By Derek Morgan
The COVID-19 pandemic has increased the mental and physical demands on our frontline healthcare workers. In what was already known to be a physically and mentally demanding work environment, staff are now working longer hours to curb workforce shortages, experiencing higher patient-to-nurse ratios, and coping with increasing hostility from patients/family members and the public. Exposure to these conditions can create greater psychological stress and physical strain on an already exhausted workforce. Having to perform demanding tasks such as transferring or repositioning patients during times of stress and fatigue can also predispose staff to musculoskeletal disorders (MSD) and overexertion injuries.
An MSD or overexertion injury can occur when the physical demands of a task exceed the capacity of a worker. With an overexertion injury, an imbalance is created between what needs to be done and the worker’s capabilities, causing an overloading of tissues and resulting in damage (injury). Repeated exposure to similar, less dramatic imbalances overtime exposes muscles, tendons, ligaments, joints and spinal discs to cumulative trauma, which, with insufficient rest and recovery, can increase the risk for an MSD. Traditionally, healthcare workers have faced a higher risk of injury from MSD, especially during tasks involving the lift, transfer or repositioning of patients.
Patient handling is a common activity in healthcare which can be a physical burden for staff due to the frequency of lifting/lowering or pushing/pulling movements that require high forces and awkward or static postures. Back injuries and related muscle strains of the upper body are common injuries seen amongst caregivers. Biomechanical demands such as force, posture and repetition/duration are often regarded as the primary culprits for MSD and overexertion injuries. However, psychosocial work factors (e.g., work pressure, shift work, lack of control, environmental stressors) and work organization factors (e.g., how work is structured) can also influence the risk of injury. Psychosocial work factors can alter physiological and behavioural responses whereas work organization factors can inadvertently increase exposure to greater physical demands.
Although we will not explore the interaction between biomechanical, psychosocial and work organization factors here, it is important to acknowledge that the etiology of an MSD can be multi-factorial. This can present a challenge when identifying and controlling associated hazards, particularly when it comes to patient handling activities, but interventions that incorporate multi-components and various control strategies can be effective.
A common, and often required, control measure is the implementation of a comprehensive patient handling program which addresses equipment, policies/procedures and training, among other elements. Yet, despite the presence of such a program, healthcare workplaces still face challenges and barriers, including fewer staff available, larger people with less mobility, improvised settings and satellite worksites.
So, what can we do today to support safe patient handling activities amid such challenges?
A Participatory Approach
A participatory approach is used to engage and empower frontline staff, managers and internal subject matter experts to make decisions and solve problems as a team. This can be initiated at the manager level during huddles or team meetings. Internal subject matter experts have also been successful utilizing this approach. When using this approach, workplace parties become actively involved in the recognition, assessment and control of hazards in the workplace. During periods of change and growing complexity, a participatory approach can be used to address new or emerging hazards along with potential control strategies. The resulting benefits include hazard control measures that are applicable and feasible for the environment and its conditions. Moreover, as communication is encouraged and staff have input and gain control over their work, this approach also has the potential to mitigate psychosocial work factors. A participatory approach can therefore serve a dual purpose as an MSD intervention.
The Institute for Work and Health has reported encouraging findings using a similar approach applying a peer-coaching model. In this program, workers were designated as peer coaches who received training on patient handling equipment and associated procedures. Upon training completion, these peer coaches provided both formal and informal frontline coaching to their nursing peers. When the use of equipment was paired with this coaching and mentorship support, the resulting impact was a reduction in injuries. This is a great example of how leveraging knowledge and skills from within can support and sustain safe patient handling practices. Although this example requires necessary resources, which may be under extreme pressure in our current environment, it reinforces the essence of a participatory approach which engages and harnesses frontline knowledge and experience.
Assessing patient needs
An effective patient handling program requires a thorough and comprehensive patient assessment. Initial and ongoing assessment of patient mobility determines the type of patient handling equipment or procedures that should be used and the level of staff assistance required to safely move a patient. It is essential to continually review patient mobility status to ensure the frequency of handling tasks, equipment and environmental issues that may impact safe patient handling tasks have been properly estimated and identified.
A plan to communicate and document patient mobility findings and status must also be considered. Ensuring there is an efficient and consistent way to document each assessment and communicate those findings to caregivers establishes consistency in handling tasks. This could include the use of patient whiteboards, charts or bed signage.
Re-assessment of the patient’s condition should also be done throughout the day at point of care to capture changes in mobility status. Throughout the day a patient could become fatigued, for instance, which could alter the prescribed equipment or procedures.
A major objective of a safe patient handling program is to reduce the physical demands associated with lifting, transferring and repositioning patients. The most effective way to reduce the physical demands is to introduce engineering controls such as patient handling assistive devices and technologies. Ensuring access and availability to necessary equipment and devices protects staff and promotes quality care. Availability of the equipment and accessories should be clearly communicated. Device location (storage) should be considered along with labelling of equipment; slings should also be inventoried to ensure adequate supply. If equipment is not easily available, it will not be used.
Equipment must always be in good working order to avoid unnecessary or adverse conditions. As discussed with equipment availability, if equipment is not maintained and functional, it will not be used. A preventive maintenance program must be in place. Regular inspections of all equipment such as transfer or lift devices and their attachments must be carried out. Any unsafe equipment and/or sling should be removed from service and labelled immediately for repair where possible. A clearly defined and communicated process on what to do when equipment is found to not be working should also be established.
When equipment or other devices have been redeployed to other areas of the workplace or off-site, it’s imperative that staff complete pre-use checks for mechanical devices and accessories such as slings. Tip sheets can be very helpful to ensure key aspects of the equipment are reviewed.
Model of care
Consider the use of non-clinical staff to help ease the burden on nursing staff. A recent publication found the redeployment of non-nursing clinical staff can be an effective strategy to leverage available resources while reducing nursing burden. This initiative deployed physical therapists and occupational therapists to partner with ICU nurses to help provide daily care for severely ill patients with COVID-19. This team-based approach was found to reduce the burden on nurses while maintaining standards of care.
Use of a similar model to support patient handling practices would require necessary customization to effectively support patient populations, situational needs and adherence to professional practice guidelines. However, with staff redeployment and COVID-19 surges, an effective use of resources may give rise to alternative strategies of care.
We know that MSD can be cased by many factors in the workforce. The interaction between biomechanical, psychosocial and work organization factors can create ideal conditions for MSD and overexertion injuries. Addressing these factors in combination can yield the greatest impact, but may never eliminate the risk associated with patient handling activity. In healthcare environments, a safe patient handling program is an integral component of the overall occupational health and safety program. Standardizing our approach to patient handling techniques and associated measures by utilizing staff knowledge, ensuring access to proper, functioning equipment, and good communication/training can help address the physical demands associated with these tasks.
For more information on how to enhance your current safe patient handling program, access Public Services Health & Safety Association’s Handle with Care resources at pshsa.ca/ergonomics.
Derek Morgan MHK, CRSP, CHSC is a health and safety consultant with Public Services Health & Safety Association. Derek has been with the organization since its inception supporting organizations in the health and community care sector.