The Scope of the Problem

Healthcare workers, particularly nurses, are in short supply in the United States, and a high rate of workplace injury in this group contributes to the problem. Occupational medicine providers are in a position to help protect this scarce resource through vigorous advocacy of injury prevention programs. In this article I am focusing on back injuries, which have a particularly high incidence among healthcare workers.

Figures published in the American Hospital Association’s 2001 Trendwatch, indicate that 126,000 nurses were needed to fill vacancies in U.S. hospitals. It is estimated that by the year 2020, there will be a shortage of 400,000 nurses nationwide. Fewer people are entering nursing training programs and the average age of nurses, 43.3 years as of March 2000, continues to rise.

In general, people aged 25 to 45 are most affected by low back pain, and, among nurses, there is also an age-related increase in the incidence of low back pain.

Nationally, it is estimated that 80% of adults experienced low back pain severe enough to cause them to seek treatment and/or modify activities.

Hospitals lead all industries for lost day cases of back pain, and the inciting event for most back injury is patient transfer. Knowing that patient transfer is a high-risk factor should help us focus efforts on prevention.

The following Bureau of Labor Statistics list shows that healthcare workers occupy six of the top ten occupations at highest risk for back injuries.

1. Nurses Aides

2. Construction Workers

3. Garbage Collectors

4. Licensed Practical (Vocational) Nurses

5. Truck Drivers

6. Registered Nurses

7. Health Aides

8. Machinists

9. Radiology Technicians

10. Therapists

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Factors Associated with Work-Related Low Back Pain

Previous workers’ compensation claim for low back pain is a predictive factor. While previous back injuries may be revealed during a preplacement physical assessment, acting on that information requires quite a bit of thought. Due to the vagaries of predicting future back injuries, and to legal constraints imposed by the Americans with Disabilities Act (ADA), few people will actually be screened out of a job because of a previous back injury. The preplacement exam is perhaps best viewed as an opportunity to discuss preventive strategies with the prospective employee.

Psychophysical demand refers to the effort perceived by an individual while performing a task and is felt to indirectly measure aerobic demand, tissue tolerance to strain, physical capacity, and work style.

Overlooked, and often under appreciated, is the importance of psychosocial issues at work. These include job satisfaction, performance reviews, and perception of the work environment. Experience seems to bear out the common sense assumption that a pleasant work environment, which is free of conflict and harassment and where help is available to employees when needed, may reduce injury and minimize the effect of those injuries that do occur.

Biomechanical demands are measurable stresses and strains placed on the body by physical activities such as lifting and bending. In the case of the lumbar spine, the best studied forces include peak shear force between vertebrae, and peak and cumulative lumbar compression forces. These forces are determined largely by the amount of weight lifted, pushed, or pulled and the relationship of that weight to the employee’s body. These biomechanical factors are the basis of the NIOSH lifting formula, which suggests that the average individual is at risk for back injury when lifting over fifty pounds, even when using good body mechanics.

The Importance of Ergonomics

Ergonomics is the study of the relationship of people to the physical activities they perform. Ergonomic considerations include force, repetition, awkward postures, static postures, motion (acceleration, complex motions), and recovery time (consideration of fatigue and cardiovascular fitness). It places an emphasis on work practice, biomechanics, work environment, and tool use.

Prevention is Key

Primary prevention focuses on the avoidance of injury. Secondary prevention stresses early detection (of conditions such as minor aches and pains) and intervention to prevent progression to more serious problems. Tertiary prevention, such as traditional medical care, attempts to minimize the effect of an injury that has already occurred, and may include medications, therapy, time out of work, and alternate duty. Currently, our injury management system emphasizes tertiary prevention, but we should make efforts to drive the system toward primary prevention.

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Primary prevention may include engineering controls such as:

Mechanical assistance devices, though expensive, costing on average between $5,000 and $6,000, have the potential to eliminate injury. There are barriers to use that need to be addressed administratively, including proper training of employees in use of the equipment, making equipment easily accessible, ensuring batteries are kept charged, and emphasizing the use of the devices even when employees are rushed for time and feel manual lifting is simply quicker.

Slide boards are inexpensive, low tech, patient transfer devices. Proper use requires planning, but can take advantage of gravity, allow the healthcare worker to stop in mid-transfer, and permit one- or two-person assists. Similarly, gait belts are inexpensive, but provide a good connection to the patient and require good balance and body mechanics to use. Transfer discs are particularly helpful when a patient cannot stand or step well as in Parkinson’s disease or multiple sclerosis. It is necessary to stand close to a patient, keep the back straight, and maintain balance during transfer.

Administrative approaches to prevention include adequate staffing, which increases the ability to get help when needed and reduces hurrying and stress. It is important to note that the employee’s perception of staffing levels may be even more critical than more objective measurements of those levels. All employees should be adequately trained in lifting and moving, although training alone has not consistently been shown to reduce back injury. In order to make training more effective, it should occur not only during new employee orientation, but also on a regular basis thereafter. It is perhaps most effective as part of a return-to-work plan for people who have suffered back injuries.

A relatively new concept in the administrative approach to injury reduction is that of lift teams. The theory is to transfer risk from many people to a few selected, well-trained individuals. Generally, these two-person teams are medically screened, thoroughly trained, and employ mechanical lift devices. Although reviews have been mixed, they have been generally favorable in terms of back injury reduction and in cost-benefit considerations.

Lastly, physical conditioning appears to play a role in reducing the frequency and severity of back injury. A good physical conditioning program should address flexibility through some type of daily stretching routine, cardiovascular conditioning (e.g., though a low impact aerobics program about every other day), and strength training, especially addressing the trunk muscles.

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Summary

Injuries, particularly back injuries, among healthcare workers pose a major problem for the workplace and contribute significantly to our current nursing shortage. Injuries have multiple causes, requiring a multi-faceted approach to prevention. Although occupational medicine providers cannot singularly solve this shortage, they can contribute toward reducing it by partnering with hospitals, nursing homes, and home care agencies to strengthen preventive measures.

[Editor’s Note: Occupational health programs are encouraged to partner with their healthcare clients by presenting information such as this article as part of an educational program. Additional resources can also be found at:

www.aha.org (American Hospital Association)

www.ncsbn.org (National Council of State Boards of Nursing)

www.sreb.org (Southern Regional Education Board)

www.gao.gov (General Accounting Office)

www.bls.gov (Bureau of Labor Statistics)

www.aacn.nche.edu (American Association of Colleges of Nursing)

jama.ama-assn.org (Journal of the American Medical Association)]