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Ergonomic exposures of nursing home personnel following a safe resident handling intervention

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Alicia Beth Kurowski
Abstract:
The efficacy of a nursing home Safe Resident Handling Program (SRHP) to reduce the ergonomic exposures of nursing assistants was evaluated. The healthcare version of the PATH method was used by 12 observers to examine postures, manual handling, and resident handling pre-intervention and at three months, 12 months, 24 months, and 36 months post-intervention. There were marked downward trends in proportion of work time spent repositioning and transferring residents, and increased use of handling equipment in transferring (Cochran-Armitage tests: all p-values < 0.001). While resident handling post-intervention, nursing aides were more likely to be in neutral trunk postures, walking rather than standing still, working with both arms below 60 degrees, and less likely to lift loads greater than 50 pounds. Lateral transfer devices were infrequently observed in use for repositioning; additional training on the use of this equipment is recommended to increase the potential benefits of the intervention program. A biomechanical index was developed that combined the compressive forces on the spine resulting from the observed postures and manual handling, in order to obtain a comprehensive analysis of the physical workload of nurses and nursing assistants in long-term care facilities. Informed by a prior biomechanical model that incorporated workers' self-reported frequencies of postures and manual handling, observational data of ergonomic job features was used. The University of Michigan's Three-Dimensional Static Strength Prediction Program (3DSSPP) was used to calculate compressive forces on the lumbar spine resulting from 17 combinations of trunk, arm, and leg postures and manual handling activities. Each force estimate was then used as a weight for the observed frequency of that combination of PATH variables by job group, and the contributions were summed to obtain total physical loads. These total loads were computed for the four observational surveys from before to three years after the ergonomics intervention. Over the follow-up period the physical workload index (PWI) decreased both for nursing assistants (-24.2%) and for nurses (-2.5%). The index for nursing assistants was much higher during resident handling than other tasks. By the end of follow-up, the index for nursing assistants while resident handling decreased by 40.9% of the baseline value. Differences in the efficacy of the SRHP in five of the nursing homes in the sample were examined. Two outcome measures were considered: changes in equipment use while resident handling and changes in the PWI for nursing assistants over a two-year period following SRHP implementation. Questionnaires, administrative data, employee satisfaction surveys, and staff exit interviews following the collection of ergonomic observations were examined for explanatory factors of between-center differences in outcomes. Of the explanatory factors, significant correlations related to the outcome measures were the percentages of agency staff used to fill shifts, work shifts involving obstacles to getting work done, 'never' feeling time pressure, adequacy of supplies and equipment, 'poor' ratings for quality of teamwork and staff-to-staff communication, and observed understaffed shifts. The facility with the most positive outcome measures was associated with many positive changes in explanatory factors and the facility with the least positive outcome measures experienced negative changes in the same explanatory factors. These explanatory factors might also inform future analysis of the outcome measures on individuals.

TABLE OF CONTENTS LIST OF TABLES xii LIST OF ILLUSTRATIONS xiv ABBREVIATIONS xvi CHAPTER I: INTRODUCTION 1.1 Objectives and Specific Aims 1 1.2 Background 4 1.2.1 The Nursing Home Industry 4 1.2.2 Clinical Staff in Nursing Homes 4 1.2.3 Risk of MSDs in Clinical Work 7 1.2.4 Interventions in Healthcare to Reduce MSD Risk 8 1.2.5 Biomechanical Modeling of Clinical Work 11 1.2.5.1 Index of Physical Workload. 14 1.2.7 Explanatory Factors for Successful SRHPs 15 1.3 Significance 17 1.4 Dissertation Organization 19 Literature Cited 20 CHAPTER II: CHANGES IN ERGONOMIC EXPOSURES OF NURSING ASSISTANTS AFTER THE INTRODUCTION OF A SAFE RESIDENT HANDLING PROGRAM IN NURSING HOMES 2.1 Introduction 25 2.2 Methods 29 vn

2.2.1 Background to the Intervention Process 29 2.2.2 Study Design 30 2.2.3 Ergonomic Exposure Assessment Method 30 2.2.4 Path Template Development 31 2.2.5 Data Collection Procedures 32 2.2.6 Supplemental Cover Sheets 34 2.2.7 Data Management and Analysis 35 2.2.8 Healthcare Workers Questionnaire 36 2.3 Results 37 2.3.1 Baseline Activities and Ergonomic Exposures 37 2.3.2 Resident Handling and Equipment Use after SRHP Implementation 39 2.3.3 Changes in Body Postures after SRHP Implementation 44 2.4 Discussion 47 2.4.1 Limitations and Strengths of This Study 50 2.5 Conclusions and Recommendations 52 Literature Cited 54 CHAPTER HI: A PHYSICAL WORKLOAD INDEX TO EVALUATE A SAFE RESIDENT HANDLING PROGRAM FOR CLINICAL STAFF IN NURSING HOMES 3.1 Introduction 57 3.1.1 Biomechanical Assessment of Clinical Work 58 3.2 Methods 61 3.2.1 Weighting Factors 62 Vl l l

3.2.2 Scores 62 3.2.3 Posture and Manual Handling Inputs 63 3.3 Results 68 3.3.1 Weighting Factors 69 3.3.2 Scores 71 3.3.3 Physical Workload Index 73 3.4 Discussion 75 3.4.1 Limitations and Strengths of This Study 76 3.5 Conclusions and Recommendations 80 Literature Cited 81 CHAPTER IV: EXPLANATORY FACTORS FOR DIFFERENCES AMONG NURSING HOMES IN PHYSICAL WORKLOAD AND THE USE OF HANDLING EQUIPMENT 4.1 Introduction 83 4.2 Methods 87 4.2.1 Outcome Measures 88 4.2.1.1 Equipment Use While Resident Handling 89 4.2.1.2 Physical Workload Index 89 4.2.2 Explanatory Factors 89 4.2 2.1 Factors from Questionnaire Responses 90 4.2.2.2 Environmental Factors from Administrative Data 91 4.2.2.3 Factors from Employee Satisfaction Surveys 92 4.2.2.4 Factors from Coversheet Data 92 IX

4.2.3 Domains for Explanatory Factors 93 4.2.4 Correlation Coefficients 93 4.3 Results 94 4.3.1 Safe Resident Handling Outcomes 95 4.3.1.1 Equipment Use While Resident Handling 95 4.3.1.2 Physical Workload Index 97 4.3.2 Center Characteristics in Relation to SRHP Effectiveness 99 4.3.2.1 Explanatory Factors 100 4.3.2.2 Facility Characteristics 102 4.3.2.2.1 Resident Case-Mix 102 4.3.2.3.4 Wellness Programs. 102 4.3.2.3 Equipment Factors 102 4.3.2.3.1 Access To Handlins Equipment At Baseline 102 4.3.2.3.2 Adequacy of Supplies and Equipment 103 4.3.2.4 Staffing Factors 104 4.3.2.4.1 Aeencv Staff. 104 4.3.2.4.2 Understaffins 104 4.3.2.5 Turnover 105 4.3.2 5.1 Nursins Assistant Turnover 105 4.3.2.5.2 Administrative Turnover 105 4.3.2.6 Personal Work Factors 106 4.3 2.6.1 Job Satisfaction 106 4.3.2.6.2 Obstacles to Getting Work Done on Time 107 x

4.3.2.6.3 Time Pressure 107 4.3.2.7 Interpersonal Relationships 108 4.3.2.7.1 Supervisor Support 108 4.3.2.7.2 Staff-to-Staff Communication 109 4.3.2.7.3 Quality of Teamwork I l l 4.4 Discussion 112 4.4.1 Limitations and Strengths of This Study 115 4.4.2 Conclusions 118 Literature Cited 120 CHAPTER V: CONCLUSION 5.1 Objectives 122 5.2 Accomplishments 123 5.2.1 Limitations and Strengths of This Dissertation 125 5.3 Future Recommendations 129 5.2.1 Recommendations for Research 129 5.2.1 Recommendations for Practice 131 APPENDIX A: PATH Template 133 APPENDIX B: PATH Coversheet 135 APPENDIX C: Survey on Frequencies of Physical Exposures at Work 144 APPENDIX D: Equation for Biomechanical Model of Lumbar Loading 146 APPENDIX E: Interpolated Hip and Knee Angles for Walking 148 APPENDIX F: 3DSSPP Input and Output 150 BIOGRAPHICAL SKETCH OF AUTHOR 168 XI

LIST OF TABLES Table 2.1: Population Demographics 37 Table 3.1: Example of Scoring Method for Trunk Posture 63 Table 3.2: Trunk Postures 63 Table 3.3: Arm Postures 64 Table 3.4: Leg Postures 64 Table 3.5: Manual Handling Actions 64 Table 3.6: Percentage of Observations with No Load Handled (Neutral Trunk) 66 Table 3.7: Percentage of Observations with No Load Handled (Flexed Trunk) 66 Table 3.8: Population Demographics 68 Table 3.9: Compressive Forces on L5/S1 and Weighting Factors Resulting from Trunk Postures 69 Table 3.10: Compressive Forces on L5/S1 and Weighting Factors Resulting from Arm Postures 69 Table 3.11: Compressive Forces on L5/S1 and Weighting Factors Resulting from Leg Postures 70 Table 3.12: Compressive Forces on L5/S1 and Weighting Factors Resulting from Lifting Loads with an Upright Trunk 70 Table 3.13: Compressive Forces on L5/S1 and Weighting Factors Resulting from Lifting Loads with a Flexed Trunk 71 Table 3.14: Observed Frequencies of Postures and Manual Handling for Nursing Assistants 72 Xl l

Table 3.15: Observed Frequencies of Postures and Manual Handling for Nursing Assistants While Resident Handling 72 Table 3.16: Observed Frequencies of Postures and Manual Handling for Nurses 73 Table 4.1: Explanatory Factors and Data Sources 90 Table 4.2: Data Collection - Observation Periods and Observation Moments 94 Table 4.3: Demographic Information for Observed Nursing Home Workers, by Facility 95 Table 4.4: Equipment Use While Resident Handling - Proportion of Work Time Observed, Standard Errors, and Confidence Intervals 95 Table 4.5: Summary of Center-Specific Explanatory Factors and Outcome Measures 99 Table 4.6: Selected Correlation Coefficients for Explanatory Factors and Program Outcome Measures (Spearman Tests) 101 xiu

LIST OF ILLUSTRATIONS Figure 2.1: Baseline Trunk Angle for Observations of LPNs and Nursing Assistants 38 Figure 2.2: Frequency of Resident Handling 40 Figure 2.3: Equipment Use While Resident Handling 40 Figure 2.4: Frequency of Resident Handling Activities 41 Figure 2.5: Equipment Use While Repositioning and Transferring 42 Figure 2.6: Weight in Hands While Repositioning and Transferring 43 Figure 2.7: Changes in Trunk Posture While Resident Handling 44 Figure 2.8: Changes in Arm Angle While Resident Handling 45 Figure 2.9: Changes in Leg Action While Resident Handling 46 Figure 3.1: Physical Workload Index for Nurses, Nursing Assistants, and Nursing Assistants While Resident Handling 74 Figure 4.1: Equipment Use While Resident Handling by Facility 96 Figure 4.2: Physical Workload Index for Nursing Assistants by Facility 97 Figure 4.3: Physical Workload Index for Nursing Assistants While Resident Handling by Facility 98 Figure 4.4: Slope for Physical Workload Index vs. Percent Change in Perceived Adequacy of Supplies and Equipment 103 Figure 4.5: Slope for Physical Workload Index vs. Administrator Turnover 106 Figure 4.6: Equipment Use While Resident Handling vs. Percent Change in Never Feeling Time Pressure 108 xiv

Figure 4.7: Workers' Assessment of Supervisor Support over Time 109 Figure 4.8: Slope for Physical Workload Index vs. Percent Change in Perceived Staff-to-Staff Communication 110 xv

ABBREVIATIONS 3DSSPP - THREE DIMENSIONAL STATIC STRENGTH PREDICTION PROGRAM BLS - BUREAU OF LABOR STATISTICS CMA - CERTIFIED MEDICINE AIDE CNA - CERTIFIED NURSING ASSISTANT DON - DIRECTOR OF NURSING EMG - ELECTROMYOGRAPHY FTE - FULL TIME EMPLOYEE GNA - GERONTOLOGICAL NURSING ASSISTANT IRR - INTER-RATER RELIABILITY LPN - LICENSED PRACTICAL NURSE MCPHI - MULTI-COMPONENT PATIENT HANDLING INTERVENTION MSD - MUSCULOSKELETAL DISORDER NIOSH - NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH OHSAH - OCCUPATIONAL HEALTH AND SAFETY AGENCY FOR HEALTHCARE OSHA - OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

PATH - POSTURES, ACTIVITIES, TOOLS, AND HANDLING PDA - PERSONAL DIGITAL ASSISTANT PWI - PHYSICAL WORKLOAD INDEX RN - REGISTERED NURSE SRHP - SAFE RESIDENT HANDLING PROGRAM UC - UNIT COORDINATOR xvn

1 CHAPTER I: INTRODUCTION 1.1 OBJECTIVES AND SPECIFIC AIMS In 2003 the Occupational Safety and Health Administration (OSHA) released ergonomic guidelines for the nursing home industry based on reviewing existing ergonomics practices and programs, State OSHA programs, and scientific research (OSHA, 2003). This document recommends eliminating manual resident lifting whenever possible. The patient care industry has developed devices to prevent exposure to the forceful exertions required to lift and move patients who are not fully ambulatory, and several studies have evaluated their efficacy (Park, 2009; Enkvist, 2006; Nelson, 2006; Collins, 2004; Nelson, 2003a, 2003b; Silverstein, 2003). The objective of this study was to assess the ergonomic exposures of nursing assistants in nursing homes after a company-implemented Safe Resident Handling Program (SRHP). Baseline pre-intervention measurements as well as 3-month, 12- month, 24-month, and 36-month measurements were collected using the PATH method (Buchholz, 1996) and evaluated overall and by facility. The specific aims of the first study were to evaluate the effects of a multi- component Safe Resident Handling Program (SRHP) over a three-year follow-up period in a sample of nursing homes by examining observed changes in manual handling and

2 resident handling activities, use of handling equipment, as well as trunk, leg, and arm postures among nursing assistants. Cochran-Armitage trend tests were used to identify significant trends over time for postures and manual handling. The second study's specific aims were to evaluate further the efficacy of the SRHP by modifying and computing a Physical Workload Index (PWI) for nurses and nursing assistants using an additive biomechanical model. The index was based on a prior model (Klimmer, 1998; Hollmann 1999) and consisted of inputs reflecting the frequencies of observed postures and manual handling activities resulting from the direct ergonomic observations and biomechanical weighting factors resulting from the observational variables. In order to evaluate the SRHP, the PWI for nursing assistants was used to describe physical workload both overall and while restricted to resident handling activities for each time period. The physical workload of nursing assistants was also compared to that of a population of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) both before and after the SRHP intervention in nursing homes. The specific aims of the third study were to examine the efficacy of the SRHP among nursing assistants on the facility level by examining possible explanatory factors for differences in the outcome measures in five nursing homes. Changes in equipment use while resident handling as well as changes in the PWI for nursing assistants were examined over a two-year period following SRHP implementation. Center and shift characteristics that might explain differences were identified by reviewing questionnaires, administrative data, employee satisfaction surveys, and staff exit interviews following ergonomic observations. Correlation coefficients were computed between explanatory

3 factors and outcome measures were examined to identify potential relationships (and to inform future analyses on the individual level).

1.2 BACKGROUND 4 1.2.1 The Nursing Home Industry The U.S. National Nursing Home Survey conducted in 2004 reported that there were 1,324,500 residents 65 years and older living in nursing homes (Jones, 2009). This constituted 3.7 percent of the US population age 65 and older (Wan, 2005). The number of nursing home beds increased by 12 percent from 1.62 million to 1.81 million between the years of 1985 and 1999. Three-quarters of the residents required assistance in at least three activities of daily living (for example bathing, getting dressed, eating, and toileting), and 42 percent of the residents are diagnosed with dementia (AARP, 2001). Nursing homes typically consist of several units made up of bedrooms which are usually shared by at least two residents. Central to each unit is a nursing station, where RNs and LPNs perform most administrative work. In addition to bedrooms, each unit has at least one shower room where residents are bathed, a dirty linen closet, and a supply closet. Units also have dining areas and common areas where the residents can attend activities. These facilities mainly cater to long-term care for the elderly; however certain facilities also maintain rehabilitation units and/or assisted living units. There may also be specialized units such as those which provide care for residents with dementia and similar disorders. Many nursing homes also have rehabilitation rooms, dining rooms, hair salons, and activity rooms, as well as other services such as administrative offices. 1.2.2 Clinical Staff in Nursing Homes Occupations of nursing home staff include rehabilitation, recreation, dietary, housekeeping, administration, and social work. Clinical nursing staff includes RNs, LPNs, Certified Nursing Assistants (CNAs), Geriatric Nursing Assistants (GNAs), and

5 Certified Medicine Aides (CMAs). In some states, employees are first trained as CNAs, and upon completion of an approved GNA course and examination they are promoted to the status of GNA. CMAs are GNAs who have completed additional training requirements which allow them to mix and administer medications. Some Unit Coordinators (UCs) are promoted from certified GNA, CNA, or CMA positions, and thus must perform some direct care to maintain their certification. Because residents require 24-hour care, there must be clinical nursing staff working nights and weekends. Facilities are typically staffed in three shifts: days (7:00 am to 3:00 pm), evenings (3:00 pm to 11:00 pm), and nights (11:00 pm to 7:00 am). Most of the clinical staff are assigned to a permanent shift, as opposed to rotating shifts. RNs in nursing homes perform minimal resident handling. They supervise the actions of LPNs, GNAs, CNAs, and CMAs. Their job duties are mainly administrative in nature, such as completing paperwork and creating care plans for residents. However, RNs also evaluate residents' health conditions and perform complicated procedures such as starting intravenous fluids (Jervis, 2002). At the start of each shift, RNs meet with those from the previous shift to discuss each resident, specifically changes in health status, medications, rehabilitation, or care plans. RNs communicate with the employees they supervise, as well as with physicians, family members, and visitors. Typically, LPNs in nursing homes work under the direction of RNs. In some cases, LPNs supervise nursing home units. They also perform medical tasks such as mixing and distributing medications, wound care, and checking vital signs (Jervis, 2002). Medications are usually administered twice per shift. On the day shift, for example, medications are delivered once in the morning, and once in the afternoon. Administrative

6 tasks such as completing paperwork and making phone calls to physicians and physical therapists are also performed. The majority of resident handling activities are performed by GNAs and CNAs. Their main job duties include bathing, dressing, toileting, feeding, and otherwise assisting the residents in the facilities (Jervis, 2002). These types of activities frequently include manual handling actions such as transfers and repositions and often require the use of mechanical lifts. When a shift starts, GNAs and CNAs meet with their supervisors and are given their work assignments. On the first shift GNAs and CNAs are required to wake up each resident, assist in bathing them, dressing them, and delivering breakfast. Because of the amount of work required in the early morning in addition to residents' preferences, tasks are not always completed in this order. A typical goal for GNAs and CNAs is to complete all of these tasks by the time lunch is served (between 11:30 am and 12:00 pm). Due to the varied acuity of residents, some may be able to bathe, dress, and feed themselves, while others require additional care. After lunch is served, GNAs and CNAs make rounds to each resident for whom they are responsible, which involves toileting activities such as assisting residents to the bathroom and changing diapers. At the end of each shift GNAs and CNAs are required to complete some basic paperwork about each resident. Other tasks which are performed throughout the day include toileting, making beds, and cleaning up food trays. CMAs perform medical tasks such as mixing and administering medications, which is traditionally part of an LPN's job duties. CMAs are not permitted to administer injections or perform wound care. In many facilities, if understaffing of GNAs arises,

7 CMAs are often pulled from their medical positions and required to work on the units as GNAs. 1.2.3 Risk of MSDs in Clinical Work Manually lifting, transferring, and repositioning residents by clinical nursing staff results in elevated physical effort and high internal loading in muscles, ligaments, and joints which can increase the likelihood of developing work-related musculoskeletal disorders (MSDs) (Waters, 2007). CNAs and LPNs in nursing homes had more than twice the risk of developing work-related low back disorders compared to all other female workers (NIOSH, 1998). In 2009 nursing assistants had the highest incidence rate of MSDs per 10,000 full-time workers and they ranked second for work-related injuries and illnesses requiring days away from work for all eligible occupations (BLS, 2010). The NIOSH guide, "Safe Lifting and Movement of Nursing Home Residents" (Collins, 2006), addressed the challenges of manual resident handling in nursing homes stating, "These conditions contributed to the 211,000 occupational injuries suffered by caregivers in 2003. ... Due to the ongoing demand for skilled care services, musculoskeletal injuries to the back, shoulder, and upper extremities of caregivers are expected to increase." The relationship between physical work factors and MSDs has been documented in nursing home and hospital workers (e.g. Lagerstrom, 1998; Smedley 1995, 1997; Trinkoff 2003; Fujimura, 1995). A review of 42 studies researching low back pain among nursing jobs reported relationships between low-back pain and patient/resident handling, 'save the patient' situations, awkward work postures, static standing, and working as a nursing aide compared to a registered nurse (Lagerstrom, 1998).

8 In 2003, Trinkoff reported on perceived physical demands of randomly selected RNs. Twelve physical demands items including physical effort, repetitive motion, lifting heavy objects or people, and working in awkward postures were analyzed for their association with neck, shoulder, and back MSDs. All physical demands were significantly associated with back MSDs, and 11 of 12 demands were significantly associated with neck and shoulder MSDs (Trinkoff, 2003). A cross-sectional study based on questionnaires distributed to 1616 nurses in hospitals (Smedley, 1995) found the nsk of low back pain to increase with perceived frequency of manual patient handling, including repositions and transfers. A follow-up study (Smedley, 1997) surveyed the same population of nurses with an 88% response rate, and results mirrored the 1995 study. A 1995 study in Japanese nursing homes indicated that nursing assistants with low back pain perceived resident handling activities, especially toileting, repositioning, and transferring, to be more stressful than did workers without back pain (Fujimura). 1.2.4 Interventions in Healthcare to Reduce MSD Risk Safe patient handling interventions are fundamental for reducing MSDs among healthcare workers (Collins, 2006). Typical multi-component patient handling interventions include patient assessment, provision of patient handling equipment, written policies for equipment use, and training on patient handling procedures (Hignett, 2003). Systematic reviews of patient handling interventions indicated that multi-component interventions were more effective than manual handling training only for preventing back pain and injuries in nurses (Dawson, 2007), and equipment use alone was not as effective as multifaceted interventions (McCoskey, 2007). Research on safe patient handling

9 programs has been performed in hospital, nursing home, and home health settings. Nurses have been studied more often than other workers. Findings have included reductions in forces on the lumbar spine (Nelson, 2003), back injuries (Engkvist, 2006), workers' compensation claims and lost injury days (Park, 2009; Engkvist, 2006; Nelson, 2006; Collins, 2004; Li, 2004), OSHA 200 log incidents (Collins, 2004; Evanoff, 2003), self-reported injury rates (Collins, 2004), and claim costs (Park, 2009; Alamgir, 2008; Badii, 2006; Miller, 2006; Nelson, 2006; Engst, 2005; Chhokar, 2005; Li, 2004; O'Reilly Brophy, 2001). Mechanical devices were evaluated in an Australian hospital and compared to two control hospitals (Engkvist, 2006). The cross-sectional study used a questionnaire to examine the number of injuries, pain and symptoms, and absence from work among nurses. The nurses at the intervention hospital reported significantly smaller numbers of back injuries, less pain, fewer symptoms, and less absence from work due to musculoskeletal symptoms. Another intervention study examined the effectiveness of mechanical aids such as total body lifts and sit-stand lifts in reducing musculoskeletal symptoms, injuries, lost workday injuries, and workers' compensation costs for 138 nurses in a community hospital (Li, 2004). Questionnaires were distributed, and OSHA logs and workers' compensation data were analyzed. The authors reported considerable increases in musculoskeletal comfort (as ranked on a five point scale) for all body parts studied, a decrease in injury rates, lost workday injuries and workers' compensation costs. In 2004, Collins et al. reported on an injury prevention program consisting of implementation of mechanical lifting equipment and repositioning aids along with a

10 written "zero lift" policy and staff training for all nursing staff in several nursing homes. Three years of pre- and post-intervention data were collected. Injury rates were examined through workers' compensation claims, incidents on OSHA 200 logs, employee reports, and human resources data. The authors reported a 61% decrease in the number of claims from workers' compensation, a 46% decrease in OSHA 200 log incidents, and a 35% reduction in employee injury first-reports. Severity and cost of injuries also decreased in this period. Nelson et al, (2003 c) examined nine different patient handling tasks, of which ceiling lifts were introduced for bed-to-wheelchair transfers. The intervention was assessed in a laboratory setting through the use of a 3-D electromagnetic tracking system, surface EMG, and questionnaires. The study reported that lumbar force was reduced by 58%, and moments at the lumbar spine, left shoulder, and right shoulder were decreased by 54%), 69%), and 45% respectively. The nurses in the study population reported increased comfort when transferring patients with the ceiling-mounted lifts as opposed to manual handling. In addition to evaluating interventions in patient handling tasks, this study also reported on some reasons why patient lifts were not used, such as, "difficulty using in confined spaces, extra time required, lack of accessibility or availability, difficulty using and storing, and poor maintenance." The effects of a lifting device intervention in four hospitals and five nursing homes were examined (Evanoff, 2003). Mechanical lifting devices were provided to assist caregivers with patient handling activities. Pre- and post-intervention musculoskeletal injury rates were examined and interviews regarding device use were carried out in both settings. The authors reported overall decreases in the number of injuries, number of lost

11 day injuries, and the total number of days lost due to injuries. However, these decreases were larger for nursing homes than hospitals. Injury rates in hospitals declined from 6.6 to 5.7 per 100 full time employees (FTEs) while injury rates in nursing homes declined from 6.9 to 4.9 per 100 FTEs. Results from interviews indicated a significant difference in the frequencies of perceived lift use between hospitals and nursing homes (16% vs. 38%), which was partially attributed to the quickly changing nature of patient acuity observed in hospital settings. 1.2.5 Biomechanical Modeling of Clinical Work Biomechanical modeling is technique that is valuable for investigating the effects of multiple exposures. Ergonomic exposures such as the physical workload of healthcare workers has been modeled in laboratory settings using static and dynamic models and incorporating patient handling tasks such as transferring and repositioning with and without the use of mechanical handling equipment (OHSAH, 2006; Skotte, 2002; Marras, 1999; Zhuang, 1999; Garg, 1992a; Garg, 1992b; Gagnon, 1986). A biomechanical evaluation of compressive and shear forces on the lumbar spine while performing manually and mechanically assisted patient handling was conducted by the Occupational Health and Safety Agency for Healthcare (OHSAH) in British Columbia, Canada (2006). Ground reaction forces and hand reaction forces were used as input variables in a linked segment model of the body. Peak compressive and shear forces resulted from the manual repositioning of a patient. Additionally, peak shear forces were observed while turning patients. Compressive and shear forces of the L4/L5 joint were examined (Skotte, 2002) using a biomechanical model that minimized the sum of 14 cubed muscle stresses. Ten

12 female healthcare workers performed nine patient handling tasks using a male stroke patient in a laboratory setting. Individual peak compressive forces ranged from 1283 to 5509 N. Compressive forces for the two tasks involving lifting the patient were significantly higher than all other tasks. The mean compressive forces for these two tasks were 4132 N and 4433 N which exceed NIOSH's proposed safety limit of 3400 N for manual handling. An EMG-assisted biomechamcal model was used (Marras, 1999) to determine spinal loading for four repositioning techniques and three patient transferring techniques while performing six tasks. Twelve experienced (nursing assistants at a long-term care facility) and five inexperienced participants volunteered to perform the tasks using a 50 kilogram female as a 'patient.' Maximum values of compressive force, anterior-posterior shear forces, and shear forces on the L5/S1 joint were used to estimate spinal load. The authors reported high forces for all transferring and repositioning techniques; compressive forces ranged from about 4000 N to 9000 N. It was determined that even the 'safest' task would put a healthcare worker at nsk for low-back injury. It was acknowledged that in a real-time setting there would be potential for greater risks to caregivers considering the 'patient' used in this study was small and cooperative. Another study (Zhuang, 1999) explored the effects of transfer methods and resident weight on the biomechanical stress of nursing assistants. Nine nursing assistants were recruited from nursing homes to participate in evaluating nine electrically controlled lifting devices, a slide board, a gait belt, and a manual transfer. Force platforms and a three-dimensional biomechanical model were used to measure low-back loading. It was

Full document contains 187 pages
Abstract: The efficacy of a nursing home Safe Resident Handling Program (SRHP) to reduce the ergonomic exposures of nursing assistants was evaluated. The healthcare version of the PATH method was used by 12 observers to examine postures, manual handling, and resident handling pre-intervention and at three months, 12 months, 24 months, and 36 months post-intervention. There were marked downward trends in proportion of work time spent repositioning and transferring residents, and increased use of handling equipment in transferring (Cochran-Armitage tests: all p-values < 0.001). While resident handling post-intervention, nursing aides were more likely to be in neutral trunk postures, walking rather than standing still, working with both arms below 60 degrees, and less likely to lift loads greater than 50 pounds. Lateral transfer devices were infrequently observed in use for repositioning; additional training on the use of this equipment is recommended to increase the potential benefits of the intervention program. A biomechanical index was developed that combined the compressive forces on the spine resulting from the observed postures and manual handling, in order to obtain a comprehensive analysis of the physical workload of nurses and nursing assistants in long-term care facilities. Informed by a prior biomechanical model that incorporated workers' self-reported frequencies of postures and manual handling, observational data of ergonomic job features was used. The University of Michigan's Three-Dimensional Static Strength Prediction Program (3DSSPP) was used to calculate compressive forces on the lumbar spine resulting from 17 combinations of trunk, arm, and leg postures and manual handling activities. Each force estimate was then used as a weight for the observed frequency of that combination of PATH variables by job group, and the contributions were summed to obtain total physical loads. These total loads were computed for the four observational surveys from before to three years after the ergonomics intervention. Over the follow-up period the physical workload index (PWI) decreased both for nursing assistants (-24.2%) and for nurses (-2.5%). The index for nursing assistants was much higher during resident handling than other tasks. By the end of follow-up, the index for nursing assistants while resident handling decreased by 40.9% of the baseline value. Differences in the efficacy of the SRHP in five of the nursing homes in the sample were examined. Two outcome measures were considered: changes in equipment use while resident handling and changes in the PWI for nursing assistants over a two-year period following SRHP implementation. Questionnaires, administrative data, employee satisfaction surveys, and staff exit interviews following the collection of ergonomic observations were examined for explanatory factors of between-center differences in outcomes. Of the explanatory factors, significant correlations related to the outcome measures were the percentages of agency staff used to fill shifts, work shifts involving obstacles to getting work done, 'never' feeling time pressure, adequacy of supplies and equipment, 'poor' ratings for quality of teamwork and staff-to-staff communication, and observed understaffed shifts. The facility with the most positive outcome measures was associated with many positive changes in explanatory factors and the facility with the least positive outcome measures experienced negative changes in the same explanatory factors. These explanatory factors might also inform future analysis of the outcome measures on individuals.