Oh, My Achin'
At high risk for back injuries, nurses can prevent problems by praticing proper body mechanics and pushing for assistive technology, lift teams in their facilities

By Phil Barber
January 16, 2003

When Anne Hudson, RN, suffered an injury to the lumbar region of her lower back while working in an Oregon hospital in 2000, one of the first things she did was attempt to gather information. She wanted advice, descriptions of health products, perhaps even a sympathetic ear. But when she fired up her modem, she found no chat rooms or Web sites devoted to the subject.

So Hudson turned to the American Nurses Association, then to the Oregon Nurses Association. Neither offered to help her personally, although the ANA did direct her to some important literature on the subject.

What she read eventually helped Hudson metamorphose from a victim to an advocate. She found ample evidence of the back injury risks faced by nurses and plenty of suggestions for improvement. But nobody seemed to be doing much about the situation.

Even worse, she discovered that many nurses were effectively being forced out of the industry because few hospitals offer permanent light duty.

"We've lost 2,000 RNs just in Oregon since 1993," Hudson said, citing the Bureau of Labor Statistics for accepted workers' compensation claims for disability.

"Where are these nurses? No one knows. No one's tracking them."

Wear and tear

Judged by any rational measure, nursing is hard on the back. According to the bureau, six of the 10 jobs at highest risk for back injuries are in health care. Nurses aides are the most vertebrally challenged in the land, and only construction workers and garbage collectors have it worse than LVNs. RNs rank sixth, right behind truck drivers.

Here are some more numbers likely to get you reaching for your lower back: The Occupational Safety and Health Administration has estimated that nearly half of all health service workers will experience at least one work-related musculoskeletal disorder during their careers. Bernice Owen, Ph.D., RN, who has written extensively on the subject, said 38 percent of nurses have suffered back pain severe enough to require leave from work, and that 12 percent are considering an exit from the profession because of back pain.

"The effect is cumulative," said Kevin Byrne, president of CorpMed.com, a company that produces a computer-based, OSHA-approved ergonomics clinic (worth 9.6 hours of continuing education credit). "You think you don't have back pain, but the wear and tear is there. It may be subclinical. Sooner or later, something gives."

No one expects the situation to improve in the coming years. For one thing, the progressively direr shortage of nurses ensures that they will be rushed in their duties. And then there is the national patient profile. "Given the weight of Americans going up, these problems are not going to go away quickly," said Alan Hedge, Ph.D., professor of ergonomics at Cornell University.

And yet measures can be taken to prevent back injuries. Studies show that regular exercise and pre-work stretching go a long way in preventing chronic back pain as well as the corollary, that obese nurses are significantly more likely to suffer from musculoskeletal disorders. Even mood can have some bearing, according to one longitudinal study conducted in England.

Nurses also must be sure to use proper lift techniques whenever possible. Common suggestions include:

• Begin your lift with the object or patient between the level of the knuckles (with arm hanging at side) and the shoulder.
• Plan before the lift and be realistic about your abilities.
• Get a firm grip on the object/patient.
• Bring the object/patient as close to your body as possible.
• Point your feet in the direction of movement and separate them at shoulders' width.
• Move the object/patient in a straight line; avoid twisting or sideways bending of the back.

Of course, in this profession, lifting with ideal body mechanics is easier said than done. The bulk of on-the-job back injuries comes while moving or turning patients, which is a little different than hauling boxes or 2-by-4s.

"Human beings don't have handles," Byrne said. "When they're in bed, you can't get close to them. Anyway, the average person in industry isn't expected to lift 200 pounds."

And certainly not 200 pounds with a tendency toward instability, uncertainty or even combativeness. "You might have a 300-pound person who's helping you lift him, then suddenly he's not helping," said Carolyn Blue, MSN, RN, an associate professor at Purdue University School of Nursing. "Do you let him hit the floor? The usual reaction is to help him. So some things are just unavoidable."

On the other hand, many factors can be controlled. One important element of a back-friendly work environment is ergonomics. Tight, cluttered spaces tend to hamper a nurse's movements. Low beds or drug trolleys require too much stooping and long periods of standing are no good, either. OSHA has created a set of ergonomic guidelines for nursing homes, going so far as to fine facilities that repeatedly register a high percentage of employee back injuries. Many would like to see the agency next turn its attention to acute care hospitals.

Ergonomics is not the complete answer, though. A study at Ohio State University showed that in most situations, even a two-person lift places undue strain on the vertebrae. Fortunately, the technology is available to assist nurses, including slide sheets, roller boards, transfer discs, bridgers, gait belts, overhead lifters and slings, and standing and raising aids. Yes, these devices require an initial burst of capital, but the money saved on downtime and workers' compensation claims can more than balance out the costs.

"There's usually a return on investment within two years," said Greg Gale, vice president of marketing for Arjo, the nation's largest supplier of patient-handling equipment. "And we guarantee a 30 percent reduction in claims within six months."

According to Gale, acute care hospitals make up about 30 percent of the company's business. That's half as much as nursing homes, but hospitals showed greater growth this year. Arjo's contract with Columbia/HCA, for example, covers about 25 of the hospital group's locations.

Need a lift?

In the long run, the best way for nurses to protect their backs might be to lobby for lift teams. Pioneered by William Charney of San Francisco General Hospital, it's a concept with a developing track record of success.

In a lift-team hospital, nurses do practically no intense patient handling. When someone must be transferred from wheelchair to bed or helped from bed to bathroom, a lift team is called. The lifters don't have to be strapping men, nor must they come from a medical background. But they are specifically trained to move people, and they have the proper hardware at their disposal.

Tri-City Medical Center of Oceanside, Calif., is one hospital that has opted for lift teams. It started with a grant that covered the purchase of $160,000 worth of equipment and the hiring of one two-person lift team, which worked an eight-hour shift. Compared to the previous year, reported injuries dropped from 22 to six, days lost from 722 to zero and workers' comp costs from $224,000 to $14,000.

The results were so good that in July, Tri-City went 24/7 with its lift-team program. The expenditure for the new personnel was $180,000. That's no small change, but Liberty Mutual, Tri-State's insurer, estimated first-year savings of $234,000 in claims. No additional equipment had to be purchased. After an awkward transition, morale among nurses is said to be higher than ever.

"These guys are spoiled," said Rudy Gastelum, ANP, RN, Tri-City's employee health nurse, about the lift teams. "The nurses cook them lunch, throw parties for them. The patients all know them by name."

But will hospitals voluntarily adopt these strategies, even with positive cost-benefit evidence? Hudson, who is working with Charney on a book about preventable back injuries to health care workers, doesn't think so. She believes it will happen only when industry-specific legislation prohibits manual lifts.

"Without outside legislation, it will not happen," Hudson said. "But when the first state passes such legislation, others will soon follow, just as it happened with needlestick legislation in California. We will have zero-lift legislation in this country."

Contact Phil Barber at barzell@napanet.net