Patient handling injuries are common among health care workers and the risk of injury increases with the number of patient handling tasks performed (Concha-Barrientos et al., 2004 and U.S. Department of Labor, 2005). Back pain is also prevalent among nurses and other health care workers (Bejia et al., 2005, Bos et al., 2007, Engkvist et al., 2000, Landry et al., 2008 and Maul et al., 2003). A meta-analysis reported that the annual incidence of low back pain among patient handling nurses was between 40% and 50% (Hignett et al., 2003). Studies of back-related workers' compensation claims reveal that nursing personnel have the highest claim rates of any occupation and are among the highest at risk for musculoskeletal disorders that require medical treatment or that produce lost workdays (Bonauto, Silverstein, & Adams, 2006). A high prevalence of musculoskeletal injuries (MSI) also contributes significantly to high patient care cost and to the shortage of nursing personnel (Bonauto et al., 2006 and Concha-Barrientos et al., 2004).
In an extensive review of studies dealing with the relationship between low back disorders and ergonomic work factors, evidence for an association of low back disorders with lifting was reported and a positive dose-response relationship was found Bernard et al. (1997, July). All manual transfer and repositioning techniques pose an increased risk based on spinal loading Marras et al., 1999 and Zhuang et al., 2000). Patient handling activities subject health workers to high biomechanical loads (Marras et al., 1999 and Zhuang et al., 2000). If standard manual patient handling techniques continue to be used, possibly because they are more time efficient, then such techniques can be improved to reduce the biomechanical hazard (Nelson, Lloyd, Menzel, & Gross, 2003). Reducing the risk for MSI related to patient handling requires not only the reduction of biomechanical forces involved with each activity, but also the reduction of overall exposure to patient handling. Frequent lifting has been shown to be associated with earlier onset of back injury compared to infrequent lifting, irrespective of nursing occupation (Stobbe, Plummer, Jensen, & Attfield, 1988). Other tasks such as moving occupied beds, moving other heavy equipment, and holding patient limbs while applying anti-embolism stockings, add to the biomechanical stresses experienced by nursing personnel (Waters, Nelson, & Proctor, 2007). Studies have suggested that the implementation of ceiling lifts may reduce musculoskeletal injuries and that they may pay for themselves through a reduction of injury claims (Chhokar et al., 2005, Ronald et al., 2002 and Zhuang et al., 1999). Since an aging population has created the need for proactive injury prevention in health care workers and patients/residents have become heavier over time, facilities have purchased additional patient handling equipment and have implemented body mechanics training. However, the nature of the patients being transferred is not a useful predictor of shoulder and back injuries in nursing personnel (Myers, Silverstein, & Nelson, 2002). Many articles also suggest that education and training alone, without work modifications, does not decrease the number of occupational low back injuries (Edlich et al., 2005, Garg, 1999, Johnsson et al., 2002 and Videman et al., 1989). In contrast, several studies, including our previous research (Black, 2008) have shown that ergonomic interventions are effective in reducing the risk of injury.
MSI prevention interventions target four domains: (a) elimination of risk factors (exercise programs), (b) engineering controls (lift team, lifting devices and equipment), (c) administrative controls (no-lift policy), and (d) training/education (Stetler, Burns, Sander-Buscemi, Morsi, & Grunwald, 2003). Several studies have shown that the decreases in injury rates correspond to implementation of injury prevention measures, the provision of lifting equipment, MSI prevention programs, and return to work programs (Collins et al., 2004, Evanoff et al., 2003, Garg, 1999, Hartvigsen et al., 2005, Li et al., 2004, Nelson et al., 2006, Owen et al., 2002, Ronald et al., 2002 and Yassi et al., 2001). It had also shown that the intervention program increases in caregiver job satisfaction and reduces workers’ compensation injury rates (up to 61%), lost workday injury rates (up to 66%), restricted workdays (up to 38%), and the number of workers suffering from repeat injuries (Collins et al., 2004, Collins et al., 2006, Garg, 1999, Nelson, Owen, et al., 2003 and Tiesman et al., 2003).
A Transfer, Lifting and Repositioning (TLR) program may prevent injuries while performing one type of maneuver and not another depending on the emphasis of the intervention. Also, some patient handling maneuvers may be more stressful, pose a higher risk of injury and thus have a greater potential for improvement. Ronald et al. (2002) found no significant change in overall MSI rates or repositioning MSI injury rates, but did see a significant reduction in injury rates related to transferring and lifting injuries. The lack of improvement in overall MSI rates in the Ronald et al. study may have been due to the mild changes that their intervention made, that is, changes in mechanical lift type, the implementation of a new policy encouraging the use of transfer belts, and a “no manual lifting” policy. Collins et al. (2004) reported a more detailed analysis of patient handling tasks associated with injuries. Post intervention reductions were observed for injuries associated with unclassified transfers, bed to chair and chair to bed transfers and turning/rolling, toileting or lifting a patient off the floor, breaking a resident's fall and repositioning in bed. Garg, Milholland, Deckow-Schaefer, and Kapellusch (1999) studied the long-term effect of “zero-lift program” adopting participatory-team approach with modern, battery operated, portable hoists and other patient transfer assistive devices. The Garg et al., 2007 and Garg, 1999 studies showed improvements in patient comfort and safety, and less soreness and tiredness at the end of their shifts among nursing personnel.
Although research suggests the effectiveness of multi-factor injury prevention interventions on reduction of MSIs among health care workers, little is known about the risk of repeated injury after a multi-factor TLR intervention program among health care workers. Therefore, the present study investigated the risk of repeated patient handling injuries following the implementation of a multi-factor injury prevention program on musculoskeletal disorders among health care workers. The result of this study will contribute to our understanding of potential sustainability of a multi-factor TLR intervention on reducing MSI injuries, to tracking whether TLR program are working in the long-term, and enhancing subsequent intervention program for continuous improvement. Evidence of the effectiveness would also provide further justification for the cost of the multi-factor injury prevention program.
