AMA Journal of Ethics^®

Introduction

Being a health care professional is a tough job. Anyone who has spent time in health care knows firsthand the multitude of responsibilities and pressures these professionals field every workday. Whether it is overseeing a patient’s intake, coordinating care with other staff, facilitating a patient’s rehabilitation, or cleaning patients and administering medications, the work of health care is physically and mentally demanding.

In recent years, the strains of one particular job duty—patient handling, which typically involves manually lifting, moving, or repositioning patients—have become dangers, increasingly severe and all too common. Changes in working conditions have led to a greater likelihood of a musculoskeletal injury for health care professionals than for workers in all industries [1]. These injuries—often to health care workers’ backs, necks, legs, and arms—are frequently devastating, severely hampering the ability of a nurse, for example, to carry out routine duties or ending her career entirely [2, 3].

Since researchers began adducing evidence of just how widespread these injuries were in nursing personnel and other staff in the 1990s [4], several states have sought to address the problem of nursing-specific musculoskeletal injuries through laws and programs. Laws enacted to better protect nurses, nursing assistants, and orderlies, however, have met with mixed success.

Working Conditions that Lead to Injuries

The rise in workplace injuries among nurses and staff stems from a combination of three trends. First, demands on the bodies of nurses and hospital staff have been intensified by an ongoing shortage of nurses around the country that began in 1998 and worsened due to national economic instability beginning in the early 2000s [5]. Although the number of positions in the health care sector has grown since 2001 and the number of nurses entering the labor market has increased, it is estimated that there could be as many as 260,000 unfilled nursing posts in the US by the year 2025 [5]. With fewer staff members, nurses and other personnel must care for more patients and execute more duties.

Second, rising rates of obesity in the US mean that health care professionals are caring for patients who are heavier and sicker [2]. Nurses and staff must regularly maneuver patients who weigh 300 pounds or more and whose limbs alone can weigh 60-70 pounds [2].

Third, because hospitals are treating patients with comparatively minor procedures and health issues in outpatient clinics and reserving hospital beds for those with serious conditions requiring around-the-clock care [2], staff members are encouraged to help patients get out of bed and move as often as possible, even though these patients might have limited ability to move under their own power [2]. In assisting patients with moving around their rooms, repositioning them in their beds, and other tasks that require physical support of patients, people who do hour-to-hour care face many possibilities for injury.

The Injuries that Result from Patient Handling

The stories of nurses, nursing assistants, and orderlies who have experienced an injury while handling a patient often follow a common pattern: one moment, the staff member is lifting or turning over a patient and, the next, hears a pop and feels a sharp pain running down his or her back and legs—the signs of a collapsed disc [6]. As one nurse put it, “It felt like hot tar was just going down my spine, into my butt” [3]. Hours later, the pain is so consuming that walking feels impossible, and what lies ahead could be months, if not years, of physical rehabilitation, surgeries, and medications that might or might not alleviate the suffering.

Researchers have found that patient handling injuries are not in fact abrupt, freak instances but the result of compounded damage from weeks, months, or years of using lifting techniques hospital staff have been trained to execute [6]. While supposedly protective, in actuality these maneuvers do little if anything to protect staff when they must bend over patients repeatedly, lift patients while reaching, or shift patients’ unevenly distributed weight [7].

Safe Patient Handling Laws

Political and legal attention to nursing and staff injuries began in the 1990s, when federal researchers at the National Institute for Occupational Safety and Health (NIOSH) investigated back injuries in nursing home staff [4]. What NIOSH found, and what the Bureau of Labor Statistics continues to report [2], is that nursing assistants and orderlies suffer back and other musculoskeletal injuries at three times the rates of construction workers and that personal care aides, nursing assistants, and orderlies have more injuries than people in any other occupation. In 2003, the American Nurses Association launched the national Handle With Care campaign to “build a health care industrywide effort to prevent back and other musculoskeletal injuries” [8].

Spurred by these advocacy efforts [9], 11 states have enacted safe patient handling laws or promulgated rules and regulations to address and prevent workplace injuries to nursing staff: Ohio, Texas, Washington, Rhode Island, Maryland, New Jersey, Minnesota, Illinois, New York, Missouri, and California [9, 10]. Except for Ohio, all of these states’ legislation has required health care facilities to establish comprehensive safe patient handling programs [9].

These programs include the development of policies for handling patients, the creation of guidelines for appropriate training, and the acquisition of necessary equipment [9] designed to help health care professionals safely lift and move patients. In addition, these programs call for the collection and evaluation of data in each health care facility to better understand and address the policy and equipment needs of specific patient care environments [9]. All decisional authority for these actions is to come from a safe patient handling committee composed of health care workers who provide direct patient care at a designated facility and specialists with expertise in implementing and overseeing safe patient handling programs [9].

Some of these state laws also include additional features. For example, in Washington State, the safe patient handling law mandates that hospitals obtain needed lifting equipment, for which they will receive a tax credit [11]. In New Jersey, the state law sets out a nonretaliation provision stipulating that a facility cannot take legal action against a health care worker for refusing to lift or move a patient due to either a reasonable concern about patient or worker safety or a lack of appropriate training or access to safe lifting equipment [12]. Ohio’s legislation is different from that of the other ten states; it created a long-term, interest-free loan program for nursing homes to use to purchase and install equipment and fund staff education and training that discourages staff from manually lifting patients [13].

When safe patient handling laws are passed and the programs are actually implemented in health care settings, the results are impressive. When 31 rural community hospitals in Washington State implemented a “zero lift program,” replacing manual patient lifting with lifting equipment and devices, patient handling injury claims decreased by 43 percent [14]. Two years after instituting a safe patient handling program, a medical center in New Jersey saw a 57 percent reduction in workplace injuries and an 80 percent reduction in lost workdays [15].

These significant drops in both the number and the severity of injuries yield significant financial savings, too. Although the Occupational Safety and Health Administration (OSHA) acknowledges that the costs of instituting safe patient handling programs can be significant (e.g., equipment, training), it cites numerous studies demonstrating that the capital investments in these programs can be recovered in less than five years [16]. At Stanford University Medical Center, an $800,000 safe lifting program resulted in a five-year $2.2 million net savings, approximately half of which came from a decrease in worker compensation claims and a reduction of pressure ulcers in patients [17]. And, in New York, the largest health care provider in the western part of the state made a full return on its $2 million investment in three years and saved $6 million in patient handling injury costs over seven years [18].

Obstacles to Establishing Safe Patient Handling Laws and Programs

Unfortunately, resistance to establishing safe patient handling laws and programs and the lax oversight of existing programs continue to stifle their development and implementation.

A 2015 investigative series by National Public Radio (NPR) posited several reasons why safe handling programs are being undermined or loosely monitored. For one thing, the series argued, nurses, nurse assistants, and orderlies are too often considered secondary within the highly hierarchical medical world; although industry groups and associations recognize that nurses and others are susceptible to disabling on-the-job injuries, they do not make responding to this problem an organizational priority [2, 3]. Nurses at some hospitals have reported that their claims have been ignored by administrators and hospital leadership and that they suspect the reason could be financial—specifically, that money paid to an injured worker or used to implement a safe patient handling program is money not spent on infection control measures or other patient care matters [3].

In the case of enacting safe patient handling laws, the NPR series found that opposition to enacting protective legislation has been framed by politicians and hospital lobbying groups in terms of keeping unnecessary, burdensome regulations and “costly mandates” out of the hospital setting [3].

Regarding enforcement of extant laws, officials admitted to NPR that these laws typically have little enforcement power because conducting inspections and assessing adherence to the law requires money, personnel, and resources that many state labor safety departments simply do not have [3]. Even the assistant secretary of OSHA acknowledged the slow uptake and enforcement of these laws, stating that Congress is perhaps best equipped for moving these standards forward by creating a national law on safe patient handling [3].

Congress did act on this matter in December 2015, introducing in both the House [19] and the Senate [20] the Nurse and Health Care Worker Protection Act of 2015, which “requires the Department of Labor to establish a standard on safe patient handling, mobility, and injury prevention to prevent musculoskeletal disorders for health care workers” [21]. Future action on this bill remains to be seen.

Conclusion

Work-related dangers faced by nurses, nursing assistants, orderlies, and other health care workers are real and frequent. With changing patient populations and working conditions, health care workers face unnecessary risks of disabling pain and suffering. Safe patient handling laws and the programs they support offer considerable benefits: reducing the injury rates of the hospital labor force, curtailing injury-related costs, enhancing patient care and safety, and acknowledging the physically demanding nature and overall value of nursing and other health care work.