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Back Care for Nurses

Alan Hedge, Ph.D., FErgS, AFBPsS
Professor, Ergonomics
Cornell University
Ithaca, NY, USA

Construction workers, warehouse personnel, delivery goods drivers, nurses, shopkeepers and farm workers. If you had to choose, which of these occupations suffers the highest incidence of back injury? You might think that construction workers or delivery goods drivers might be the riskiest occupations for back injuries, because the work involves a lot of bending and lifting, but you'd be wrong! Many people are surprised to learn the nursing is the riskiest occupation for back injuries! In fact, nursing has the second highest incidence of all types of non-fatal work-related injuries in the U.S.A.

The latest Bureau of Labor Statistics are shown below in Table 1, and nursing easily tops the list of occupation as most associated with work-related musculoskeletal disorders. By what is this and what can be done to reduce risks? 

TABLE 1

Number (in 1,000s) of work-related musculoskeletal disorders involving time away from work and median days away from work by occupation, 1998.

(Source: Bureau of Labor Statistics, 1998)

In all industries combined, 1998 injury data show that nearly 12 out of 100 nurses in hospitals, and 17.3 out of 100 nurses working in nursing homes report work-related musculoskeletal injuries, including back injuries, which is about double the rate for all industries combined.

Recent Research on Back Injuries in Nursing

A Dutch questionnaire survey of back pain prevalence and physical work demands compared nurses working in institutional care with nurses working in patient's private homes, where there was more frequent and heavy lifting and transferring of patients, plus more static workloads. Results showed that back pain prevalence was relatively high among these community nurses, as compared to rates among nurses in other health care sectors. Community nurses with back pain, who continued to work, reported providing less efficient home care work. Total sick leave incidence due to musculoskeletal disorders, other than back pain, exceeded that due to back pain alone among these community nurses. [1]

Similar results have been reported in an Australian retrospective questionnaire survey of manual handling activities and associated injuries among 269 nursing professionals working at a large teaching and referral medical center in Melbourne, Australia. [2]  Overall, 40.1% reported an injury associated with manual handling activity, of which 75.9% (82) were back injuries. The prevalence of all manual handling and back injuries was lower among the 108 full- time nurses, 20.6% and 15.7% respectively. Direct patient care activities accounted for about two-thirds (67.6%) of all manual handling injuries. Lifting patients accounted for one half of all direct patient care activity associated injuries, and approximately one-third (34.3%) of all injuries. Similar results were found for manual handling practices and injuries among Intensive Care Units (ICU) nurses working in a large tertiary referral medical center in Australia where the rate of manual handling and back injuries among ICU nurses was high (52.2% and 71.4% respectively). [3]

A retrospective case-control study at the Istituti Ortopedici Rizzoli in Bologna (Italy) investigated the risk factors for low-back pain in hospital workers.  Compared with a control group of hospital staff, the risks of  low-back pain were significantly higher in nursing and health aides (OR= 21.67), in nurses (OR: 20.21), in therapists (OR: 16.36) and in X-ray technicians (OR: 13.64). The risk of occupational back injury was highest in the orthopedic wards, in the plaster-rooms, in the operating blocks and in the sterilization plants. Increased risk of back pain was strongly associated with specific manual handling. Non- occupational factors( cigarette smoking, previous trauma leading to hospital admission, and for women, number of children), showed only weak associations. [4] 

What are the risk factors for Back Injury?

There are two  main risk factors for back injury among nurses: lifting and transferring patients, and bed- making. During a typical shift, on average a hospital staff nurse will lift 20 patients into bed, and transfer 5-10 patients from bed to a chair. [5] Patients typically weight in excess of 100lbs, which puts this load well above the weight that would be considered 'safe' for industrial workers for this frequency of lifting. As with many hospitality workers, bed- making also increases the risks of back injury because of the bending and stretching involved in putting sheets onto a bed. [6]

Ergonomics can change Injury Risks

Throughout the '90s there has been a steady decline in the incidence of non-fatal injuries among nursing professionals, and much of this probably can be attributed to better training and better equipment.

FIGURE 1

Annual injury incidence rate (in 1,000s) among nursing professions from 1992 - 1998.

(Source: Bureau of Labor Statistics, 1998).

Workplace intervention programs can be effective in reducing back injuries. A 2-years inception cohort study investigated risk factors for 320 nurses, who incurred 416 back injuries, at a large teaching hospital in Winnipeg, Canada. [7] Results showed that back injuries that occurred while lifting patients resulted in greater time loss, the degree of pain was strongly related to the duration of time loss, and that participation in the return-to-work program focusing on back injury prevention reduced the duration of time loss.  

Back Injury Prevention Training

Training seems to play an important role in reducing the incidence of injury, as shown by the fact that about 80% of injuries occur among nursing aides, orderlies, and attendants compared with 20% occurring among registered nurses. Research has shown that training programs can be effective. In response to concerns over high incidence and severity of back injuries among nursing staff and others at a 440-bed acute care Australian hospital, the impact of a one-year Back Injury Prevention Program was evaluated. [8] The program  that was implemented included:

• an ergonomic evaluation of patient handling - identification of ergonomic risk factors
• pilot testing of equipment designed to reduce injury risks, especially in patient transferring activities
• purchase of new equipment identified as being most effective by the testing
• train-the-trainer program - in this way trainers can impart their knowledge to others and so on
• training of 374 nurses and other patient handling staff (approximately one-half of the nursing staff at the hospital). 

At the end of the program, trainees showed increased knowledge of injury risk factors, a marginal increase in the use of mechanical patient transfer devices, and a decrease in repositioning of patients in bed, compared with control subjects. Furthermore, compared with the average injury rates for the prior 3 years, trainees showed a 30% decrease in injuries. The authors concluded that back injury training increase knowledge of the injury risk factors and changed risky behaviors, such as how often patients were moved. Optimal training effectiveness is, however, also dependent on the availability of engineering controls, such as patient transfer devices.

Ways to Reduce Injury Risks

There are several ways that hospitals, care facilities and nursing professionals can reduce injury risks. These include:

• using lifting assistance devices - a variety of devices is available to help lift and move patients from bed to seat, such as:
  • gait belt - this is a specialized belt that fits snugly around the patient's waist and has hand straps for the nurse or caregiver to grasp while assisting during transfers or walking.
  • walkers - lightweight metal frame devices with rails that can be gripped by the patient to help to support their body weight during transfer and rising from sitting.
  • rails - wooden or metal rails that are fixed to walls or equipment, such as beds, to allow the patient to help to support their body weight during transfer.
  • 'Hoyer' lifts - a hydraulic lift that consists of a metal frame and a heavy canvas swing. It is capable of lifting and suspending a patient for transfer.
  • sliding boards - a smooth board with tapered ends made of either wood or plastic that is used to help someone get from one sitting surface to another.
  • draw/lift sheets - a regular flat sheet placed under a person in bed can be used to move them. If the sheet is strong enough it can also be used to lift and transfer the patient.

• using appropriate equipment - there is a choice of powered equipment available to reduce patient handling activities, such as powered beds to change a patient's posture, height adjustable chairs, and powered wheelchairs.
• use appropriate beds - the height of the bed determines how much bending and reaching a nurse has to do. Nurses are different heights, so a simple-to-operate, height-adjustable bed is important to allow bed height to be appropriately adjusted  to the nurse.
• use back belts - the general use of back belts in the distribution industry has been questioned. However, in a study of 47 employees over a 6-month period, the use of back belts significantly reduced injury risks. The test group with back belts worked 22,243 hours and had no injuries, whereas the control group worked 23,109 hours and lost 80 hours due to back injuries. [5]
• implement regular equipment maintenance procedures - equipment must be kept in good working order. 
• ergonomic design of workplaces -  use architectural and design features, such as rails or ramps, to minimize awkward movements.
• providing better ergonomics training - train nurses and and health aides in good work postures and ways of minimizing twisting, bending and/or lifting items from the floor. Also train them in safe lifting practices, and in the correct use of appropriate equipment. Provide ways of refreshing and reinforcing the training.
• provide adequate staffing - injury risks can be reduced by increasing the number of people available to assist with lifting patients.
• systematic record-keeping - implement processes that facilitate more detailed statistics on manual handling activities and outcomes so that this can help to identify injury trends before more serious incidents occur.

[1]    Knibbe, J. J. and  Friele, R. D. (1996) Prevalence of back pain and characteristics of the physical workload of community nurses, Ergonomics, 39 (2), 186-198.

[2]    Retsas, A. and Pinikahana, J. (2000) Manual handling activities and injuries among nurses: an Australian hospital study, J Adv Nurs., 31 (4), 875-883.

[3]    Retsas, A. and Pinikahana, J. (1999) Manual handling practices and injuries among ICU nurses, Aust J Adv Nurs., 17 (1), 37-42.

[4] Rossi, A.; Marino, G.; Barbieri, L.; Borrelli, A.; Onofri, C.; Rolli, M.; Baldi, R. (1999)Backache from exertion in health personnel of the Istituti Ortopedici Rizzoli in Bologna. A case-control study of the injury phenomenon in the 10-year period of 1987-1996, Epidemiol Prev., 23 ( 2), 98-104.

[5] Allen, S.K. and Wilder, K. (1996) Back belts pay off for nurses, Occ. Health & Safety, 65 (1) 59-62.

[6] Milburn, P.D. and Barrett, R.S. (1999) Lumbrosacral loads in bedmaking, App. Ergonomics, 30, 263-273.

[7] Tate, R. B., Yassi, A. and Cooper, J. (1999) Predictors of time loss after back injury in nurses, Spine, 24 (18), 1930-5; discussion on page 1936.

[8]  Lynch, R. M. and Freund, A. ( 2000) Short-term efficacy of back injury intervention project for patient care providers at one hospital, Aihaj, 61 (2), 290- 294.

Endnote:

OR = Odds Ratio. This measures the odds of a disease in exposed individuals, such as nurses, relative to the odds of disease in unexposed individuals, that is, non-nurses.