Check that monitor -- twist. Silence that alarm - strain. Assess that chest tube drainage -- stoop. Recheck that blood pressure -- bend. Grab that chart -- reach. Move that gurney -- push. Get rid of that laundry bag -- heave. Transfer that patient -- lift -- higher. Now repeat. Again and again for eight hours or more.
The act of nursing can be described as an ergonomic nightmare. In an average shift, staff nurses must perform repetitive movements and lifts over and over and over again -- often at a quick pace, with no breaks and with little help, human or otherwise. They consider themselves lucky when they go home without suffering a major on-the-job injury. But experts and nurse advocates say that all those twists, turns, bends and lifts take their toll in the form of repetitive stress that makes nurses ripe for disabling musculoskeletal disorders (MSDs), like back and shoulder injuries.
"It's relatively rare when a nurse will have an acute occurrence and be able to say 'Oh, that's when I damaged my back.' Rather, it happens over a period of time with a gradual increase in problems," said Ohio Nurses Association (ONA) member Mary Runyan, RN, CCRN, who has endured the ongoing pain of a work-related injury throughout much of her 32-year nursing career.
are under way to prevent workplace injuries. Some are regulatory, like
the Occupational Safety and Health Agency's (OSHA) ergonomics standard,
which ANA supports and would like to see strengthened. The standard would
require employers to address ergonomics -- ensuring a good fit between
the worker and the work that must be performed -- in industries where
Other nurse-backed initiatives involve securing strong contract language on health and safety issues, and legislation that improves staffing. And still others are aimed at building awareness among nurses and administrators that back pain, neck strain and other post-shift ailments are not an "inevitable" part of the job.
Coast-to-coast pain Runyan has an appalling statistic: Half of the 20 RNs who work with her in the ICU of an Ohio hospital have missed work up to three months each due to back injuries that could have been prevented. Runyan is among those casualties. Within two years of becoming a nurse, she began to suffer from sciatica. "I was lifting patients all the time, and I was aware that it was causing a problem. But the pain didn't stop me from performing my job," Runyan said.
A pattern soon emerged. She'd have intense back pain requiring her to take time off from work. She'd undergo physical therapy, visit a chiropractor, or both. Then she'd go back to work, feeling relatively pain-free. But the pain always returned, because of the way ICU nurses are forced to work.
There are no assistants in the ICU, so nurses have to do it all - turning, lifting, getting people out of bed, taking them to radiology," Runyan said. "They also have to bring patients to the ICU in beds with oxygen tanks on them, while pushing IV poles and constantly correcting the forward motion of the bed."
In 1982, Runyan had back surgery after one of her discs herniated, causing a piece of the disc to break off and float freely. The following year, she began having problems with the next disc up, and in 1998 she needed hip surgery, the result of overcompensating for her back pain. But Runyan, who's now the ICU head nurse, keeps on working.
Registered nurse Becky Rice no longer works in the ICU of a Washington, DC, hospital. She currently is waiting to schedule her second surgery -- once her workers' compensation benefits are restored. (Ten months after her injury, hospital administrators filed for bankruptcy and claimed they could no longer pay benefits to Rice and 112 others who sacrificed their health on the job.)
Rice, a member of the District of Columbia Nurses Association (DCNA) who now speaks out on back injury prevention, first hurt herself in February 1999 while helping another nurse boost a ventilator-dependent, comatose patient up in bed. The pain was both immediate and intense. And despite properly positioning herself prior to the lift, she suffered a severe lower back injury.
Rice then did what other nurses often do.
"I worked for two days in excruciating pain, hoping it would go away," Rice said. It did not, and instead, she had her first surgery.
Now, she worries about her finances and the effect her injury has had on her husband and her son.
"My husband has had to do alone the work that both of us used to do together," said Rice at a Washington, DC-based OSHA hearing on the proposed ergonomics standard. "I have not been able to go back to work, and feel I may have to eventually look for something in another field. Although I love my job and caring for patients, I can't risk my health on a daily basis."
T he days leading up to Rice's disabling injury were particularly brutal. She was assigned to a roughly 350-pound, unresponsive patient. Many of those days, staffing was minimal, so she didn't have enough available co-workers to help her turn or lift the patient. But she and the other RNs did their best to provide the type of care Rice says patients need and deserve.
Alaska Nurses Association member Maggie Flanagan, RN, recently returned to work on a per diem basis after suffering a back injury (see story, page 19) that kept her away from the NICU for eight months and caused her to lose her regular hours and benefits.
Like Rice, Flanagan told her story at an OSHA hearing on the proposed standard held in Chicago. She described how she helped a charge nurse hoist a 75-pound monitor onto a shoulder-high shelving unit, because there was no other hospital staff to assist. Having already experienced repetitive stress-related back and shoulder pain, Flanagan's back went into spasms immediately after the lift.
"For months after I was hurt, I could not bathe or dress my children," Flanagan testified. "I couldn't perform simple chores, like laundry or using the dishwasher. My five-year-old had to buckle his three-year-old brother in the car seat if I had to drive."
And, Flanagan recently said, "I'm still in pain every day."
Oddly enough, nurses who've had back injuries frequently switch to the NICU to avoid further workplace injuries. Flanagan said they don't realize that they are placing themselves at risk for neck and shoulder problems from repeatedly having to spend long periods of time in awkward postures and routinely reaching to perform patient care.
They're not alone
Each year, 1.8 million U.S. workers experience work-related MSDs, such as injuries from overexertion or repetitive motion. Women disproportionately suffer from some of the most severe MSDs - not because they are physically more vulnerable - but because a large number of working women are in jobs associated with heavy lifting, awkward postures or repetitive motion, according to OSHA.
OSHA estimates that nearly half of all workers in the health services industry, which includes RNs, will experience at least one work-related MSD during their working lives. That statistic ranks them only behind employees who work in the warehouse and transportation industries.
Nurses and ergonomic experts say engineering controls like mechanized lifting devices and redesigned workstations, as well as strict weight-lifting limits could go a long way to prevent injury. But a key piece of the safety puzzle is appropriate staffing. Research has shown that even the strongest women should lift no more than 46 pounds at a single time, and having enough "bodies" available would help prevent even occasional single-person lifts.
In her 1995 groundbreaking study at the Minnesota Nurses Association (MNA), Labor Relations Staff Specialist Elizabeth Shogren, RN, looked at the connection between downsizing and workplace injuries. MNA researchers found a 65.2 percent increase in RN injuries -- mostly related to patient transfers and sharps -- at 12 Minneapolis/St. Paul-area hospitals between 1990 and 1992. During that same time, RN positions had been reduced by 9.2 percent.
Catherine Parker, MSN, RN, knows the importance of keeping nurses healthy. She is the manager for employee health services of two recently merged eastern Nebraska community hospitals. The merged medical center has had to start recruiting nationally because of the nursing shortage.
"If we can control injuries by doing our part internally, then we have a better chance of retaining our nurses," said Parker, a Nebraska Nurses Association member. "As case manager for workers' compensation claims, I work very closely with nurses in their recovery. Our goal is to bring them back."
Parker said the most common workplace injuries among nurses at her facility are accidental needlesticks, followed by back injuries primarily related to lifting.
When nurses do return to work, Parker helps them ease back into their roles. For example, they might do medications or new admissions only, or they might have restrictions, such as lifting limits. If nurses are unable to return to their former roles, Parker works with them to determine if positions on other units would be appropriate or if they must change careers, which she admits is a difficult proposition for most nurses.
Shogren added that management and co-workers need to support nurses who return to work after an injury and respect the limitations that are placed on their activities.
"When people have back injuries, somehow there's a belief that they're malingering," she said. "When it happened, there was no blood. They weren't hauled off to the ER struggling for their life. But it's the type of injury that lasts a lifetime if it's not taken care of the right way."
To improve workplace conditions, ANA, its constituent member associations (CMAs) and CMA nurses are advocating for legislation that improves staffing levels, and promoting injury prevention practices, such as lifting teams, weightlifting restrictions and the use of ergonomically correct equipment.
On another front, ANA and CMAs have crafted strong contract language that addresses threats to nurses' health and safety.
In Minnesota, for example, contract language covering some 75 to 80 percent of MNA's collective bargaining members states, "It shall be the policy of the hospital that the safety of the nurses, the protection of work areas, the adequate education, and necessary safety practices, and the prevention of accidents are a continuing and integral part of its everyday responsibility."
The contract language also details how MNA bargaining unit members will work with management to continually improve workplace health and safety and the treatment of ill, injured or disabled nurses, as well as promote the continued and appropriate employment of these nurses.
At Runyan's facility, nurses negotiated wellness programs that address injury-prevention strategies, such as proper lifting techniques and the use of assistive devices.
"In our latest contract, we negotiated bargaining unit representation on the hospital's existing safety committee and made it into a health and safety committee. Now, addressing the health and safety of nurses will be a part of their every day responsibility," Runyan said.
In another effort to protect the well-being of RNs, ANA and nurses nationwide are working to guarantee that the OSHA ergonomics standard -- which was first proposed in November 1999 -- becomes a reality. OSHA has conducted a number of regional public hearings, and ANA leaders and CMA members have been there to give nursing's perspective.
ANA President Mary E. Foley, MS, RN, spoke in support of the standard at the May hearing held in Washington, DC, but with several caveats. ANA wants OSHA to require health care facilities to eliminate hazards from nurses' workplaces now -- before any more RNs suffer MSDs. Under the current proposal, health care facilities would not be required to evaluate and institute ergonomic changes until an OSHA "recordable" injury occurs and is reported.
ANA also wants to ensure that health care facilities are required to take a comprehensive approach to evaluating RNs' workplaces for ergonomic hazards -- looking beyond just reported back and shoulder injuries.
"In patient care settings, individual jobs may be quite varied," Foley testified. "Certain jobs, particularly in the operating room and radiology, have specific risks associated with hands and wrists."
She also called on OSHA to require health care facilities to provide ergonomics program training annually, as opposed to every three years. And, she said, nurses must be included in the process of identifying MSD hazards and evaluating engineering controls to prevent them.
OSHA wants to implement the standard by the end of the year, but groups like the American Health Care Association and the U.S. Chamber of Commerce have been working feverishly to weaken or eliminate this regulatory measure. Opponents claim that compliance-related costs would be overly burdensome, and ergonomic controls, such as lifting devices, would remove the human touch from nursing care.
Most nurses think neither argument holds water. They say that patients feel more secure when nurses use assistive devices during transfers. They also contend that making their workplaces safe will cost their employers less in the long run than constantly having to pay workers' compensation benefits and expenses related to recruiting and training new employees. (During the ergonomics hearings, OSHA identified more than40 health care facilities of various sizes in 14 states that have voluntarily and successfully implemented ergonomics programs -- so it is possible.)
The final piece
For nurses to be safe on the job, they need to know what can hurt them. They need to be educated about the signs and symptoms of MSDs as the OSHA ergonomics standard would require. And they need a clear and non-punitive process in place for the early reporting and treatment of their signs and symptoms, which initially can be very subtle.
Too many RNs still are not aware of the effect that repetitive stress motions have on their overall health or believe having aching muscles and joints just comes with the territory. Add in the short-staffing nurses face today, and it's a custom-made recipe for workplace injuries. Taking the time to get an assistive device or wait for help before attempting a patient lift is one of the best injury-prevention strategies nurses have, but it's a hard one for most RNs to embrace.
Shogren said that when she speaks to nurse groups, she often gives them this scenario: Two nurses are working the night shift when a 180-pound patient falls out of bed. The patient requires a four-person lift. What should the nurses do? Most nurses attending Shogren's workshop will say that the two nurses should put the patient back in bed themselves. She says they should wait until two more staff arrive to help.
"Nurses don't understand that they don't have to put themselves at risk," Shogren said. "They have the right to protect themselves, and it doesn't mean they are 'bad nurses' when they do."
Susan Trossman is the senior reporter for The American Nurse.
Preventing workplace injuries
1. Evaluate all patients first and then wait for appropriate assistance before attempting any lift. Elicit as much of the patient's help in transfers. They might help more than you think.
2. Eliminate lifting whenever possible. Learn how to use assistive devices and other engineering controls properly and use them.
3. Take the time to raise beds and other equipment to the proper working level, and work with physical therapy to learn lifting techniques using proper body mechanics.
4. Build awareness among co-workers and administrators that repetitive stress motions can lead to musculoskeletal injuries.
5. Insist that assistive devices are available and easily accessible, and work with management to purchase new equipment based on nurses' evaluations.
6. Report a suspected injury right away, have it documented and keep track of your workers' compensation case.
7. Work with your constituent member association (CMA) to pass staffing legislation.
8. Write to your congressperson or senator in support of the OSHA ergonomics standard. For their contact information, visit ANA's website at www.NursingWorld.org, and go to "CapitolWiz."
9. Negotiate strong contract language and use it. Check out California OSHA's "A Back Injury Prevention Guide for Health Care Providers" on the web at www.dir.ca.gov/DOSH/dosh_ publications/index.html, and to learn more about the proposed ergonomics standard, go to osha-slc.gov/ergonomics.standard/overview.html.
Ergonomic practices at work
Joanne Waldron, RN, works in the emergency department of a rural Minnesota hospital with a patient population that is largely older and physically and medically challenged. As a result, they are more fearful and more difficult to move, often requiring complete lifts. Waldron is the only RN in the ER during her shift.
She frequently finds herself in awkward positions, such as trying to transfer an elderly, weak patient out of the back seat of a car into a wheelchair without the wheelchair accidentally scratching the car. She also transfers patients by herself back into cars and on and off carts and X-ray tables. Sometimes the Minnesota Nurses Association member will grab a physician, X-ray technician or any able body to help.
At a recent MNA meeting, Waldron met with a group of other ER nurses to share the types of equipment and methods that help them prevent injuries, as well as those that do not. The ER nurses most often use slide boards and regular flat and draw sheets to help them lift, and they felt these methods generally worked well, Waldron said. In her case, her facility uses disposable sheets, which can't be used for lifting. One nurse described a hydraulic lift that keeps the patient flat during the transfer and is good for moving heavy patients.
Waldron described a lift used at an area long-term care facility. It has a foot rest and a place for the patient to hold onto, so the patient feels more secure during the transfer. Also, because it's a battery-operated, hydraulic system, the patient is transferred smoothly. Carts also can make or break a safe workplace. In Waldron's facility, one of three carts in the ER can be raised and lowered to suit the transfer, so the patient doesn't have to step onto a stool first. It also has braking and steering pedals at either end.
At another facility, a nurse described a new cart that has L-shaped handles at the head, which makes it easier to steer, she said. Waldron's hospital has made some other ergonomic changes house-wide. For example, nurses now have two different charting levels, where they can comfortably write standing or sitting in "decent" chairs, Waldron said. The linen hampers are now on wheels, and nurses no longer are required to lift the laundry bags into larger bins.
Waldron also saw another change in the dialysis unit where she used to work 10 years ago and continues to fill in as needed. It's a change she's personally welcomed. While she was working there full time, she began to suffer from lower back pain from repeatedly bending at the waist to wash the dialysis machines, put in needles and take blood pressures on roughly six patients every 30 minutes. She also started to develop carpal tunnel syndrome from having to pump up the sphygmomanometer so frequently. Nurses linked pumping up the manual BP machines with carpal tunnel syndrome and ultimately convinced the administration to replace the devices with automatic machines.
At one of the Nebraska hospitals where Catherine Parker, MSN, RN, works, the staff is getting ready to pilot an assistive device that is powered by a motor and requires a tracking system installed in the ceiling and walls of the patient's room. The patient wears a harness and can be completely lifted or supported while walking anywhere in the room where there are tracks. "We'll be the first acute care facility in the U.S. to use it," Parker said. "We're hoping patients will feel more secure, and that we'll have a successful trial."
also described the availability of some innovative beds
The key, according to Minnesota Nurses Association Labor Relations Staff Specialist Elizabeth Shogren, RN, is to have enough assistive devices on hand and easily accessible -- not down the hall a half a block.
A weighty issue
nurses report that their patient-loads are literally heavier than ever
before. That certainly was the case
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