention. Eight participants, including one nursing Table 3 Post hoc analysis for self-study education packet intervention
Self-study Education Packet All nursing personnel .05), which resulted in estimated $90,000 savings. The data were
Practice improvements require specific evidence for implementation. The literature indicates that information available to the Bureau of Labor Statistics is received from a worker’s compensation report as aggregated numbers, and therefore, obscures unit setting-specific issues and trends. As OSHA points out, it collects only small amount of private sector data, which may not represent
Figure 1 Actual injury data are plotted with four critical time periods; implications are noted. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
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Key Practice Points
Safe Patient Handling
Multidimensional context-specific interventions are needed to reduce musculoskeletal nurse injuries on a rehabilitation unit.
Patient handling tasks are not mindless activities and therefore require due attention when tasks are performed. Even though there is enough evidence that poor body mechanics, back and transfer belts by themselves do not prevent injuries, the myths about manual lifting are persistent (ANA, 2013; Campo et al., 2013). As literature identifies, the evidence-based approach to safe patient handling does require appropriate ergonomic equipment in conjunction with algorithm transfer approaches (Mayeda-Letourneau, 2013; Rockefellar, 2008; Theis & Finkelstein, 2014; Waters, 2007).
Safe patient handling tasks are not mindless activities; therefore, an algorithm approach is advocated. Nurses must build capacity in understanding basic research knowledge and infuse evidence into practice.
all organizations and general conclusions should not be drawn (United States Department of Labor, 2010). In addition, the Bureau of Labor Statistics data do not reflect injuries that occur but are not reported by the nurses. Therefore, empowering nurses in decision-making based on their setting is important in reducing nursing injury rates (Krill, Staffileno & Raven, 2012; Krill, Raven, et al., 2012). Communication The rehabilitation nurses in this study recognize the lack of communication and interdisciplinary collaboration as determinants for work-related musculoskeletal injuries, a result not reported in the literature. The call for interdisciplinary collaboration is quite clear in the Institute of Medicine report (2010). Communication is a dynamic determinant that can affect care at multiple levels. It is logically conceivable that this determinant plays a role in nursing injuries; however, a systematic evaluation of nursing opinion about work-related musculoskeletal injuries is missing from the literature. Self-Engagement and Education The phenomenon of the Hawthorne effect is well known in research but its implication in work-related musculoskeletal injury has not been reported in the literature. It is clear that nursing injury rates dropped before quality improvement interventions were put in place (Figure 1). This brings up an important issue about the impact of self-engagement and education. As Missar et al. (2012) point out, safe handling programs with a quality improvement lens provide nurses an opportunity to selfengage and educate themselves about this issue. This study finding is similar to Theis and Finkelstein (2014) findings that periodic hands-on education about safe patient handling is needed.
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Research Knowledge Evidence-based practice requires understanding of research concepts (Melnyk & Fineout-Overholt, 2011). Implementation of a journal club where the majority of nurses were associate degree RNs who had no exposure to the research concepts was a daunting task. Findings are consistent with Purkis, Jackson, Hundt, and Stockman (2008) and Jones, Crookes, and Johnson (2011) that nurses are often unfamiliar with research terminology and found reading articles to be a tedious process. Other barriers included lack of preparation for journal club discussion; most nurses did not read the article even though it was provided ahead of time. Nurses expressed concerns that this is new for them; however, they were willing to participate. Most nurses acknowledged that this was an important activity for professional practice. Conclusion There are multiple ways of addressing nursing injuries. These results suggest that self-engagement and education play an important role in reducing work-related musculoskeletal injury. The interactional nature of communication and interdisciplinary collaboration require further scrutiny to understand their role in the prevention of work-related musculoskeletal nursing injuries. The continuous quality improvement method could decrease nursing injuries. Pragmatism in clinical practice requires an evidence-based team approach with support from nurses, leadership, and other stakeholders who are the ultimate beneficiaries.
Acknowledgment The author wishes to acknowledge and thank the nurses who supported and participated in this project. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 0, 1–10
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