Crit Care Nurs Clin N Am 19 (2007) 241–245

Index
Note: Page numbers of article titles are in boldface type.

A tasks in, 235, 237

Air-assisted devices, for lateral transfers, 179
American Nurses Association, ‘‘Elimination of
Manual Patient Handling,’’ 214, 216
Antiembolism stockings, devices for, 209
risk for and prevention of musculoskeletal
injury with, 138–139
Association of periOperative Registered Nurses
(AORN), ergonomic guidelines of,
131–132
for lateral transfer, 134–135
problems and solutions associated with,
236–237
Bed design, for bariatric patient, 238
Bed making, musculoskeletal injury in,
137–138
Bed mattress, for bariatric patient, 238
Bed space. See Space.
Bed-to-chair transfers, 181–182
Body mechanics, in manual handling, 197

B C
Ceiling lifts. See also Lift(s).
Back injuries. See also Low back injury and
for bed-to-chair transfers, 181–182
problems.
for lateral transfers, 177–178
incidence of, 213
for limb holding, 184
Bariatric patient, education for care of, 239 for repositioning in bed, 181
pericare of, technological solutions for, for toileting in bed, 183–184
183 in University of Iowa Hospitals and Clinics
program, 217, 219
Bariatric patient handling, 223–240
admission process and, 227, 231 Change, behavior analysis techniques for, 202
case study, 230–235 case studies of, 201
admission, 231 implementation of, in Netherlands program,
equipment provided, 237–239 209–210
history, 230–231 incentives for, 201–202
systems status and care in, 231–235 leadership role in, 201
tasks and daily care plan, 237 models for, 198–200
emotional support for nursing personnel motivation for, 200–201
and, 239 resistance to, 202–203
equipment for, in case study, 237–239 training for, 200
patient assessment and equipment fit, 238
Change process model(s), building trust and
resources for, 224–234
emotional commitment, 198
algorithms, 224, 229–233
collaborative, 199
assessment tool, 234
communication in, 199–200
equipment pool, 224
social marketing and, 199–200
injury prevention training support, 227
comparison with nursing process, 198–199
policy and procedure manual,
leadership top down, 198
224–228
work procedures, 224 Chronic pain, psychosocial factors in, 147–148
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242 INDEX

Coaches, for assistive equipment use, in study of medical ICU in Las Vegas hospital,
University of Iowa Hospitals and Clinics 156
program, 219, 221 study protocol, collection of baseline data, 157
in safe handling program, Netherlands, 209, identification of high-risk tasks, 157, 161
211 identification of high-risk units, 157
presite visit data on high-risk units, 157–159
Coaching, for safe patient handling, 202, 209, 211
team site visit for ergonomic assessment, 160
Compressive forces, in patient handling, unit summary sheet, 160, 162
biomechanical evidence for, 188–189
Ergonomics, in acute care, 204
reduction of, with lifting devices for patient
handling, 189, 191 Ergonomics program, sustaining staff nurse
support for, 197–204
Compressive forces, in patient handling, 188–189
change process models and, 198–199
Coping skills, musculoskeletal disorders pain and coaching in, 202
disability and, 148 communication in, 198–199
incentives for, 201–202
motivation in, 200–201
D
peer leaders/unit champions for, 202
Disability and return to work, psychosocial social marketing for, 199–200
factors in, 147–148 training for, 200

E
Education, for bariatric patient care, 239 F
for patient handling tasks, 190–191 Floor-based lifts, for bariatric patient pericare,
183
Equipment, for bariatric patient, 238–239 for bed-to-chair transfers, 182
ErgoCoaches, in safe patient handling program, Friction-reducing sheets, for repositioning in bed,
in Netherlands, 209, 211 180
Ergonomic assessment of critical care unit,
155–165
CCU background, 155–156 H
CCU/ICU background, patient-focused High-risk tasks, musculoskeletal disorders from,
vs. health care worker protection, 131–143. See also Musculoskeletal disorders
156 (MSD), tasks with high risk for.
high-risk patient handling tasks, prioritization on CCU, identification of, 161
of, 161 space reqirements for. See also Space
musculoskeletal disorders risks in vs. in nursing requirements, for high-risk tasks.
homes, 163 space requirements for, 167–175
presite visit unit profile, equipment inventory, technology solutions for, 177–186
159 in bed-to-chair transfers, 181–183
patient population/staffing/equipment use, in lateral transfers, 177–179
158–160 in limb holding, sustained, 184
space/maintenance/storage, 158 in patient transport, 184–185
recommendations, change from patient focus in repositioning, 179–181
to nurse/patient safety dyad, 163 in toileting in bed, 183–184
dissemination of information on
musculoskeletal disorders incidence, 164
education about need for assistive I
equipment, 163 Injury(ies), incidence rate for, 187
use of Lewin’s model of planned change, low back, 188–189, 188–190
164 overexertion, 187, 213–214
recommendations for, formulation of, 160, 162 overuse, 214
risk analysis of, 160 unreported, 187–188
 INDEX
Iowa model, for safe patient handling, 213–222
baseline data collection for, 217–219
dissemination of results, 220–221
education of staff, 219
equipment selection in, 218–219
equipment trials and evaluation, 217
expert opinion and, 216–217
lessons learned, 221
management support and, 219
outcome evaluation, 219–220
patient outcomes, 220
pilot the change, 217
policies and procedures development in, 219
practice guidelines and implementation of
change, 218
priority of topic, 216
research and related literature in, 216
securing financial support for, 217–218
staff outcomes, 220
team formation for, 216
unit assessments, 217
vendor fair for equipment, 217
knowledge-based triggers for, ANA
‘‘Elimination of Manual Patient Handling,’’
214, 216
OSHA Ergonomics OSHA Guidelines for
Nursing Homes, 214
VA Patient Care Ergonomic Resource Guide,
214
of evidence-based practice for quality care,
214–215
problem-based and knowledge-based triggers
for, 214
J
Job satisfaction, in reduction of musculoskeletal
disorders, 148
Job strain, as musculoskeletal disorders risk
factor, 148–149, 189–190
L Minimal stand assist device, in University of Iowa
Lateral transfer, 208–209. See also Transfers.
air-assisted devices for, 179
Association of periOperative Registered
NursesÕ guidelines for, 134–135
ceiling lifts for, 177–178
friction-reducing devices for, 179
mechanical transfer devices for, 178
physical demands of, 134–135
safe performance of, 136
space requirements for, 177–179
Lateral transfer devices, in University of Iowa
Hospitals and Clinics program, 218–219
243
Lifters, for transfers, 208–209
Lifting, in critical care, 192
weight limitations for, 213
Lifting/moving, heavy objects or equipment, risk
for and prevention of musculoskeletal injury
in, 139–141
Lift(s), ceiling. See Ceiling lifts.
floor-based, 182–183
for bariatric patient, 238
sit-to-stand, 182
Lift team, decrease in low back injuries with, 191
Limb support, ceiling lifts for, 184
in critical care, 192–193
Low back, compressive and shear forces on, in
patient handling, 188–189
perceived stresses on, during lifting and
repositioning, 190
Low back injury and problems, causes of,
188–189
nursing personnel perception of, 189–190
work stress and, 189–190
M
Maneuvering heavy material, guidelines for,
transportation device for, 209
Manual handling, American Nurses Association
and elimination of, 214, 216
of load, NIOSH guidelines for, 205–206
risks with, 213–214
UK regulations for, 214
Manual patient handling, alternatives to, 142
internal loads in, 142
musculoskeletal disorder risk in, 131
Minimal lift program, 187–196
studies of, 191
Hospitals and Clinics program, 218
Musculoskeletal disorders (MSDs), incidence of,
155
pain in, cognitive-behavioral therapy for,
149–150
prevalence of, in Netherlands, 205–206
psychosocial factors in, 145–153
as etiologic agents, 146
case study of, 149–150
disability and return to work and,
147–148
interventions to reduce, 148–149
244
Musculoskeletal (continued )
reduction of, cognitive-behavioral therapy in,
149–150
job satisfaction in, 148
risks for, job strain, 148–149, 189–190
manual patient handling, 131
tasks with high risk for, 131–143
applying antiembolism stockings, 138–139
lateral transfers, 134–136
making occupied beds, 137–138
moving heavy objects and equipment,
139–141
pushing occupied beds, 132–134
repositioning from side to side, 137
repositioning to head of bed, 136–137
N on side, 181
National Institute for Occupational Safety and
Health (NIOSH), weight limits for lifting, 213
O Safe handling program(s). See also Iowa Model.
OSHA, Ergonomics OSHA Guidelines for Nursing
Homes, 214
Overexertion injury, 213–214
costs of, 187
Overuse injury, 214
P preliminary results, 210–211
Patient handling, in critical care, 192
shear and compressive forces in, biomechanical
evidence for, 188–189
Patient handling tasks, education and training for,
190–191
intervention program for, assistive devices in,
191
lift team for, 191
minimal lift program for, mechanical lifts in,
191
perioperative, 192–193
Patient transport, physical demands of, 132–133
powered technologies for, 184–186
safety tips for, 133–134
Positioning. See also Repositioning.
for treatment, 209
Psychosocial factors, definitions of, 145–146
in musculoskeletal disorders, 145–153
case study, 149–150
cognitive-behavioral therapy in reduction
of, 149–150
INDEX
conceptual models of, 146–147
contribution of, research evidence lacking
for, 146
evidence for, as etiologic agents, 146
in disability and return to work, 147–148
R
Repositioning. See also Positioning.
from side to side, 137
guidelines for, in safe handling program, in
Netherlands, 208
in bed, 189
devices for, 180–181
manual, 179–180
in critical care, 192
nursing personnel perception of stresses in, 190
to head of bed, physical demands of, 136
tips for, 137
S
creating culture of change for, 213–222
in Netherlands, analysis of ergonomic situation
and, 205–207
implementing change for, 209–210
observation of ergonomic problems in, 207
peer leaders in, 205–211
physical load exposure and, 206–207
practice guidelines for, 207–209
prevalence of musculoskeletal disorders
and, 205–206
pushing and pulling and, 207
task force for, 207–208
sustaining staff nurse support for, 197–198
University of Iowa Hospitals and Clinics,
213–222
Shear forces, in patient handling, 188–189
Shoulder, perceived stresses on, during lifting and
repositioning, 190
Sit-to-stand lifts, for bed-to-chair transfers, 182
Sling design, for bariatric patient, 238
Social marketing, application to safe patient
handling, 200
for change, 199–200
Space, in ICU, evidence-based practice in health
care architecture and, 168–169
historical perspective, 167–168
recommendations in USA and UK, 168
planning, for bariatric patient, 239
 INDEX 245

Space requirements, for high-risk tasks, 167–175 V

areas, 171
Veterans Administration, Patient Care Ergonomic
functional space experiments, 169–170
Resource Guide, 214
length, 171–173
link analyses for, 170 Veterans Administration Medical Center, Florida,
resuscitation, 169–172 tasks with high risk for musculoskeletal
transfer from bed to bed, 169–172 disorders, 131–143. See also Musculoskeletal
washing and dressing patients, 169–172 disorders (MSDs), tasks with high risk for.
width, 171, 173
for lateral transfer, 177–179
W
Stand assist device, in University of Iowa
Weight limits for lifting, 213
Hospitals and Clinics program, 218
Workload, and patient safety, 121–129
Stresses, on low back and shoulder, nurses
assessment of, systemic, 127
perceptions of, 190
dimensions of, 121–124
cognitive, 122–123
T emotional, 123
Total assist devices, portable, in University of physical, 121–122, 125
Iowa Hospitals and Clinics program, 218–219 quantitative and qualitative, 123–124
Transfers, guidelines for, 208–209 relations between, 124
in critical care, 192 time pressure and, 123
manual, in Netherlands, 206–207 variability of, 124
manual and mechanical, compressive and impact of, on health, 125
shear forces in, 188–189 on patient safety, 126
on quality of working life, 125–126
Transfer(s), lateral. See Lateral transfer. systemic, 126–127
mechanical, 188–189 perception of, 125
Transport, in critical care, 192 sources of, 124–125
of bariatric patient, 238–239 static or postural, 206–207
technological solutions for, 184–185 guidelines for, 208–209

Transportation device, for heavy objects, 209–210 Work-related musculoskeletal disorders

(WMSDs), 131. See also Musculoskeletal
U disorders (MSDs).
incidence rates for health care workers, 131
University of Iowa Hospitals and Clinics. See also
risk for, 131
Iowa Model.
safe patient handling program, 213–222 Work stress, low back problems and, 189–190
 Crit Care Nurs Clin N Am 19 (2007) 121–129

Workload and Patient Safety Among Critical

Care Nurses
Pascale Carayon, PhDa,*, Carla J. Alvarado, PhD, CICb,
Systems Engineering Initiative for Patient Safety
a
Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering,
University of Wisconsin-Madison, 610 Walnut Street, 575 WARF, Madison, WI 53726, USA
b
Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 610 Walnut Street,
575 WARF, Madison, WI 53726, USA

Workload is a major characteristic of the work
environment of critical care nurses [1]. It also is
one of the most important job stressors among
ICU nurses [2–6], which may have negative conse-
quences for nurses and the patients they care for.
An analysis of the Australian Incident Monitoring
Study data for ICUs shows that a nursing staff
shortage may lead to compromised quality of
care [7]. The main cause of nursing staff shortage
was inappropriate staffing for patient load (81%
of the incidents). Insufficient nursing staff was
linked to problems with incorrect matching of pa-
tient needs and staff experience, suboptimal stan-
dard of nursing care and patient supervision,
inadequate supervision of inexperienced staff,
and subsequent inadequate documentation. The
nursing shortage and the resulting understaffing
can create conditions of high workload for critical
care nurses.
A lot of work has been done to develop
measures of workload in ICUs. These measures
often are focused on ICU patient needs, patient
acuity, or severity of illness [1]. These patient-level
measures of workload include the Therapeutic In-
tervention Scoring System [8,9], Nursing Man-
power Use Score [10], Nursing Activities Score
[11], and Comprehensive Nursing Intervention
Score [12]. There is increasing recognition that
measures of nursing workload in ICUs at the pa-
tient level are not sufficient and need to include
* Corresponding author.
E-mail address: carayon@engr.wisc.edu (P. Carayon).
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doi:10.1016/j.ccell.2007.02.001
measures of organizational and system factors
[1,13]. Spence and colleagues [13] identified several
system factors that contribute to nursing work-
load as measured by the Patient Dependency
Score (an estimate of the nursing hours required
for patient care at different levels of dependency).
The most significant factors were related to the or-
ganization of work (ie, organization of managers,
cooperation with doctors, cooperation with peer
nurses, use of relief staff, and planning of shift
schedules).
This article describes the various types of
workload faced by critical care nurses, including
the physical workload of patient handling. The
objective is to show that safe patient handling can
be achieved by examining the entire work system
of ICU nurses and the various types of workload
they experience. The links between workload and
patient safety also are described.
Dimensions of workload
Table 1 shows the various dimensions of work-
load of critical care nurses and provides examples
of each of the dimensions.
Physical workload
Physical workload of ICU nurses not only is
related to nursing practice, including moving,
lifting, and bathing patients, but also to disjointed
supply sources and missing and nonfunctioning
equipment [14]. Disjointed supply sources (sup-
plies or equipment needed for a task located in
ccnursing.theclinics.com
122 CARAYON & ALVARADO

Table 1
Dimensions of workload
Dimensions of workload Definitions and examples
Physical workload Amount of physical work, including patient handling
Cognitive workload Information overload
Time pressure Working under temporal constraints and tight deadlines
Emotional workload Dealing with emotional issues, such as patient death, end-of-life care,
and family demands
Quantitative workload Amount of work
Qualitative workload Difficulty of work
Workload variability Changes in workload: increase in workload (eg, code situation) and
decrease in workload (eg, night shift)

another area of a unit or hospital) and missing or
nonfunctioning equipment require repetitive
travel around units or even to distant locations
in the hospital, such as other patient care units
or the central equipment reprocessing area, add-
ing miles of walking to nurses’ activities.
Almost all critical care nurses find their work
physically strenuous. The physical and ergonomic
layout of ICUs often is poor; the limited space
between patient beds and ICU equipment is
especially problematic. The causes of severest
nurse physical workload distress are lifting, work-
ing in awkward postures, and stooping [15]. With
an increase in bedside procedures and technolo-
gies in ICUs, nurses often are required to move
heavy equipment in and out of patient areas.
There is little or no acknowledgment that this
type of task requires heavy lifting and moving;
nurses under task and time constraints often find
it easier to move equipment alone than to wait
for additional help.
Although most ICU nurses receive some nurs-
ing school education about ergonomics and body
mechanics contributing to musculoskeletal injury,
few nurses are aware of the amount of lifting they
will do in ICUs and the safest ways to perform
these tasks. The American Nursing Association
believes that the essential functions for most
nurses should depend on knowledge and care
judgment not physical strength [16]. In defining
the clinical role of critical care nursing practice,
Brilli and colleagues [17] focus on nurses’ under-
standing and support for technical medical care,
including diagnosis, treatment, care planning,
and priority setting; no mention is made of the
need for physical lifting and moving equipment.
Trinkoff and colleagues [18] have examined
a comprehensive array of nursing task physical
demands, such as lifting and awkward postures.
Nurses practicing in hospital emergency, critical
care, or operating room/post-anesthesia care
specialties stated the highest level of physical de-
mands in their work. As the number of self-
reported physical demands increased so did the
likelihood of inadequate sleep, pain medication
use, and absenteeism.
Cognitive workload
Cognitive workload is related to the need for
ICU nurses to process information, often in a short
period of time. For instance, code situations
require quick decision making and a lot of in-
formation that needs to be processed quickly [19].
Critical care nurses do the majority of family
communication, patient assessment, evaluation,
and care in ICUs. Through their cognitive skills,
nurses readily recognize clinical changes that
prevent further deterioration in patients [17].
Nurses perform many cognitive adjustments
across patients throughout an assigned period of
care. These adjustments are planned (eg, work
shift changes or morning reports for assigned pa-
tients) and unplanned (eg, stable patients sud-
denly changing status to an unstable condition)
[20]. This constant conscious shift in thinking
from one patient to another extends far beyond
actual bedside care. Nurses often perform cogni-
tive tasks while waiting on other systems or pro-
cesses (eg, delivery of medications, laboratory
results, and retrieving necessary patient supplies).
This cognitive and physical multitasking, al-
though common in ICUs with high patient acuity,
often is overlooked in management decisions ad-
dressing nurse staffing ratios.
Additionally, interruptions disrupt nurses’
concentration and cognitive processing. Human
beings find it difficult to stay attentive, vigilant,
 WORKLOAD AND PATIENT SAFETY
and productive, particularly when they are inter-
rupted, fatigued, or in a work overload situation
[21]. Nurses whose attention constantly is shifting
from one item to another may not be able to for-
mulate a complete and coherent picture of tasks at
hand or complete assigned care activities [22].
Some interruptions are necessary, such as point-
ing out critical monitor changes or emergent
needs of other patients assigned to a nurse’s
care. Most interruptions are about communicat-
ing information or asking questions about pa-
tients, however; for instance, asking about
information and questions about patients who
are soon to be admitted to or discharged from
a unit. The stream of constant interruptions dis-
rupts nurses’ ability to identify and assess patient
needs, increasing the cognitive workload [20], even
potentially leading to patient error.
Increased understanding of the work complex-
ity in ICU environments and nurses’ cognitive
workload are critical to successful patient safety
improvement efforts and the recruitment and
retention of critical care nurses [14].
Time pressure
Time pressure relates to the need to work fast,
under tight deadlines and temporal constraints.
High time pressure is related to burnout experi-
enced by ICU nurses [23]. Time pressure is related
to the number of tasks ICU nurses have to per-
form under temporal constraints. ICU nurses
perform a large variety of tasks, including assess-
ments, measurements, documentations, and thera-
pies on a regular or frequent basis. Changes in
standards of care for ICU patients sometimes
can introduce additional tasks for ICU nurses,
therefore adding to the already high time pressure.
One example is the introduction of glycemic con-
trol, which involves insulin infusions and monitor-
ing of blood glucose levels. This requires
additional work by ICU nurses, up to 2 hours
for a single patient during a 24-hour period [24].
Emotional workload
Emotional workload is prevalent particularly
in critical care environments because of patient
acuity and severity. Critical care nurses deal with
very sick patients and are the main interface with
the families of those patients. ICU nurses are
educated and trained to provide highly technical
expert care and also need to deal with end-of-life
123
care [25]. Often, ICU nurses experience obstacles
to providing end-of-life care that can add to their
emotional workload. The following obstacles are
reported by ICU nurses: continuing aggressive
treatment even when advanced directives exist,
physicians too optimistic to a families, and deal-
ing with angry families.
Critical care nurses report that dealing with
family demands is related to increased workload
[26]. Families play an important role in ICUs,
such as watching out for the patients or just ’’be-
ing there.’’ Sometimes the perspectives of the
nurses and the families are not aligned, however,
and conflicts or problems may arise [27]. For in-
stance, nurses may experience time limitations in
their capacity to handle some of the family situa-
tions or demands.
Verbal and physical assaults by patients and
their families also can be a source of emotional
workload [28]. A study by May and Grubbs [28]
examines reports of verbal and physical assaults
by a group of 86 emergency department, ICU,
and general floor nurses. Approximately 85% of
the ICU nurses reported verbal assaults by pa-
tients and family members and 78% reported
physical assaults.
Quantitative and qualitative workload
Frankenhaeuser and Gardell [29] differentiate
quantitative workload from qualitative workload:
quantitative workload is defined as the amount of
work, and qualitative workload is defined as the
difficulty of the work. Quantitative workload of
critical care nurses can be measured using the var-
ious patient-level measures of workload (discussed
previously); these measures provide some measure
of the amount of work critical care nurses have to
perform. Quantitative workload also is related to
work hours: the amount of work performed in-
creases with increasing work hours. Scott and col-
leagues [30] found that critical care nurses tend to
work much longer than their scheduled work
shift: in a study of 502 nurses who provided
data for 6017 work shifts, they found that in
86% of the shifts, nurses worked longer than
scheduled. Longer work duration was related to
increased risk for errors and difficulty in staying
awake. Fatigue also can contribute to musculo-
skeletal injuries.
Qualitative workload of critical care nurses is
related to the rapid pace of knowledge in critical
care medicine and nursing and implementation of
new technologies and devices. Schaufeli and
124 CARAYON & ALVARADO

colleagues [31] found that intensive use of sophis- Relations between the dimensions of workload
ticated technology was related to high burnout
The various dimensions of workload are not
among ICU nurses. In addition, critical care
independent of each other. For instance, quanti-
nurses need to carry out procedures accurately
tative workload, or the amount of work, is related
and react to urgent situations efficiently [19].
to physical workload: the more work critical
This time pressure can add to the qualitative
nurses have to perform, the more likely they are
workload experienced by nurses.
exposed to physical workload. The number of
patients nurses care for and the nursing require-
ments of the patients also are related to physical
Workload variability workload.
Time pressure combined with physical work-
Workload variability is the extent to which
load may increase the risk for musculoskeletal
workload continually changes during a period of
injuries significantly for critical care nurses. In
time [32]. Among critical care nurses, one cause of
rushing to perform a task, nurses may not have
workload variability is related to shifts (eg, day
the time to use lifting devices. Moreover, a lifting
shift versus night shift). ICU nurses who work
device itself may add to nurses’ workload, as the
day shifts report higher levels of perceived work-
device used must be decontaminated and made
load than ICU nurses who work during night
ready for the next patient in a physical environ-
shifts [26]. The higher day shift workload may
ment not designed to facilitate optimal cleaning
be correlated directly with other patient care ser-
and disinfection. Nurses actually might choose
vices availability. Many hospital departments are
not to use a safety device as its cleaning or
closed or staffed only for emergency care during
decontamination seems too onerous a task given
night shifts. Night shift nurses often describe the
the physical environment and time pressure.
shifts as more relaxed, with more time spent
The cognitive workload associated with con-
with patients because there tend to be fewer inter-
sistent adherence to patient care guidelines may
ruptions and things are less hectic. Nurses report
increase physical workload as nurses encounter
experiencing a greater sense of autonomy and in-
problems and barriers to guideline compliance in
dependence on night shifts as they have control of
an ICU. Critical care nurses often are the primary
their work and task time. Night shifts often leave
care providers responsible for ensuring compli-
the nurses with sedentary tasks, however, such as
ance with these guidelines. The Institute for
charting, organizing supplies, or monitoring sleep-
Healthcare Improvement [34] is conducting a na-
ing patients. Many night shift nurses admit to de-
tionwide effort to save lives by implementing
veloping bad eating patterns. They note that
strategies to facilitate guideline compliance. A sig-
hospital cafeterias are closed at night, leaving
nificant attribute of this program is nurses’ role in
them with high-calorie vending machine snacks
monitoring care guideline compliance and taking
or takeout pizza as typical meal options in addi-
corrective action with ICU care teams. Although
tion to lack of physical exercise in their work
the empowerment of nurses to ‘‘stop the proce-
tasks. Geliebter and colleagues [33] observed night
dure’’ is critical to guideline compliance, it also
shift nurses reported gaining more weight, exercis-
adds to their cognitive, quantitative, and qualita-
ing less, and increasing food intake than the day
tive workloads.
shift group since starting their jobs on their cur-
rent shift.
Code situations are another example of work-
Sources of workload
load variability. Workload suddenly increases
because health care providers need to concentrate Understanding that the way work is organized
on the patients in danger, therefore reducing the can contribute to workload is critical for de-
number of staff available to care for other veloping interventions aimed at reducing (or
patients. Additionally, critical care nurses’ role managing) workload and its impact on critical
in the code may vary from finding and assessing care nurses. A range of patient care factors also
patients, initiating cardiopulmonary resuscita- may contribute to high workload in ICUs, such as
tion before a code team’s arrival, to then re- the number of postoperative events [35].
cording the events and interventions on the official The authors propose that the work system
resuscitation record that documents all events and model of Carayon and Smith [36–38] can be used
interventions. to describe sources of workload and define the
 WORKLOAD AND PATIENT SAFETY
interrelationships between the dimensions of
workload (Fig. 1). The work system comprises
five elements [36,37]:
 Individual critical care nurses
 Performance of various tasks (ie, direct care,
indirect care, and other tasks; patient care
characteristics)
 Use of various tools, equipment, devices, and
technologies
 Physical environment (eg, the patient room
and the nursing station)
 Specific organizational conditions (eg, shift
schedules, nursing management, teamwork,
communication with physicians and other
health care providers, and interruptions)
Physical workload is related particularly to the
tasks and their physical characteristics (eg, lifting
patients), the availability of equipment and de-
vices, and the layout of patient rooms. These
microergonomic factors also are related to the
macroergonomic characteristics of the work sys-
tem, such as an organization’s management being
committed to providing the right equipment to
nurses. Cognitive workload is affected by the
characteristics of the tasks of critical care nurses:
those tasks, in particular operational tasks (eg,
patient care and psychologic support of patients),
can be demanding and at the same time satisfying
[39].
Improving the design of nurses’ work system
(eg, nurse-physician collaboration) is suggested as
a strategy to reduce workload and deal with the
nursing shortage crisis [40]. Laschinger and Fine-
gan [41] identified ‘‘empowerment’’ as a predictor
of nurses’ perception of workload. Empowerment
was conceptualized as a characteristic of work en-
vironments that provide nurses with access to
Fig. 1. Model of workload of critical care nurses.
125
information, resources, and support necessary
for accomplishing their work in a meaningful
manner [42]. Organizational factors and other as-
pects of the work environment of critical care
nurses can affect workload.
Impact of workload
Workload experienced by critical care nurses
can lead to various outcomes: (1) impact on health
of the nurses, (2) quality of working life (eg, job
dissatisfaction, stress, burnout, and turnover in-
tention), and (3) patient safety (see Fig. 1).
Impact on health
A major impact of working conditions on
health of critical care nurses is work-related
musculoskeletal disorders, such as back disorders.
Physical workload is a working condition that is
a primary contributor to work-related musculo-
skeletal disorders of critical care nurses [18]. The
psychosocial aspects of work, however, such as
time pressure and emotional workload, also can
be contributors to work-related musculoskeletal
disorders [43]. Time pressure and emotional work-
load are job stressors that could lead to increased
risk for work-related musculoskeletal disorders
via the following mechanisms [43]: (1) job
stressors that could lead to physiologic changes
(eg, increased muscle tension), which can make
critical care nurses more vulnerable to work-re-
lated musculoskeletal disorders, (2) job stressors
that may heighten the impact of physical work-
load, and (3) job stressors that may increase
nurses’ sensitivity to pain and, therefore, increase
the likelihood that nurses experience and report
musculoskeletal pain.
126 CARAYON & ALVARADO
Impact on quality of working life
Workload also can affect the quality of work-
ing life experienced by critical care nurses, such as
job satisfaction, stress, burnout, and attitudes,
such as turnover intention. In particular, burnout
is recognized as a problem among ICU nurses and
is related to high workload [44]. Burnout may be
contagious: ICU nurses who perceive that their
colleagues are experiencing burnout more likely
report burnout, even after controlling for the im-
pact of job stressors (eg, workload) [45].
Physical workload experienced by nurses can
affect not only physical health, such as musculo-
skeletal disorders, but also turnover intention or
turnover. Fochsen and colleagues [46] conducted
a longitudinal study to identify the predictors of
turnover among Swedish nurses. Nurses who re-
ported musculoskeletal problems of the neck and
shoulder or knees and those who had limited use
of transfer devices were more likely to leave their
job. A multifaceted intervention aimed at reducing
physical workload of patient handling and work-
related musculoskeletal disorders in nursing home
care units and spinal cord injury units was shown
effective (eg, decrease in musculoskeletal injuries)
and to lead to increased job satisfaction [47].
Impact on patient safety
Medical errors are widespread in critical care
settings. A prospective observational study by
Bracco and colleagues [48] of consecutive patients
admitted during 1 year to an ICU examined 777
critical incidents. The cause of the incidents was
classified as equipment, patient, or human related.
The cause was classified as equipment related
when the incident was attributed to a technical
equipment failure not associated with human mis-
use. The cause was classified as human related
when actions did not go as intended or an in-
tended action was not the appropriate one. In
all other cases, the incident was classified as
patient related. Thirty-one percent of the incidents
were human-related incidents, 2% equipment-
related incidents, and 67% patient-related inci-
dents. A recent study by Rothschild and colleagues
[49] examined a total of 391 patients admitted over
a 1-year period in a medical ICU and a coronary
care unit. They found 120 adverse events among
79 patients (20%). The most serious medical
errors were found in the category of medication
ordering or execution of treatment.
Several studies have examined specific types of
error in ICUs, such as medication errors. Cullen
and colleagues [50] compared the frequency of ad-
verse drug events (ADEs) and potential ADEs in
ICUs and non-ICUs. Two medical and three sur-
gical ICUs and four medical and two surgical
general care units participated in the study. The
rate of preventable ADEs and potential ADEs
in ICUs was 19 events per 1000 patient days,
nearly twice the rate in non-ICUs. When adjust-
ing for the number of drugs used, however, no
differences were found between ICUs and non-
ICUs.
Several studies have linked medical errors and
patient safety to nursing workload. Giraud and
colleagues [51] conducted a prospective, observa-
tional study to examine iatrogenic complications.
A total of 382 patients for 400 consecutive admis-
sions provided data. Thirty-one percent of the ad-
missions had iatrogenic complications. Human
errors were involved in 67% of the major iatro-
genic complications. The risk for ICU mortality
was approximately twofold higher for patients
who had iatrogenic complications. A major con-
tributing factor was high or excessive nursing
workload. A study of medication administration
by Tissot and colleagues [52] detected 132 medica-
tion errors in a total of 2009 observed events
(6.6%). The researchers attributed the errors not
only to deficiencies in the overall organization of
the hospital medication track but also to the nurs-
ing work overload.
Scott and colleagues [30] examined the effects
of critical care nurses’ work hours on their vigi-
lance and risk for making an error. Longer shift
durations (in particular more than 12.5 consecu-
tive hours) were associated with increased risk
for errors and near errors and with increased dif-
ficulty staying awake at work. This study did not
find an association between decreased vigilance
(eg, difficulty staying awake at work) and
increased risk for errors. Longer shift durations
increase the exposure of critical care nurses to
the various dimensions of workload.
Systemic impact of workload
The impact of workload on various outcomes
is systemic. According to the Systems Engineering
Initiative for Patient Safety (SEIPS) model of
work and patient safety [53], the various outcomes
are affected by the characteristics of the work sys-
tem and also are inter-related. Therefore, the var-
ious dimensions of workload likely affect more
than one outcome, and the outcomes are related
to each other. Nurses who experience back pain
 WORKLOAD AND PATIENT SAFETY
because of physical workload may not be able to
dedicate their full attention to their tasks (cogni-
tive workload) and, therefore, may be more likely
to commit an error (impact on patient safety).
Therefore, it is important to examine workload
of ICU nurses using a systemic approach.
A systemic approach to the assessment of
workload should fulfill the following objectives:
1. Evaluate the different dimensions of work-
load experienced by critical care nurses.
2. Identify the work system factors contributing
to different facets of workload.
3. Understand the relationships between the
different dimensions of workload.
4. Assess the impact of workload on nurses’
and patient outcomes.
In the introduction, various measures of pa-
tient-related workload were described. This article
emphasizes the need to go beyond those measures
and include measures of workload that represent
the various dimensions of workload. The Na-
tional Institute of Occupational Safety and Health
has created a Web site where various measures of
working conditions and job stressors are de-
scribed [54]. This is a resource for many measures
of workload, such as quantitative workload [32]
and cognitive demands [55]. Gurses [26] has devel-
oped a questionnaire to assess performance obsta-
cles experienced by critical care nurses; this
questionnaire can be used to identify the various
sources of workload in the work system (ie, per-
formance obstacles).
Summary
Interventions aimed at improving the safety of
care provided by nurses to critical care patients
need to consider the work environment, in
particular the various types of workload. Sluiter
and colleagues [56] implemented a multidisciplin-
ary structured process to evaluate work shifts to
enhance team communication. Benefits of the in-
tervention included increased satisfaction with
team communication and reduction in emotional
exhaustion. This multidisciplinary structured pro-
cess was used to address the following issues:
dealing with pressure of ICUs, teamwork, work
roles, and organizational aspects. Such a process
could be used to identify the work elements that
contribute to different dimensions of workload,
to propose interventions to reduce workload,
and to plan implementation of these interven-
tions. According to the model of workload of
127
critical care nurses presented in Fig. 1, an inter-
vention tackling workload should aim to under-
stand the work system factors that contribute to
workload and the various outcomes resulting
from the different types of workload.
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 Crit Care Nurs Clin N Am 19 (2007) 131–143

Patient Handling Tasks with High Risk

for Musculoskeletal Disorders in Critical Care
Thomas R. Waters, PhDa,*, Audrey Nelson, PhD, RN, FAANb,
Caren Proctor, BSNc
a
Division of Applied Research and Technology, National Institute for Occupational Safety and Health,
4676 Columbia Parkway (MS-C24), Cincinnati, OH 45226, USA
b
Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL 33612, USA
c
Surgical Intensive Care Unit, James A. Haley VAMC, Tampa, FL 33612, USA

Nursing remains one of the top 10 highest risk
occupations in the United States for work-related
musculoskeletal disorders (WMSDs) [1]. Com-
pared with those in other occupations, nursing per-
sonnel are among the highest at risk. Nursing aides,
orderlies, and attendants rank first and registered
nurses sixth in a list of at-risk occupations for
strains and sprains that includes truck drivers
(first), laborers (third), stock handlers and baggers
(seventh), and construction workers (eighth) [2].
Additional estimates for the year 2000 show that
the incidence rate for back injuries involving lost
workdays was 181.6 per 10,000 full-time workers
in nursing homes and 90.1 per 10,000 full-time
workers in hospitals, whereas incidence rates were
98.4 for truck drivers, 70.0 for construction
workers, 56.3 for miners, and 47.1 for agriculture
workers [3]. In 2001, for cases involving days
away from work among registered nurses, 4547
were categorized as overexertion in lifting and
14,832 were listed as sprains or strains [4].
Work-related musculoskeletal disorders (WMSDs)
in nursing persist as one of the leading and most
costly occupational health problems in the United
States. Nurses suffer a disproportionate amount of
musculoskeletal disorders attributed to overexer-
tion from lifting unsafe loads and to the potential
cumulative effect of repeated patient handling
The findings and conclusions in this report are those
of the authors and do not necessarily represent the views
of the National Institute for Occupational Safety and
Health or the Veterans Health Administration.
* Corresponding author.
E-mail address: trw1@cdc.gov (T.R. Waters).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.008
tasks [5]. A variety of patient handling tasks exist
within the context of providing nursing care,
such as lifting, transferring, and repositioning pa-
tients. Continuous, repeated performance of these
activities throughout a working lifetime without
the use of mechanical assistive equipment results
in the development or exacerbation of musculo-
skeletal disorders. Because patient handling tasks
conventionally are performed manually without
the use of assistive equipment, nurses are exposed
to high levels of biomechanical loads on the spine.
Although nurses historically have been educated
and trained to use ‘‘proper’’ body mechanics and
manual techniques to prevent injury from lifting
and transferring patients, questions arise regard-
ing the value of these methods and applicability
to the practice of nursing [6,7].
The risk for development of WMSDs associ-
ated with manual patient handling crosses all
specialty areas of nursing. No nurse effectively is
free from the risk for injury. The purpose of this
article is to describe high-risk patient handling
tasks performed frequently in critical care units,
delineate the physical demands associated with
each task, identify technologic solutions, and
outline useful tips for making each task safer.
Background
The Association of periOperative Registered
Nurses (AORN) organized a task force that in-
cluded representatives from AORN, the National
Institute for Occupational Safety and Health
(NIOSH), the Patient Safety Center of Inquiry at
the James A. Haley Veterans Administration
ccnursing.theclinics.com
132 WATERS
Medical Center (VAMC) in Tampa, and the
American Nurses Association to develop an ergo-
nomic guideline for lifting and moving people and
objects in perioperative work environments. The
task force formulated clinical tools and algorithms
for high-risk tasks in perioperative settings that
incorporate current ergonomic safety concepts,
scientific evidence, and available technology, in-
cluding safe patient handling equipment and de-
vices [8]. This article expands on the work done by
the AORN for perioperative settings by applying
the ergonomic principles proposed by AORN to
nursing tasks in critical care settings.
Another ergonomic task force, led by the Patient
Safety Center of Inquiry at the James A. Haley
VAMC in Tampa, identified tasks associated with
high risk for musculoskeletal disorders on five
critical care units (two surgical ICUs, two medical
ICUs, and one cardiac ICU) at two large medical
centers to identify tasks with high risk for muscu-
loskeletal disorders. The criteria used to identify
potential high risk for WMSDs for critical care
tasks included (1) high force, (2) awkward postures,
or (3) repetitive loading. Data were collected
through direct observation of physical work envi-
ronment, technology, and work practices; digital
photography; interviews with ICU nurses and
nurse managers; and a 2-year review of WMSDs
reported in ICUs. Based on this evaluation, seven
high-risk patient handling tasks in critical care were
identified as having high risk for musculoskeletal
disorders. These include
1. Pushing occupied beds or stretchers
2. Lateral patient transfers (eg, bed to stretcher)
3. Moving patients to the head of a bed
4. Repositioning patients in bed (eg, side to
side)
5. Making occupied beds
6. Applying antiembolism stockings
7. Lifting or moving heavy equipment
For each of these high-risk critical care nursing
tasks, a brief description of the task is provided,
the physical demands discussed, solutions pro-
posed, and helpful tips for performing each task
safely provided.
High-risk task #1: pushing occupied beds
or stretchers
Description of the task
Critical care nurses identified ‘‘road trips’’ as
one of the most physically demanding tasks
et al
performed. These trips involve pushing an occu-
pied bed or stretcher off the unit for diagnostic
testing, surgery, or other procedure. In addition to
the weight of patients and beds or stretchers, these
tasks are compounded by adding the weight of
medical devices, such as intra-aortic balloon
pumps, intravenous pumps, and portable ven-
tilators. In addition, nurses may be expected
to monitor patients while performing these tasks
or manually ventilating patients while walking
or pushing. Typically, these tasks require two or
more persons for safety, and at least one person
usually is walking backwards. The required force
to push or pull an object is the same, but pushing
is preferred over pulling because pulling often is
done with one hand and with a twist of the trunk,
resulting in unbalanced loads on the spine [9]. For
this reason, pulling force limits for these tasks are
not provided.
Physical demands
Factors that contribute to the physical demand
of these tasks include distance traveled, weight
being pushed, and uneven gradients (eg, slopes or
thresholds). The wheels of beds and equipment get
stuck in elevator and door thresholds. The poten-
tial physical risk factors associated with this task
include excessive pushing or pulling and lifting
demands. The likely result of excessive pushing,
pulling, or lifting forces generated during this
task is high-resultant spinal anterior-posterior
shear and compression forces that likely exceed
the recommended spinal tissue load tolerance
limits. These limits are proposed as 3400 N (770
lb) for spinal disc compression force [10,11] and
1000 N (225 lb) for spinal shear force [12]. Push-
ing force requirements associated with four pa-
tient transport tasks proposed by the AORN are
listed in Table 1 [8]. Table 1 also provides a series
of recommendations for the number of nurses and
equipment needed to perform a task safely. These
recommendations are based on pushing force
limits recommended by researchers at the Liberty
Mutual Insurance Research Institute for Safety
[13]. Additional information about pushing force
limits is discussed later.
Another problem with transporting patients is
lifting occupied beds over small barriers, such as
a door or elevator threshold. A basic biomechan-
ical analysis (Fig. 1) shows that lifting an occupied
bed over a barrier or door threshold requires
a high amount of lifting force that easily could
exceed the recommended weight limit (RWL) for
 WMSD RISK IN CRITICAL CARE 133

Table 1
Physical demands and recommendations for safe patient transport
Ergonomic
Transport task Pushing force lb/(kg) Max push distance ft/(m) recommendation
Pushing an occupied 43.8 lb (19.9 kg) O200 ft (60 m) Task is acceptable
stretcher for one caregiver
Pushing an occupied bed 50.0 lb (22.7 kg) !200 ft (30 m) Minimum of two caregivers
required
Pushing an unoccupied 69.7 lb (31.7 kg) !100 ft (30 m) Recommend use of a
specialty surgical bed powered
transport device
Pushing an occupied 112.4 lb (51.1 kg) !25 ft (7.5 m)
specialty surgical bed
Reprinted with permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Peri-
operative Setting. Copyright Ó 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.

safe manual lifting, even when two nurses perform
the lift under ideal lifting conditions.
The following example is provided to show
how a task easily could exceed the recommended
lifting limits: if W (ie, the weight of the bed plus
the weight of the patient) is 300 lb and the lift oc-
curs at point B (the end of an occupied bed), then
according to static equilibrium (see Equation 1 in
Fig. 1), L is equal to 150 lb. This exceeds the RWL
for lifting, as defined by the NIOSH lifting equa-
tion (NLE), even with two nursing personnel lift-
ing the end of the occupied bed over a barrier
under ideal conditions [10,11]
Proposed solutions
Two primary solutions are available for re-
ducing the physical demands associated with
transporting patients that exceed the recommen-
ded push/pull force limits for one person. These
include the use of two or more persons to perform
a task or the use of a powered transport device. If
the required force exceeds the push/pull force
y Weight of Load Lifted (L)
A B
x than pulling tasks [9].
Weight of Occupied Bed + Patient (W)
3 ft
6 ft
Momentz ( L 6 ) (W 3) 0
Momentz L 6 W 3
W a bed or stretcher must be lifted over
Momentz =L
2
Fig. 1. Simple biomechanical model of lifting occupied
bed over barrier.
limits for two caregivers or a task is performed
frequently, then a powered transport device is
suggested, although it is recognized these pieces of
equipment are not available for every type of
device that is transported with patients. If trans-
porting patients requires lifting a bed or stretcher
over a barrier, then a powered transport device
reduces the risk for musculoskeletal disorder
significantly for caregivers.
Safety tips
1. The height of a bed or stretcher should be po-
sitioned so that the hands are at a middle
push point of 3 ft (0.92 m) from the floor.
For tasks where the push point is lower
than 3 ft (0.92 m), maximum and sustained
push forces should be decreased by approxi-
mately 15% [8,13].
2. Manual patient transport tasks should not be
performed more frequently than once every
30 minutes. For transport tasks performed
more frequently than once every 30 minutes,
a powered patient transport device is the best
solution [8].
3. Pushing tasks are less physically demanding
4. If push force limits for one caregiver are ex-
ceeded (see Table 1), it is necessary to use
two or more caregivers to complete the task
or use a powered transport device. In some
(Eq. 1) cases, even multiple caregivers may not be
able to perform a task safely, especially if
a door or elevator threshold [8].
5. The wheels on beds or stretchers need to be
maintained properly to facilitate easier
134 WATERS
transport. Wheels that are too small, casters
that do not face forward easily, or wheels
that are maintained poorly increase the
amount of effort needed to complete the task.
6. When possible, select a transport route that
has a minimum number of inclines, declines,
or barriers, such as door or elevator thresh-
olds to traverse.
7. Use bariatric equipment if patient weight
exceeds the acceptable weight capacity for
conventional patient handling equipment
(the weight capacity usually is listed on the
equipment). This may require special plan-
ning related to getting the equipment through
standard-size doorframes and elevators.
Bariatric equipment is designed specially
with greater weight capacity than normal
lifting assist equipment.
High-risk task #2: lateral patient transfers
(eg, bed to stretcher)
Description of the task
Nurses in critical care units often engage in
lateral patient transfers (eg, laterally moving
a patient in a lying position from one surface to
another). This task often is completed with two or
more caregivers pushing or pulling a patient
laterally toward the destination position.
Physical demands
Both caregivers often must reach out with
extended arms, either at the start or end of the
task, to push or pull a patient from one surface
(eg, a stretcher) to another surface (eg, a bed). The
potential risk factors for this task include exces-
sive pushing or pulling forces and extended
reaches. These tasks may be more difficult when
the height of nurses working together is disparate
or when a patient resists movement, such as when
a patient is confused or may be guarding a surgical
wound. The likely result of excessive pulling or
lifting forces generated during this task is high
resultant spinal shear and compression forces that
may exceed the recommended spinal compression
or shear force load tolerance limits of the spinal
tissues or excessive shoulder loading. The amount
of pulling force required for this task is dependent
on patient weight and the coefficient of friction
between the sliding surfaces, which is a measure of
the degree of slipperiness between a patient and
et al
bed surface or between the sheet under a patient
and a bed surface. As the slipperiness or smooth-
ness between the surfaces increases, the required
pulling force decreases. Data for determining the
maximum pulling force limit is published by
researchers at the Liberty Mutual Insurance Re-
search Institute for Safety. According to these, the
maximum pulling force acceptable to 75% of
women is 51 lb (23 kg) for maximum initial pulls;
the 51-lb maximum pulling force value is for one
caregiver. The actual required pulling force may
be difficult to determine. As a rule of thumb, with-
out a friction-reducing device, the required pulling
force to move a patient is approximately 75% of
a patient’s body weight [14]. With newer sliding
sheets, the required pulling force may be as low
as 25% of a patient’s body weight [14].
Based on published pulling strength data, the
AORN published an ergonomic tool for assessing
lateral transfers of patients between a stretcher
and an operating room bed. The ergonomic tool is
shown in Fig. 2. According to the AORN re-
commendation, the desirable approach for lateral
transfer of patients involves use of a lateral trans-
fer device, such as friction-reducing sheets, slider
boards, or air-assisted transfer devices. If only
a draw sheet is used without a lateral transfer
device, care providers exert a pull force up to
72.6% of patient weight [8]. The AORN recom-
mendation assumes that one caregiver or anesthe-
sia care provider supports a patient’s head and
neck to maintain the airway during lateral trans-
fers. The remaining mass of the patient’s body
equals 91.6% of his or her total body mass [8].
The rationale for the AORN recommendation is
based on research indicating that for a pulling
distance of 6.9 ft (2.1 m) or less, where the pull
point (ie, starting point for the hands) is between
a caregiver’s waist and nipple line, and the task
is performed no more frequently than once every
30 minutes, the maximum initial force required
equals 57 lb (26 kg), and the maximum sustained
force needed equals 35 lb (16 kg) [8]. According
to the AORN recommendation, each caregiver
safely can contribute a pull force required to
transfer up to 48 lb, equal to 35 lb/0.726 (dis-
cussed previously). For one caregiver plus an
anesthesia care provider, the maximum patient
weight that safely can be transferred manually is
52.6 lb, equal to 48 lb/0.916 (described previ-
ously). For two caregivers plus an anesthesia
care provider, a patient safely can be transferred
manually weighing up to 104.8 lb, equal to
(48 lb  2)/0.916 (described previously). If there
 WMSD RISK IN CRITICAL CARE 135

Can
Caregiver assistance not
patient
Start Yes required. Stand by for safety
transfer without
as needed.
assistance?

No
See Rationale* See Rationale*

What is the
Prone starting Supine
position?

Is weight Will patient

No No
> 73 lbs? stay supine?

Use 2-3
caregivers*
Yes Yes

Use assistive technology Use lateral

(min. 3-4 caregivers)* transfer device Is weight
No
A mechanical device is preferable (min. 4 >157 lbs?
for this task. Additional caregivers)*
technologies are needed
for turning a patient from supine to Yes
prone and from prone to supine.
Use one of the following:
mechanical lift with supine sling,
mechanical lateral transfer
Note: < means less than; > means greater than
device or air-assisted lateral
transfer device
(min. 3-4 caregivers)*

* One of the caregivers may be the anesthesia provider

The number of personnel to safely transfer the patient should be adequate to maintain the patient's body alignment,
support extremities, and maintain patient's airway.
For lateral transfers it is important to use a lateral transfer device that extends the length of the patient.
Current technologies for supine to prone include: Jackson Frame, Spine Table, etc.
Destination surface should be slightly lower for all lateral patient moves.
A separate algorithm for prone to jackknife is not included as this is assumed to be a function of the table.
If patient's condition will not tolerate a lateral transfer, consider the use of a mechanical lift with a supine sling.
During any patient transferring task, if any caregiver is required to lift more than 35 lbs of a patient's
weight, assistive devices should be used for the transfer.
While some facilities may attempt to perform a lateral transfer simultaneously with positioning the patient
in a lateral position (ie, side-lying), this is not recommended until new technology is available.
The assumption is that the patient will leave the operating room in the supine position.

* The rationale for this tool is provided in the AORN Guidance document [8].

Fig. 2. AORN ergonomic tool for assessing lateral transfer between stretcher and operating room bed. (Reprinted with
permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting.
Copyright Ó 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.)

are three caregivers plus an anesthesia care pro-
vider, then a patient safely can be transferred
manually weighing up to 157.2 lb, equal to (48
lb  3)/0.916 (described previously). If a patient
weighs more than 157 lb, then the tool suggests
that either a mechanical lifting device, mech-
anical lift with supine sling, mechanical lateral
transfer device, or air-assisted lateral transfer de-
vice and a minimum of three to four caregivers
be used.
136 WATERS
Proposed solution
The best solution for a lateral transfer that
exceeds the acceptable pulling force limits for one
person is to add one or more nurses to do the job,
use a friction-reducing device to reduce the pulling
force, or use a powered lateral transfer device.
Tips for performing lateral patient transfer
tasks safely
1. Previous research shows that there is no safe
way to lift a patient manually from a bed to
another bed, even with two nurses and ideal
lifting conditions [12]. Therefore, this task
should not be performed as a manual lift.
2. Historically, nurses have completed this task
using a standard draw sheet or creatively in-
serting a plastic trash bag under the draw
sheet to reduce friction. These strategies,
however, do not reduce the risk sufficiently.
Forces associated with excessive reaching
and lumbar hyperflexion are reduced by
48% when a friction-reducing device is used
compared with a draw sheet or trash bag.
Subjective evaluations by nurses demonstrate
that they preferred the use of a friction-re-
ducing device to a standard draw sheet as
a way to minimize musculoskeletal discom-
fort [15,16].
3. A friction-reducing device reduced effort sig-
nificantly, by 25% for the spine and 33% for
the shoulders [14].
4. Observations of nurses using these devices re-
vealed the friction-reducing device was not
intuitive in its use, and, despite training,
nurses did not use it to its full capacity.
Nurses should be required to demonstrate
proficiency in the use of friction-reducing de-
vices to assure appropriate use at onset and
over time to fully use this type of patient
care equipment [16].
5. Friction-reducing devices with long handles
or straps reduce reach and associated forces
on the back, shoulders, and arms signifi-
cantly and are preferable to friction-reducing
devices without long handles or straps [15].
High-risk task #3: moving patients
to the head of a bed
Description of the task
Patients who are physically dependent and in
bed need to be repositioned frequently to prevent
et al
pressure ulcers and other adverse events associ-
ated with immobility. Despite careful reposition-
ing, over time, patients tend to shift downward in
the bed and need to be pulled back to the head of
the bed for comfort and safety.
Physical demands
This task is similar to the lateral transfer task
(described previously), where a caregiver is stand-
ing at the side of a patient’s bed. Because of the
line of action of pulling a patient to the head of
the bed, however, hand forces are parallel to the
body rather than in-line with the front of the
body, creating large lateral shear and torque
forces on the spinal tissues. Additionally, to
accomplish the task, caregivers often have to
work with their arms extended fully, increasing
the loads on the muscles, ligaments, and joints of
the shoulder. When the arms are extended, the
mechanical moment for the task is increased. An
increase in the moment arm results in larger tor-
que forces on the spine and shoulder. No limits
for maximum acceptable torque forces on the
spine are proposed, but studies show that axial ro-
tation during lifting can increase the risk for low
back pain in some workers [12]. Examination of
the required muscle forces at the shoulder reveal
that the maximum recommended force that an av-
erage woman is able to pull laterally across the
body with arms extended fully is 22 lb (10 kg) or
11 lb (5 kg) per hand [8]. It is likely that the shoul-
der strength is exceeded before the lateral shear
force limit is reached for most repositioning tasks,
such as this. In addition, only approximately 44%
of women have the torso strength capacity to do
this task. The 44% value was determined using
a 3-D strength prediction program developed by
researchers at the University of Michigan [17].
Proposed solutions
There are only a few solutions available for this
task. The best overall solution is to use a floor-
based or ceiling-mounted patient lift that elimi-
nates the need to pull or lift patients manually.
Using a floor-based lift, however, is time consum-
ing and may not be accepted readily by nurses.
Use of a ceiling lift with a ‘‘disposable’’ reposi-
tioning sling that can stay under a patient im-
proves the acceptance of such lift use. Skin
integrity always is a concern when leaving slings
under patients and must be considered. An alter-
native is to use a friction-reducing device and ad-
ditional caregivers. This approach may reduce the
 WMSD RISK IN CRITICAL CARE
maximum required forces, but it does not solve
the problem of pulling across the body.
Tips for moving patients to the head of a bed safely
1. This task requires two or more caregivers. It
is unsafe to move an occupied bed away from
a wall and attempt to lift a patient unassisted.
2. The task should be performed with caregivers
positioned at the sides of a bed.
3. Pulling patients up in bed is made easier by
lowering the head of the bed and raising the
patient’s knees [16].
A. The forces on the shoulder can be de-
creased by 40% by raising the bed to an
appropriate working height and angling
the head of the bed downward to facilitate
this repositioning task [16].
B. The amount of musculoskeletal discomfort
in performing this task also can be de-
creased by nearly 31% by angling the
bed surface and raising a patient’s knees
before sliding them [16].
4. Additional research is needed to design tech-
nologic solutions for the high-risk, high-vol-
ume patient handling task of repositioning
patients to the head of a bed.
High-risk task #4: repositioning patients
in bed (eg, rolling from side to side)
Description of the task
Patients who are physically dependent and in
bed need to be repositioned frequently to prevent
pressure ulcers and other adverse events associ-
ated with immobility. Typically, this task is
performed at least once every 2 hours, alternating
between prone, right-side lying, supine, and left-
side lying, as tolerated by patients. Thus, this task
requires rolling patients from side to side.
Physical demands
This task is similar to the lateral transfer task
described in task #2 and can be completed either
by sliding patients to the center of a bed or lifting
and moving patients to the center of a bed. For
this task, however, it is likely that the arms are
more extended for the maneuver than for a trans-
fer from bed to bed. The same risk factors are
involved and the same limitations apply as for the
lateral transfer task. As with the transfer task, the
required pulling force is dependent on patient
137
weight and the coefficient of friction between
a patient, or sheet under a patient, and bed
surface. If the task is performed with arms
extended directly in front of the body, then the
shoulder strength or anterior-posterior shear on
the spine likely is the limiting factor for this task.
If, alternatively, the task is performed laterally by
pulling across the body, then the limiting factor
likely is shoulder strength or lateral shear (dis-
cussed previously).
Proposed solutions
There are few solutions available to reduce the
physical demands associated with rolling patients
from side to side in a bed. It may be possible to
use a ceiling-mounted lift to assist in rolling
patients from side to side, but use of a ceiling
lift typically requires a manual rolling activity to
place a sling under a patient. Alternately, two
caregivers may be able to roll a patient manually
without exceeding recommended pushing and
pulling force limits, but the best technique is to
use a lift with a repositioning sheet or strap to roll
patients from side to side. Friction-reducing de-
vices may be helpful with larger, heavier patients.
Tips for repositioning a patient in bed safely
1. Performing this task manually may require
two or more caregivers, depending on patient
weight.
2. A friction-reducing device or a mechanical
lifting device should be used for bariatric pa-
tients or for patients whose pain or discom-
fort does not allow them to tolerate manual
performance of the task.
3. One caregiver safely can reposition a patient
laterally with the aid of a friction-reducing
device or a ceiling-mounted lift.
Additional research, however, is needed to
develop efficient, safe, user-friendly devices for
assisting in rolling patients from side to side,
especially as the average weight of patients
continues to increase.
High-risk task #5: making occupied beds
Description of the task
Patients who are physically dependent and in
critical care often are unable to get out of bed
because of illness, pain, fatigue, or medical
contraindications. Regardless, linens need to be
changed regularly, particularly if patients are
incontinent, bleeding, or perspiring. The task of
138 WATERS
making an occupied bed can be challenging,
particularly when patients are obese, hooked to
multiple lines, or combative or uncooperative.
This task often requires that caregivers roll
patients from side to side to make a bed.
Physical demands
To perform this task, nurses usually approach
patients from the side of a bed, roll patients onto
their side, slide a sheet under patients, then move
to the other side of the bed to roll patients back
onto the sheet and then onto their other side, then
pull the sheet out from under the patients, finally
rolling patients onto their back to finish making
the bed. The potential risk factors for this task are
excessive pushing and pulling forces, excessive
reach, and twisting. The other problem is that
nurses often have to hold patients up with one
hand while using the other hand to arrange the
sheet. The pushing/pulling forces required to
perform this task are dependent on the individual
and how much assistance can be provided by
patients. Again, the task likely is performed with
arms in a fully extended position. The pushing or
pulling force limit for this task likely is determined
by shoulder strength limits for most women rather
than the spinal shear force. Also, the task may
need to be performed with one arm, because the
other arm may be needed to hold patients on their
side while inserting or removing a sheet under the
patient.
Proposed solutions
There are few solutions available to reduce the
physical demands associated with making an
occupied bed. It is possible to use a ceiling-
mounted lift to lift the patient off the bed,
allowing for a hands-free approach to making
a bed. As discussed previously, one of the most
stressful elements of this task is rolling patients
onto one side to get the sheet under them and then
holding them in place. As discussed previously for
the patient rolling task, two caregivers may be
able to roll patients manually without exceeding
recommended pushing and pulling force limits.
Reaching and pulling patients, however, should
be avoided when feasible.
Tips for making occupied beds safely
1. Raise the bed to an acceptable comfortable
working height (about the level of the elbow)
[15]. When two or more nurses are complet-
ing this task and they are of disparate
et al
heights, the acceptable bed height should be
set approximately at the average elbow
height of the two nurses.
2. Further, avoid twisting and excessive reach
while performing this task. Nurses who
move back and forth along the side of the
bed, rather than twist in place, reduce muscu-
loskeletal strain by 58% (60% back and 57%
shoulders) [16].
3. This task is more difficult with some air mat-
tresses or overlays, which can cause increased
external forces when rolling patients toward
and away from a caregiver, as required dur-
ing the execution of this task [16].
High-risk task #6: applying antiembolism
stockings
Description of the task
Many patients in critical care units are at risk
for developing a deep vein thrombosis. One
strategy used to prevent deep vein thromboses is
the use of antiembolism stockings. In critical care,
this task nearly always is performed while patients
are supine.
Physical demands
The physical demands of this task are associ-
ated with (1) lifting and holding a leg for an
extended period, (2) the awkwardness of perform-
ing a task that takes two hands (sliding the
stockings up the leg) while holding a leg in place,
(3) resistance of extending tight elastic stockings
open to fit a leg inside, and (4) long duration of
the task. The risk factor for this task is lifting and
holding the weight of a leg for an extended period
of time and the excessive force needed to apply
stockings that intentionally are tight fitting.
Guidelines for lifting a leg have been developed
based on acceptable muscle strength and muscle
fatigue guidelines for women. The limits are
shown on Table 2 [8].
As can be seen in Table 2, the only acceptable
manual lift of a leg is a two-handed lift for pa-
tients weighing less than 54 kg (120 lb) and for
a holding duration of 1 minute or less. Performing
a two-handed lift and applying the antiembolism
stockings are not recommended for one caregiver.
Proposed solutions
One solution for lifting and holding a leg is
a mechanized lift with a strap or sling designed for
 WMSD RISK IN CRITICAL CARE
Table 2
Recommended limits for lifting legs
Reprinted with permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Peri-
operative Setting. Copyright Ó 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.
lifting body parts. For applying antiembolism
stockings, there are commercially available prod-
ucts; one device works like a shoehorn, making
the task easier, whereas another is simply a plastic
sleeve placed over the foot before application to
reduce friction.
Tips for applying antiembolism stockings safely
1. Applying antiembolism stockings from the
bottom of the bed with a pushing movement
significantly reduces muscle activity by 25%
compared with applying stockings from the
side, where a combination of lifting and pull-
ing is required [16].
2. Applying lotion to the legs, before manual
application of the stockings, is found to re-
duce the force needed to apply the stockings
slightly, although this may be contraindi-
cated if there are wounds or other skin condi-
tions on or near the legs.
High-risk task #7: lifting or moving heavy objects
and equipment
Description of the task
Patient care often includes use of equipment,
devices, and supplies that need to be brought to
a bedside. Often, these items are heavy or awk-
ward to carry or push and the distance can be
significant.
Physical demands
Critical care nurses often are required to lift
and move various heavy objects and equipment
manually, often in awkward body postures. The
risk factor for this task is potential excessive
139
spinal compression force or shear force. As the
weight of an object or the horizontal distance of
the load relative to a worker increases or as the
posture becomes more awkward, the compression
force increases and the acceptable amount of
weight that can be lifted safely decreases. The
revised NIOSH lifting equation (NLE) is an
assessment tool used to evaluate the physical
demands resulting from specified two-handed
manual lifting tasks [10,11]. To use the NLE, spe-
cific information is needed, such as the weight of
the object, the horizontal reach distance, the verti-
cal height from which the object will be lifted, and
other factors described in the NLE applications
manual [10,11]. The principal products of the
NLE are the recommended weight limit (RWL)
and the lifting index (LI) for a specified lift. The
RWL is defined for a specified lift as the weight
of load that nearly all healthy workers can per-
form for that task over a substantial period of
time (eg, up to 8 hours) without an increased
risk for developing lifting-related low back pain.
The LI value is a term that provides a relative es-
timate of the level of physical stress associated
with a particular manual lifting task and is defined
as the weight of load to be lifted (L) divided by
the RWL (ie, LI ¼ L/RWL). According to
NIOSH, it is likely that lifting tasks with an LI
greater than 1.0 pose an increased risk for lift-
ing-related low back pain for a fraction of the
population and that many workers are at risk if
the LI value exceeds 3.0.
As with several other tasks (discussed pre-
viously), the AORN developed a series of recom-
mendations for a set of lifting tasks performed
often in operating rooms [8]. These recommenda-
tions are based on the LI values calculated for
these tasks (Table 3). The NLE can be used to
140
Table 3
National Institute for Occupational Safety and Health lifting index value for typical lifting tasks performed in operating
rooms
Reprinted with permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Peri-
operative Setting. Copyright Ó 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.
calculate the RWL and LI for other two-handed
manual lifting tasks performed by critical care
nurses not listed in Table 3, such as lifting intrave-
nous pumps to attach to a bed for patient trans-
port; moving chairs to accommodate visitors;
lifting equipment to the end a bed; transporting
monitors; moving heavy bottled gas tanks; and
lifting beds and carts over electric cords or cables
in patient rooms. Those interested in more details
of the NLE should refer to the NIOSH applica-
tions manual [10,11].
Nurses also often have to push or pull wheeled
equipment or carts. These tasks have risk factors
as described for pushing an occupied operating
room bed (discussed previously). The amount of
force required to push or pull these items deter-
mines whether or not they can be done safely.
The AORN presented a recommendation for
pushing and pulling wheeled items in an operating
room work environment (listed in Table 4). For
items not listed in Table 4, the guide in Table 5
can be used to assess the acceptability of a specific
pushing task. If the required pushing force ex-
ceeds the value in Table 5 for the selected distance,
then the task should not be performed by one
caregiver. Pushing force limits for multiple
WATERS et al
caregivers can be calculated by multiplying the
values in Table 5 by the number of caregivers. It
is not recommended, however, that more than
two caregivers push equipment. As noted in Table
4, the appropriate solution is to use a powered as-
sist device.
Proposed solutions
The best approach for lifting loose objects and
equipment is to have two persons perform the lift
or use lifting assist equipment (see Table 3). The
determinant of whether or not to use a single
lifter, multiple lifters, or assistive equipment is
the weight of the load to be lifted, the frequency
of lifting, and the accessibility to reach and lift
the equipment. As a rule of thumb, for lifts that
are performed often or every day, assistive lifting
technology likely is the best choice.
Tips for lifting or moving heavy equipment safely
1. Pushing tasks ergonomically are preferred
over pulling tasks.
2. Ensure that push handles are at a correct
push height of approximately 3 ft (0.92 m).
 WMSD RISK IN CRITICAL CARE 141

Table 4
Association of periOperative Registered Nurses recommendations for pushing wheeled equipment

Reprinted with permission from AORN. AORN Guidance Statement: Safe Patient Handling and Movement in the Peri-
operative Setting. Copyright Ó 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved.

3. For tasks where the vertical height of the
push point is less than 3 ft (0.92 m) above
the floor, maximum and sustained push
forces are decreased by approximately 15%.
4. For tasks performed more frequently than
once every 30 minutes, maximum and sus-
tained push forces are decreased by approxi-
mately 6%.
5. If push force limits are exceeded, it is neces-
sary to reduce the weight of the load, use
two or more caregivers to complete the task
together, or use a powered transport device.
Powered transport devices are built into
some beds and stretchers; additionally, there
are devices available commercially to move
equipment [18].
6. Equipment or casters need to be maintained
properly to assist in moving equipment
more easily.
7. These recommendations are based on the Lib-
erty Mutual psychophysical limits for push
forces, where hands are positioned at a middle
push point of 3 ft (0.92 m) from the floor or
above and tasks are performed no more fre-
quently than once every 30 minutes [13].
Discussion
Many manual handling tasks performed by
critical care nursing staff (eg, handling and
moving patients, beds, and equipment) require
high levels of physical effort, resulting in signifi-
cantly high internal loads on muscles, ligaments,
and joints of the body, especially the shoulder and
low back. These high internal loads significantly
increase the potential for development of WMSDs
for these workers.
142 WATERS
Table 5
Push force limits
Adapted from Snook SH, Ciriello VM. The design of manual handling tasks: revised tables of maximum acceptable
weights and forces. Ergonomics 1991;34(9):1197–213; with permission.
Fortunately, there are alternatives to unsafe
manual handling tasks, such as use of floor-based
and ceiling lifts, lateral transfer devices, slip sheets,
antiembolism stocking applicators, and powered
transport devices [19]. In addition, new technolo-
gies rapidly are being developed for a wide range
of health care settings. As discussed in this article,
solutions for many of the high-risk tasks found in
critical care nursing currently are available.
Critical care nurses often are asked to perform
complex tasks that are time sensitive and require
a rapid response. There may not always be time to
look for the proper equipment to perform a task
unless the assistive equipment is in close proximity
to workers. Therefore, it is important that ade-
quate equipment is available and that the most
appropriate equipment is selected for the task.
For example, for transferring tasks requiring
a full-body lift, a ceiling lift might be preferred
over a floor-based lifting device, because the
ceiling lift always is in close proximity to the
work area, and nurses do not have to go looking
for the lift. In addition, the problem of storage of
floor-based lifts is eliminated by the use of ceiling
lifts, which are stored on an overhead track and
do not take up any floor space. It is important
that the culture of the work environment in
critical care settings be changed so that caregivers
and management make a significant effort to
provide adequate equipment and training neces-
sary to prevent the equipment from simply being
stored in a back room.
In this article, tasks with high risk for muscu-
loskeletal disorders in critical care settings are
identified clearly and appropriate solutions pre-
sented. Previous studies have shown that imple-
mentation of a safe patient handling and
movement program that incorporates the use of
this new technology can pay for itself in a short
period of time and provide a long-term benefit for
health care facilities and the nursing staff [20,21].
et al
Efforts to improve the safety of critical care
nurses are essential to assure quality patient care.
Nurses who are injured or suffer from musculo-
skeletal pain may not be able to provide rapid and
effective responses when urgent patient care is
needed. Insuring the health and safety of critical
care nurses also will help alleviate the current
nursing shortage by keeping nurses on the job
longer, reducing the risk for disruption of nursing
practice, and reducing the risk for a premature
career-ending injury.
References
[1] Collins JW, Menzel NN. Scope of the problem. In:
Nelson A, editor. Safe patient handling and move-
ment: a practical guide for health care professionals.
New York: Springer Publishing; 2006. p. 1–26.
[2] U.S. Department of Labor, Bureau of Labor Statis-
tics. Lost-work time injuries and illnesses: character-
istics and resulting time away from work, 2000.
Washington, DC: U.S. Department of Labor, Bu-
reau of Labor Statistics; 2002.
[3] U.S. Department of Labor (Bureau of Labor
Statistics). (2000). Table R6: incidence rates for non-
fatal occupational injuries and illnesses involving
days hawai from work per 10,000 full-time workers
by industry and selected parts of body affected
by injury or illness, 2000. Accessed September 13,
2006. Available at: http://www.bls.gov/iif/oshwc/
osh/case/ostb1039.pdf.
[4] U.S. Department of Labor. Bureau of Labor Statis-
tics. (2004). Nonfatal cases involving days away
from work: selected characteristics. Accessed Sep-
tember 13, 2006. Available at: http://data.bls.gov/
labjava/outside.jsp?survey¼cd.
[5] Smedley J, Egger P, Cooper C, et al. Manual han-
dling activities and risk of low back pain in nurses.
Occup Environ Med 1995;52:160–5.
[6] Nelson AL, Fragala G, Menzel N. Myths and facts
about back injuries in nursing. American Journal
of Nursing 2003;103(2):32–40.
 WMSD RISK IN CRITICAL CARE
[7] Nelson AL, and Baptiste A, (2004). Evidence-based
practices for safe patient handling and movement.
Online J Issues Nurs, 19 (3) Manuscript 3. Available
at: www.nursingworld.org/ojin/topic25/tpc25_3.htm.
[8] AORN. AORN Guidance Statement: Safe Patient
Handling and Movement in the Perioperative Set-
ting. Denver (CO): AORN Publications; 2007.
[9] Chengalur SN, Rodgers SH, Bernard TE. Kodak’s
ergonomic design for people at work. 2nd edition.
New York: John Wiley & Sons, Inc; 2004.
[10] Waters T, Putz-Anderson V, Garg A, et al. Revised
NIOSH equation for the design and evaluation of
manual lifting tasks. Ergonomics 1993;36 no 7:
749–76.
[11] Waters T, Garg A, Putz-Anderson V. Applications
manual for the revised NIOSH lifting equation
[DHHS(NIOSH) Pub. No. 94–110]. Cincinnati
(OH): Department of Health and Human Services,
National Institute for Occupational Safety and
Health, Division of Biomedical and Behavioral Sci-
ence; 1994.
[12] Marras WS, Davis KG, Kirking BC, et al. A com-
prehensive analysis of low back disorder risk and
spinal loading during the transferring and reposi-
tioning of patients using different techniques. Ergo-
nomics 1999;42(7):904–26.
[13] Snook SH, Ciriello VM. The design of manual han-
dling tasks: revised tables of maximum acceptable
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1197–213.
[14] Lloyd JD, Baptiste A. Biomechanical evaluation of
friction reducing devices for lateral patient transfers.
AAOHN J 2006;54(3):113–9.
[15] Baptiste A, Boda S, Nelson A, et al. Friction-reduc-
ing devices for lateral patient transfers: a clinical
evaluation. AAOHN J 2006;54(4):173–80.
[16] Nelson AL, Lloyd J, Menzel N, et al. Preventing
nursing back injuries: redesigning patient handling
tasks. AAOHN J 2003;51(3):126–34.
[17] Chaffin DB, Andersson GBJ, Martin BJ. Occupa-
tional biomechanics. 3rd edition. New York: John
Wiley & Sons, Inc.; 1999.
[18] VISN 8 Patient Safety Center of Inquiry. (2005).
Technology resource guide. Accessed September
14, 2006. Available at: http://www.visn8.med.va.
gov/visn8/patientsafetycenter/safePtHandling/default.
asp.
[19] Safe patient handling and movement: a practical
guide for health care professionals. In: Nelson A,
editor. New York: Springer Publishing; 2006.
[20] Collins JW, Wolf L, Bell J, et al. An evaluation of
a ‘‘best practices’’ musculoskeletal injury prevention
program in nursing homes. Inj Prev 2004;10:206–11.
[21] Nelson AL, Owen B, Lloyd J, et al. Safe patient han-
dling & movement. American Journal of Nursing
2003;103(3):32–43.
 Crit Care Nurs Clin N Am 19 (2007) 145–153
Psychosocial Factors in Musculoskeletal Disorders
Nancy N. Menzel, PhD, RN, COHN-S
University of Nevada Las Vegas School of Nursing, 4505 Maryland Parkway, Box 453018,
Las Vegas, NV 89154-3018, USA
Work-related musculoskeletal disorders (MSDs)
have a multifactorial etiology that includes not
only physical stressors but also psychosocial
risk factors, such as job strain, social support
at work, and job dissatisfaction. Once an injury
has occurred, psychosocial factors, such as de-
pression and maladaptive pain responses, are
pivotal in the transition from acute to chronic
pain and the development of disability. Inter-
ventions to prevent MSD incidence and address
psychosocial risk factors for delayed recovery are
described. There is broad agreement that work-
related MSDs have a multifactorial etiology, with
workplace and nonwork risk factors playing
a role in their cause [1–3]. In its preamble to its
Ergonomics Standard, the Occupational Safety
and Health Administration (OSHA) defined
a risk factor (stressor) as
a characteristic of the work environment that
research has shown to be associated with an
elevated occurrence or severity of MSDs. Risk
factors can involve purely external exposures,
such as shock or percussion, that act on the
musculoskeletal system. They can also involve
intrinsic response to a load or task, such as lifting
or rapid and awkward movement. The effect of
a risk factor may be modified by personal
characteristics, such as anthropometry and phys-
ical conditioning, or by concurrent or previous
non-work exposure. Risk factors can also involve
work organizational or social factors [4].
OSHA [4] defines biomechanical stressors as
‘‘the physical aspects of workstation, work piece,
tools, and work process that exert stress on the
body.’’ OSHA does not define ‘‘psychosocial risk
factor.’’ It justifies its exclusive focus in the
E-mail address: nancy.menzel@unlv.edu
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.006
standard on biomechanical risk factors by con-
cluding that they ‘‘contribute independently
from psychosocial factors, and exposure to bio-
mechanical risk factors has been observed to be
generally stronger than for psychosocial factors’’
[4].
Similar to the conclusions drawn by OSHA,
there is widespread scientific agreement about the
role of biomechanical risk factors in causing
MSDs in nurses, with strong research studies
and a comprehensive epidemiologic evidence
review supporting this conclusion [2,5–7]. The
evidence is not so clear, however, about psychoso-
cial risk factors, such as stress, as causative fac-
tors. Although many studies find an association,
the role these factors play in causation is unclear:
Are they independent factors or do they act as ef-
fect modifiers, altering the association between
physical stressors and MSDs? If they are indepen-
dent factors, what is the mechanism by which they
are believed to produce MSDs?
Psychosocial factor definitions
Psychosocial factors are defined in a variety of
ways. The National Institute for Occupational
Safety and Health [2] points out that it is a ‘‘catch-
all term’’ for the following: ‘‘1) factors associated
with the job and work environment, 2) factors as-
sociated with the extra-work environment, and 3)
characteristics of the individual worker.’’ It points
out further that these factors are believed to inter-
act with each other, affecting health and job per-
formance. Some factors specific to nursing
personnel that are identified in the literature fall
into all three categories.
Work-related factors include job satisfaction
[8], job strain (performing psychologically
ccnursing.theclinics.com
146
demanding tasks under time pressure while having
low control over the job) [9–11], time pressure
[12,13], high mental pressure [14,15], work rela-
tionships with coworkers [16], support at work
[11,15,17], and stress [18,19]. An extra-work envi-
ronment risk factor, amount of leisure time exer-
cise, was correlated negatively with low back
pain in Chinese nurses [18]. Individual (not
work-related) characteristics include pain coping
skills [20], premenstrual tension [14], having chil-
dren [14], and affective states (depression and anx-
iety) [21,22].
Why the contribution of psychosocial risk factors
remains unclear
The reasons that psychosocial factors lack
a supporting body of research evidence are
many. One is imprecision in psychosocial con-
struct definition. For example, work-related stress
in health care is defined and measured differently
in many articles on this topic, which may use
other terms, such as burnout or strain, instead of
stress [23].
A second problem is measurement of psycho-
social constructs. Whereas there are established
definitions of physical force and shear and how to
measure them, the opposite is true of constructs,
such as job strain or stress coping ability. Unlike
using objective computer programs with biome-
chanical models to calculate spinal compression
from lifting or strain gauges to measure push-pull
forces, to cite two ways to measure physical
stressors, psychosocial stress in nursing (and other
occupations) is measured using self-report (sub-
jective) instruments. These include diaries of un-
known reliability and validity [24], interviews that
leave the definition of stress up to the interviewee
[25], and instruments with acceptable psychomet-
ric values (reliability and validity), such as the Per-
ceived Stress Scale [20]. Finally, many of the
studies that have been done on psychosocial fac-
tor association with MSDs are cross sectional;
cross-sectional designs preclude inferring cause
and effect because it is not possible to determine
temporal plausibility. For example, a direct pa-
tient care provider may report back pain and de-
pression. Is the caregiver depressed because of
the pain or did the depression cause the pain?
A third problem is the lack of knowledge
about the biologic plausibility of psychosocial
factors as etiologic agents. In epidemiologic
studies, biologic plausibility occurs when the
MENZEL
association between two factors is consistent
with current medical knowledge. For example
how a psychosocial factor, such as job dissatis-
faction, is associated with the incidence of MSDs
is unknown, based on the state of the science of
the mind-body connection.
Four pathways for biologic plausibility are
hypothesized. The first is that psychosocial factors
result in muscle tension and increase spinal
loading; there are laboratory studies demonstrat-
ing this link [26–28]. The second hypothesized
pathway is that psychosocial factors may influ-
ence body awareness and result in reporting of
musculoskeletal pain or attribution of work fac-
tors as the cause. Third, psychosocial factors
may influence that transition from the original
acute injury to chronic pain, even after the origi-
nal muscle damage heals [29]. Finally, psychoso-
cial demands may be associated with physical
demands, making it seem that psychosocial fac-
tors are associated with MSDs when, in fact,
they may be confounders (not part of the real as-
sociation between exposure and disease) or effect
modifiers [30].
A fourth difficulty is the variability in outcome
definition and measurement, with some studies
using MSD pain but most using reported injury
incidence or lost days because of injury. Given
that occupational injuries are shown to be under-
reported by orders of magnitude, the latter out-
come is an unreliable and lagging indicator of
musculoskeletal stress and pain [31].
Because of the lack of standardization of terms,
tools, and outcomes, it is difficult to use meta-
analyses (the highest level of evidence) to assemble
a body of evidence using the same construct
definitions and the same measurement instruments
for psychosocial factors. One meta-analysis, how-
ever, does find an increased risk of prevalence of
occupational back pain from job dissatisfaction in
the general working population [8].
Conceptual models
The Institute of Medicine (IOM) [3] Panel on
Musculoskeletal Disorders and the Workplace
published a conceptual model for MSD etiology
that emphasizes physical risk factors, sidelining
individual risk factors outside the main causal
pathway. Although several other conceptual
models are proposed for the role of psychosocial
factors in the development of work-related
MSDs [32–34], there is none that has received
 PSYCHOSOCIAL FACTORS IN MSD
widespread acceptance, which hinders hypothesis
generation and research.
What is the evidence for psychosocial factors
as etiologic agents?
According to the Institute of Medicine [3], job
strain is the most prominent among the psychoso-
cial risk factors for upper-extremity disorders.
Other studies similarly have identified job strain
as a psychosocial risk factor for developing
MSDs [10,11,35,36].
Job dissatisfaction is associated with MSDs in
Norwegian nursing aides [37] and in Japanese, Ca-
nadian, and Icelandic nurses [14,38,39]. Similar
findings are reported for other occupational
groups [40–42]. Limited social support at work
is another psychosocial factor that has emerged
as a risk for MSDs among nurses [11,15,43].
Some individual factors are shown through
longitudinal studies to be associated with the
development of back pain: psychologic distress
or stress [19,44–46] and negative coping styles [46].
No extra-work risk factors are identified consis-
tently as etiologic risk factors.
What is the evidence for psychosocial factors
in disability and return to work?
There is evidence that psychosocial factors are
important in determining length of disability,
transition from acute to chronic pain, and return
to work, once a nurse or other worker reports an
MSD [17,47–50]. In a longitudinal study of more
than 1800 Canadian nurses, job strain and low so-
cial support at work were associated with sick
leave incidence and length [51] (although the study
does not identify the work-related injury that pre-
cipitated the absence). In another longitudinal
study of more than 4000 Norwegian nursing aides,
low support at work was associated with long-
term low back pain–related sick leaves [17]. In
a systematic review of six cohort studies of low
back pain, distress, depressive mood, and somati-
zation were associated with the transition from
acute to chronic pain [48]. For low back pain,
there is strong empiric evidence from prospective
studies that psychosocial factors are the predomi-
nant risks for developing chronicity and disability,
leading to calls for intervention early in the con-
tinuum of disease [49,50,52].
These empiric findings support the multidi-
mensional view of pain adopted by the pain
147
research community and reflected in the Interna-
tional Association for the Study of Pain [53] defi-
nition of pain, which states that pain is ‘‘An
unpleasant sensory and emotional experience as-
sociated with actual or potential tissue damage,
or described in terms of such damage.’’ Key to
this definition is the recognition that pain is mul-
tidimensional and includes not only sensory input
but also cognitive and emotional components.
Pain is a psychologic construct, not a physical di-
agnosis of tissue damage or other physical pathol-
ogy. When considered from this perspective, it is
not surprising why psychosocial factors, such as
emotion [54], work satisfaction [49], and psycho-
pathology [50], are important determinants of
pain chronicity and related disability. Further-
more, pain is a significant predictor of disability
[49,50], offering a direct path for the emotional
component of pain perception to influence
disability.
Because pain is a symptom that has sensory,
affective, and cognitive dimensions, its clinical
assessment depends on subjective reports. Because
disability is defined as restricted function, it can be
assessed reliably by self-report or work absence/
modification [55]. In chronic pain, in particular
low back pain, there may be no discernible struc-
tural impairment [55]. Tate and colleagues [56]
found that disability in back-injured nurses pre-
dicted the incidence of lost time, whereas self-
reported pain predicted how much time was lost.
A study by Waddell and coworkers [57] shows
little association between pain and disability.
Fear-avoidance beliefs about physical activity
(kinesiophobia) and work, however, were associ-
ated strongly with work loss and disability in ac-
tivities of daily living. These findings are
replicated in other studies [47,58,59].
In addition, pain catastrophizing (an exces-
sively negative orientation toward pain) is associ-
ated with chronic low back pain and disability
[47]. According to a conceptual model developed
by Vlaeyen and colleagues [58] and adapted by
Pincus and coworkers [48], when pain from an
original injury is interpreted as threatening (pain
catastrophizing), it results in fear of re-injury,
which leads to movement avoidance, hypervigi-
lance, and muscle reactivity, which lead to disuse,
depression, and disability, all of which maintain
pain. Individuals who do not catastrophize their
pain return to daily activities and recover quickly
[48,58].
These studies highlight the relationship be-
tween physical disability and psychosocial
148 MENZEL

function. Much like pain, disability is not a phys- Interventions to reduce psychosocial risk factors
ical diagnosis and has only a loose association for the incidence of musculoskeletal disorders
with tissue damage and measurable physical
In the psychosocial risk factor domain, only
pathology. This largely is because, from patients’
factors associated with the job and work environ-
perspective, disability results from an appraisal of
ment are under the appropriate control of em-
their functional abilities, the associated risks and
ployers. Although it might be possible to screen
benefits of function, and the expectations of the
for and refuse to hire nurses who have personal or
consequences of function. Like pain, disability can
extra-work risk factors, it is not legal, under
be considered a psychologic construct influenced
federal equal employment opportunity laws, and
by psychosocial factors as demonstrated in the
impractical in light of the nursing shortage.
empiric literature.
Although evidence for the role of work-related
Coping skills is a term found in the literature
psychosocial risk factors in the etiology of MSDs
on MSD pain and disability. Coping is defined by
is not as strong as for physical risk factors,
Lazarus and Folkman [60] as ‘‘constantly chang-
employers are well advised to address the factors
ing cognitive and behavioral efforts to manage
that have emerged simply as good business
specific external or internal demands that are ap-
practices that may reduce turnover and increase
praised as exceeding the resources of the person.’’
productivity, no matter what their musculoskele-
When a stressful situation is viewed as unchange-
tal health benefits.
able, emotion-focused coping is used to minimize
Job strain is a conceptual model developed by
emotional distress. Examples of emotion-focused
Karasek and colleagues [64–68] that states that
coping are using alcohol or drugs, overeating, or
work conditions involving the greatest mental de-
participating in a distracting activity. If a stressful
mand and lowest control over those conditions
situation is viewed as changeable, then problem-
produce the largest physical responses. They devel-
focused coping is called up to assess the situation
oped the Job Content Questionnaire to measure
and choose among the best solutions. In meaning-
job strain and other concepts [69] and found that
focused coping, a third strategy, stressed individ-
job strain is most severe among nursing aides,
uals modify interpretation of a stressful situation
who are at the lowest level of the health care hier-
by drawing on values, beliefs, and goals [61]. Al-
archy. Registered nurses (RNs), however, also feel
though escapist strategies often result in poor
little control over their work environment. Em-
mental health outcomes, other strategies, such as
ployers can address job strain through increased
seeking social support or choosing to change
participation, by letting nurses have a role in mak-
a stressful situation, may have positive or negative
ing assignments and agreeing on staffing ratios and
outcomes depending on individual appraisal of
by allowing nurse representation when important
the impact of the ‘‘important goals [that] have
management decisions are made.
been harmed, lost or threatened. These appraisals
Job satisfaction for nurses involves several
are characterized by negative emotions that are
variables, including pay [70,71], work organiza-
often intense’’ [62]. Cognitive-behavioral therapy
tion and workload [70,71], autonomy [72], stress,
(CBT) is effective in teaching coping skills [62].
and leadership issues [73]. Remedies for all these
According to this brief overview (above), psy-
issues are under employers’ immediate control,
chosocial factors, not tissue damage, are the most
based on an assessment of which ones are the
important factors in determining whether or not in-
most vexing to nurses in their institutions. Exit
dividuals develop disability and chronic pain after
surveys, conducted whe nurses leave employment,
an MSD. In addition, they are paramount in deter-
are one way to gather this information.
mining whether or not injured individuals take time
Low social support at work (from supervisors
off from work and the length of that leave. Despite
and peers) is identified as an MSD risk factor in
this evidence, the workers’ compensation treatment
many studies. Such support is vital to retain new
paradigm does not include approaches to address
graduates [74]. Social support equally is impor-
these factors until individuals have progressed so
tant, however, for all nurses because it serves as
far into disability and psychologic deterioration
a coping mechanism, reducing stress from the de-
that the chance for recovery and return to work is
manding job of nursing [75]. Employers should
remote [63]. Given the high cost of rehabilitation
promote social support by encouraging collegial
(tertiary prevention) compared with screening
networks and offering management training that
and early intervention (secondary prevention),
emphasizes nonpunitive approaches to leadership.
this treatment approach is not evidence based.
 PSYCHOSOCIAL FACTORS IN MSD
Interventions to reduce psychosocial risk factors
for musculoskeletal disorders and disability
Once an MSD is reported, the no-fault
workers’ compensation system is activated.
Nurses receive immediate medical care at no
cost. Treating health care providers determine
whether or not nurses can return to full or
modified duty or should remain away from work
for a specified number of days until a follow-up
visit. Whether or not nurses are paid for the days
away from work depends on whether or not they
have any paid sick leave and jurisdictions’ waiting
or elimination period for indemnity (wage re-
placement) benefits. The treatment provided
follows the jurisdiction protocol and other occu-
pational health guidelines, depending on the in-
jury. These protocols and guidelines focus on
rapid return to work. In the acute stage of injury,
the guidelines do not recommend any screening
for psychosocial risk factors, despite evidence that
these determine whether or not the pain transi-
tions to a chronic state, whether or not disability
develops, and the length of time workers stay out
of work. One reason for this avoidance is the fear
of employers and insurers that any referral for
psychologic assessment will result in a costly
workers’ compensation claim for stress or mental
health issues, such as depression. No studies have
been conducted, however, to validate or disprove
this concern.
Cognitive-behavioral therapy
CBT is shown effective as treatment for
chronic pain and depression [76–79]. CBT is based
on the premise that thought influences emotion
and behavior. Several cognitive styles, such as
pain catastrophizing, are related to poor outcome
[80]. CBT is a psychologic treatment approach
aimed at reducing distorted thinking patterns
and behaviors by replacing them with more realis-
tic substitute patterns that are critical to adjusting
to pain and injury (eg, exercise, relaxation, or
avoidance). Linton and Ryberg [81] found that
CBT prevented low back pain disability [82].
Hasenbring and associates [82] replicated this
finding.
Coping
CBT
Skills
Fig. 1. CBT to reduce MSDs.
149
Psychosocial stress and affective responses to
pain cause or worsen MSDs and associated
disability in direct patient care providers. CBT is
shown effective in helping individuals cope with
stress and pain and preventing or reducing MSDs
and disability [20]. Fig. 1 is a conceptual model of
how CBT is believed to work. Accordingly, em-
ployer and workers’ compensation insurers should
consider asking occupational health care pro-
viders to screen those who have new MSDs for
psychosocial risk factors and refer them to
a pain center for CBT. Screening tools include
the Beck Depression Inventory [83], Fear-Avoid-
ance Beliefs Questionnaire [57], Tampa Scale for
Kinesiophobia [58,84], Pain Catastrophizing Scale
[85], and the Pain Disability Index [86].
Case study
Kathy is a 58-year-old RN who has worked in
a medical ICU at a large, tertiary-care medical
center for 15 years. Although she has had work-
related back pain intermittently for the past 5
years, she has not reported it because of fears of
reprisal or job loss. Staff members who report
workers’ compensation injuries are shunned by
other staff members, who feel they have to
assume additional work for the person who is
on modified duty or absent. Her goal is to
complete 4 more years of work until she turns
62, then apply for social security retirement. She
does not like her nurse manager and her author-
itarian style. Kathy is older than all the other
RNs on her unit and finds little in common with
them. She lives alone, after a divorce 10 years
ago. She has no outside activities and spends her
days off watching television and eating to excess.
Because she works in a unit with mandatory
overtime, the nurse manager tells her she must
work 16 hours on a day that later requires her to
push an occupied stretcher. As she maneuvers the
stretcher around a corner, she assumes an awk-
ward posture and feels intense pain in her lower
back. Pain radiates down her right leg; she is
unable to complete the patient transport and calls
for assistance. Too much in pain to complete her
work assignment, she goes to the employee health
department for evaluation and treatment. Be-
cause of her incapacity, she is sent home from
work with a prescription for pain and muscle
relaxants.
Stress MSD
Pain Disability
150
The next day, she has difficulty arising from
bed without incurring severe pain and decides to
stay in bed all day not only that day but also the
next 2 before her follow-up appointment. She
barely is able to show up for her appointment, so
afraid is she of pain from moving. At the same
time, she has thought with dread about the effect
this injury will have on her plans for working 4
more years until retirement. She is certain that
she has suffered a career-ending injury, which will
have profound economic consequences.
The treatment provider refers her to physical
therapy to assist her in movement, but she misses
most of the appointments because of fear of pain
from travel and therapy. A radiograph of the
back reveals no damage other than age-related
degenerative changes in the spine. The workers’
compensation adjuster calls her to threaten claim
denial if she misses any more appointments.
Kathy calls an 800 number flashed on a television
advertisement for a workers’ compensation at-
torney and retains counsel. Her nurse manager
calls to ask when she will be coming back to work
because they are short staffed. Kathy is unable to
cope with the stress and spends her days in bed
crying and overeating. After Kathy has missed 3
months of work and received extensive medical
testing and treatment, she is referred to a neuro-
surgeon for back surgery evaluation. The neuro-
surgeon treats her chronic pain by operating on
her spine. The result is no improvement. At 6
months, the adjuster sends Kathy to a functional
rehabilitation program, but she fails the prepro-
gram psychologic screening tests for likelihood to
benefit from the program. Kathy never returns to
work.
Analysis: The work-related psychosocial risk
factors for back injury incidence were obvious
and unaddressed, making an MSD inevitable,
given the interaction of those factors with a phys-
ical stressor and the nature of cumulative trauma.
The employer could have improved social sup-
port for Kathy and similar experienced nurses by
forming a ‘‘brain trust’’ that meets periodically to
network and plan mentoring programs for new
graduates. The employer could have eliminated
its mandatory overtime policy, which creates job
dissatisfaction and stress.
Once Kathy experienced pain severe enough to
report an injury, the health care provider failed to
assess or intervene in any domain but the
physical. Kathy was exhibiting signs of depres-
sion even before the injury; once the acute injury
occurred, the depression worsened and resulted in
disability. She developed pain-related fear of
movement and pain catastrophizing, which
served to maintain the pain state. Her coping
skills consisted of distracting behaviors and were
no match for the perceived threat of the injury.
MENZEL
No amount of neurosurgery could cure her
depression and maladaptive pain-related behav-
iors, but when all you have is a hammer, every-
thing looks like a nail. Had the health care
provider done some simple screening tests at the
first follow-up visit, when it was obvious that
Kathy was not making progress, the outcome
would have been much different had she been
referred to appropriate resources with the cost
covered by workers’ compensation.
Summary
Epidemiologic studies provide only supporting
evidence of the causes of a disease, not direct
proof [87], a fact that tobacco companies were
able to exploit for many years in getting the public
to believe there was scientific uncertainty that cig-
arettes cause lung cancer. For diseases, such as
MSDs, that have multifactorial origins, a single
smoking gun never will be discovered. What is
needed is a conceptual model that acknowledges
the contributions of each factor and allows hy-
pothesis generation and empiric testing. Control
of psychosocial risk factors by federal regulators
is not on OSHA’s agenda, after its Ergonomic
Standard to control physical risk factors was re-
scinded by Congress and the White House in
2001. With no mandatory control imminent,
health care employers, treatment providers, and
risk managers should use the precautionary prin-
ciple (taking protective action in the face of lack
of scientific proof of a threat) to act as if psycho-
social factors were important contributors to the
incidence and severity of MSDs and provide ap-
propriate interventions for job strain, job dissatis-
faction, and inadequate social support at work.
Once injury occurs, workers’ compensation in-
surers should support holistic treatment and not
focus exclusively on physical risk factors. Mood
state and abnormal reactions to pain complicate
or prevent recovery if they are not addressed along
with measures that promote physical healing.
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 Crit Care Nurs Clin N Am 19 (2007) 155–165
Ergonomic Assessment of a Critical Care Unit
Sheri Stucke, PhD, APN,
Nancy N. Menzel, PhD, RN, COHN-S*
University of Nevada Las Vegas School of Nursing, 4505 Maryland Parkway,
Box 453018, Las Vegas, NV 89154-3018, USA
Direct patient caregivers experience a high in-
cidence rate of musculoskeletal disorders (MSDs)
and a high prevalence of musculoskeletal pain [1].
The back is the body part injured most frequently,
but injuries to the shoulder, neck, arm, and knees
also are reported. Nursing assistants have higher
rates of injuries than licensed nurses, but registered
nurses (RNs) are a perennial finisher in the Top 10
of most MSDs reported [2]. Although patient han-
dling is the reason cited most recently for MSDs,
shift work and long work hours are known to pre-
dispose to injury [3,4].
Unlike the body of knowledge that documents
the musculoskeletal risks associated with manual
patient handling in nursing homes [5–7], there are
few studies about similar risks for critical care
nurses. There is, however, some evidence that crit-
ical care nurses experience MSDs at least as much
as other nurses. One study from Canada found
a back pain point prevalence of 25% for critical
care nurses compared with 30% for orthopedic
nurses [8], whereas another study in the Nether-
lands found a 12-month prevalence of low back
pain of 75% in intensive care nurses compared
with 76% for nonspecialized nurses [9]. Intensive
care nurses in an Australian study had a manual
patient handling injury incidence rate of 52%
[10]. As researchers, administrators, and legislators
implement safe patient handling interventions for
nursing homes and other areas with high incidence
rates of injury, such as orthopedics, the incidence
and severity of injuries to the back, neck, and
* Corresponding author.
E-mail address: nancy.menzel@unlv.edu
(N.N. Menzel).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.005
shoulder in those workplaces will begin to decline.
The next challenge is protecting the health and
safety of nurses working in lower-risk specialty
areas, such as operating rooms and critical care
units (CCUs). Because nurses under-report work-
related injuries [11,12], the true injury incidence
rates of these units likely are much higher than
now supposed.
Background
As with many modern approaches to nursing
care, the concept of intensive care originated from
innovations implemented by Florence Nightingale
in the Crimean War, when she grouped the
soldiers injured most seriously together and pro-
vided revolutionary approaches to the prevention
of infection and epidemics [13]. Today, critical
care nursing is not limited to a specific unit or
area but is located wherever critically ill patients
are receiving care. This may be emergency rooms,
operating rooms, cardiac catheterization labora-
tories, progressive care units, telemetry units,
postanesthesia care units, or CCUs, also known
as ICUs. CCUs are special areas designed to
care for patients who are medically unstable and
at risk for death. They are characterized by high
nurse-to-patient ratios, such as 1:1, 1:2, or 1:3,
the most common ratio being 1:2. Even though
CCUs may vary significantly by their number of
beds, specialty, and design among hospitals, they
are designed to provide constant nursing and
medical surveillance of patients who have multiple
problems and are receiving multiple treatments.
According to the American Association of
Critical Care Nurses statement to the Institute
of Medicine Committee on Work Environment
ccnursing.theclinics.com
156 STUCKE & MENZEL
for Nurses and Patient Safety [14], there are nearly
1.3 million RNs taking care of hospitalized pati-
ents, with an estimated 403,000 of them critical
care nurses. CCUs are staffed with highly trained
RNs. These RNs receive advanced education by
attending critical care courses, usually offered by
the hospitals where they are employed. These
courses offer advanced education in systems,
such as neurology, cardiovascular, respiratory,
gastrointestinal, nephrology, and in areas, such
as hemodynamic monitoring and 12-lead EKG
interpretation, among other topics. The focus is
exclusively on the care of complex patients, not
on recognition of and protection from the special
occupational risks faced by critical care nurses.
A report released by the Health Resources and
Services Administration (HRSA) found that pa-
tients in acute care hospitals currently receive
more than 18 million days of care in ICUs every
year [15]. During the next decade, the demand for
ICU services is projected to grow rapidly because
of increased acuity of hospitalized patients and
the growth of the aging population. According
to the HRSA, the number of available physicians
who specialize in critical care, also known as
intensivists, likely will not meet the demands of
the aging population by the year 2020 [15]. This
has a direct impact on nursing because this short-
age will place increased demands on critical care
nurses, who already are scarce because of the
current and projected nursing shortage [16]. As
patient load or hours of work increase, the risk
for MSDs from manual patient handling exposure
increases.
Many of the patients located in critical care
areas are physically dependent and require spe-
cialized medical equipment, such as cardiac mon-
itoring, ventilator support, multiple intravenous
(IV) infusions, and possibly other technology that
can crowd the work area around patients. This
abundance of machines can make it difficult for
nurses to provide direct patient care without
maneuvering the equipment. A typical patient
room in a CCU (often retrofitted from another
use) has many pieces of equipment and furniture
at the bedside, which can restrict access to patients
and force nurses to assume awkward postures
when delivering care. There are many cables and
IV poles that also put nurses at risk for tripping.
Critical care nurses may be at high risk for MSDs
from repetitive movements, such as lifting heavy
loads and frequent patient repositioning.
Ergonomics is the science of adjusting job
tasks to match the capabilities of the worker.
The nursing workforce is approximately 95%
female [16], meaning that work tasks should be
designed to accommodate a workforce that is
shorter and has less upper body strength, a shorter
reach, and less grip strength than a workforce
with a higher percentage of men. Health care,
however, has lagged behind many other indus-
tries, such as warehousing and transportation,
that long ago instituted protections for their pri-
marily male workers from heavy, frequent lifting
and holding awkward postures. Reasons that
nurses have not received similar protections in-
clude a singular focus on patient (not worker)
health; a tradition in nursing schools of teaching
ineffective lifting procedures, such as body
mechanics [17]; lack of occupational health and
safety regulation; and a primarily female work-
force kept at the bottom of a hierarchic manage-
ment structure [18].
Because the nursing shortage is severe and
persistent, some institutions have begun to look at
ways to improve retention of their existing nursing
workforce. One key is reducing the number and
severity (length of absence) of work-related
injuries, of which MSDs are the most costly and
most likely to result in days lost from work or on
modified duty [19]. The most effective way to
reduce these injuries is by conducting a thorough
ergonomic assessment that identifies hazardous
tasks and conditions and instituting an ergonom-
ics program designed to reduce these risks.
Purpose
Because of the dearth of knowledge about
specific risks associated with the provision of
critical care, the authors conducted an ergonomic
assessment of a 23-bed medical ICU in 409-bed,
acute-care hospital in Las Vegas. The second
purpose was to evaluate the applicability to
critical care settings of the instrument, Ergonomic
Workplace Assessment Protocol for Patient Care
Environments in the Patient Care Ergonomics
Resource Guide (the Guide) [20].
Methods and materials
This was a qualitative study. The researchers
followed steps 1 through 7 of the protocol de-
scribed in the Guide:
1. Collect baseline injury data.
2. Identify high-risk units.
3. Obtain presite visit data.
 ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
4. Identify high-risk tasks.
5. Conduct team site visit at each high-risk unit.
6. Perform risk analysis.
7. Formulate recommendations.
8. Implement recommendations; involve end
users in selecting equipment
9. Monitor results; evaluate program; continu-
ously improve safety.
Steps 1 and 2: collect baseline data and identify
high-risk units
Because this was purposive and convenience
sampling, the authors did not select among areas
for the one with the highest injury rate. The
hospital allowed the researchers access to its 23-
bed medical ICU (MICU), where the staffing ratio
was one nurse for every two patients.
Step 3: obtain presite visit data on high-risk units
After receiving Institutional Review Board
approval, the authors requested that the CCU
manager complete the Pre-Site Visit Unit Profile
(Fig. 1) before their visit. Because of a recent
change in the position, however, the new nurse
manager did not feel she had the required knowl-
edge or time to complete the questionnaire. She,
therefore, designated another management-level
RN (the supervisor) who assists with the MICU
(and also is the facility’s risk manager) as the
person to complete the Pre-Site Visit Unit Profile
before the visit.
The Occupational Safety and Health Adminis-
tration log showed no MSDs for the MICU in
2004, 2005, and the first 9 months of 2006. The
maximum number of RN full-time equivalent RNs
assigned to the unit was 51. The supervisor did not
answer the question about the percent of full-time
equivalents filled. On the day of the focus groups,
two participants from the MICU were not regular
employees (one agency nurse and one travel nurse).
There were no planned changes to staffing levels or
bed numbers. The manager checked the box next to
‘‘dependent’’ without filling in a percentage. In
focus groups with staff members, nurses estimated
the percentage of dependent patients as 85% to
90%. For patient handling equipment, the super-
visor listed four Hoyer lifts (‘‘rarely used’’) and two
slide boards (‘‘frequent use’’). The Hoyer lifts were
stored on another floor, however. Staff seemed
unaware of their existence. She did not identify
built-in scales in the beds. The supervisor identified
as a problem area the inability of patients to move
and a need for ‘‘improved beds.’’ Although she
157
identified storage as a problem, she felt there was
adequate room in patient units to carry out patient
care tasks.
Step 4: identify high-risk tasks
The authors then conducted three focus groups
with 11 RNs (two men) working on the 12-hour
day shift (7:00 AM to 7:00 PM) on August 18, 2006,
to identify high-risk tasks. The focus groups were
conducted in the nurses’ break room, which was
located within the MICU. This was a private, con-
venient location. Participation in the focus groups
was voluntary. Breakfast items were offered to
those RNs who inquired or participated in the fo-
cus groups. After a prospective participant read
the informed consent and had an opportunity to
ask questions about the study, the researchers
gave a $20 gift card to a local store to those
who agreed to participate. Both researchers were
present during the entire interview process. The
focus group outline, modified from the one in
the Guide, is as follows:
1. What conditions or situations in critical care
put you at risk for back strain and injuries?
2. What critical care lifts or transfers are the
most difficult and present the highest risk?
3. What are the factors that make a lift or trans-
fer a high-risk activity?
4. What types of critical care patient conditions
contribute to high-risk situations?
5. What do you think can be done to reduce or
minimize a high-risk situation?
6. What are the barriers to risk reduction? In
other words, what are some of the reasons
that you don’t take precautionary steps?
Although the protocol recommends this step
only for identifying high-risk tasks, other issues,
such as staffing, emerged during the focus groups.
The data were reduced to common themes. The
most frequent or most intensely reported themes
for MSD risks were
1. Patient characteristics: heavy (obese), depen-
dent, resistant/combative
2. Hazardous tasks
 Transporting patients and their extensive
equipment (while manually ventilating
them on occasion) in beds with balky wheels
and IV poles that do not glide
 Frequent turning and repositioning patients
in bed
158 STUCKE & MENZEL

Fig. 1. Pre-site visit unit profile.

 ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT 159

Fig. 1 (continued)

 Reading body fluid levels 6 inches off the 3. Equipment

floor
 Emptying urine drainage every hour from 6
inches off the floor
 Having to maintain awkward postures for
prolonged periods of time during procedures
 Lack of safe patient handling and lifting
equipment, in particular self-propelled beds
 Need to get help from other staff members
for manual patient handling because of
lack of equipment
160 STUCKE & MENZEL
4. Staff
 Not enough staff to allow nurses to help
other nurses reposition or transport their
patients. Causes delays in patient care.
 Large variation among caregivers in height
and strength
 75% of staff complaining of current or
recent musculoskeletal pain
 Staff reluctance to report MSDs because of
fear of management repercussions (‘‘being
blackballed’’)
5. Maintenance
 Wheels on beds are not well maintained to
ease push/pull stress of bed transports
 IV poles broken
6. Shift length and scheduling
 12-hour shifts and frequent overtime con-
tribute to fatigue and musculoskeletal pain
7. Unit layout
 Extensive walking required
 Limited opportunities to sit
Some of the participants had misconceptions;
namely, that body mechanics are effective in
preventing injury and that if a nurse was injured,
it was because of his or her lack of fitness or
technique. The facility perpetuates this belief by
providing annual training in body mechanics. Staff
members did not know that there was a recommen-
ded weight limit for patient handling or what that
recommendation was, which is a maximum of 35
pounds [17].
From the preliminary questionnaire and focus
group data, the authors prioritized high-risk
patient handling tasks according to the protocol
(Table 1). The researchers did not include all of
the tasks in the Guide, as many were not applica-
ble or uncommon in this MICU (eg, lifting a pa-
tient from the floor or bathing a patient on
a shower trolley). Instead, the researchers added
tasks to the list that were more common in the
MICU.
Step 5: conduct team site visit for ergonomic
assessment
After meeting with the acting supervisor and the
head nurse, the researchers toured the MICU to
evaluate observable risks. The unit seemed to have
been converted from a standard semiprivate med-
ical-surgical floor by removing one bed from each
room to create single rooms. This layout reduced
or eliminated visibility of patients from the nurses’
station, however, so staff nurses established
makeshift substations near their assigned patients.
The medication carts were not height adjustable.
The hallways were crowded with furniture and
medical equipment, making navigating an occu-
pied bed to or from the elevator difficult. The staff
reported that the doors to the CT scan room are
opened manually, requiring nurses to hold an
awkward posture with hips and feet to keep the
door open until the bed is pushed through.
Based on information from the supervisor,
focus groups, and the site visit, the researchers
completed a unit summary sheet (Table 2).
Step 6: risk analysis
After reviewing the baseline injury, presite
visit, focus group, observational data, and the
identification of high-risk tasks, MSD risk factors
were identified. These include
1. Lifting/moving heavy loads
2. Reaching and lifting with loads far from the
body
3. Pushing a load a significant distance
4. Squatting
5. Maintaining awkward postures
Environmental hazards included cluttered hall-
ways, broken bed wheels, monitors not adjustable
to accommodate the gaze of the shortest nurses,
and a physical layout that required nurses to walk
long distances for medications, supplies, and
charting. Walking more than 3.5 miles per shift
is considered a risk factor for musculoskeletal
discomfort [21].
Step 7: formulate recommendations
The Guide suggests that recommendations
should be achievable and simple and includes
two categories: engineering design and adminis-
trative solutions. Engineering controls involve
external changes to the way a job is performed,
for example, the use of a mechanical lift to move
a patient from a bed to a stretcher. Administrative
controls affect the way work is done or the hours
of exposure to risk. For example, if a hospital
offers 8-hour shifts instead of 12-hour, each
caregiver’s exposure to hazardous MSD risks is
reduced by 4 hours per day, allowing adequate
recovery time between work periods.
The researchers made the following recom-
mendations. Because ergonomic concepts are new
to this facility, the first step is for the supervisor to
bring her concerns about staff safety and risks to
hospital management for further discussion.
Table 1
Prioritization of high-risk patient handling tasks
Patient description
Medical patients with
multiorgan system failure,
80%–85% dependent,
many on ventilators
and all attached to monitors,
IVs, and other equipment
Unit Miscellaneous
description information Equipment Problems identified
23-bed medical Recent 2 slide/surf High risk from transporting
ICU, all change in boards; 4 patients in beds
private rooms unit manager specialty
with private beds on
baths order for
trial
For profit hospital
Staff is unionized Turning side to side in bed
or pulling up in bed a problem
No preventive maintenance on
bed wheels
Large proportion
of obese patients
Transferring patients from
stretcher to bed
Fatigue from long shifts
Reading urinary output bags
or chest tube drainage when
stooped
Extensive walking
High reported prevalence of
MSD pain but zero injury
reporting for 2.5 years
Awkward postures from applying Rearrange standing medical order form to list
femoral pressure manually
Awkward postures from using
medicine cart
Awkward postures from reading Increase downward height adjustability of
cardiac and other monitors
Solutions
Self-propelled beds or ERGOtug Medical
Mover. Clear halls of extra equipment. Put
electric doors on CT scan room
Explore value of friction-reducing devices
ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
Institute routine maintenance program
On admission for patients over 250 lb, rent
bariatric beds or consider purchase if
percentage of bariatric patients exceeds
30% in a 3-month period
Powered lateral assist device or AirPal
Limit overtime; provide seating and break
opportunities
Provide mirrors on poles to visualize levels
without stooping. Change emptying
frequency to every 3 hours once level
is read and recorded.
Redesign unit layout with mini–nurse stations.
Provide chairs reserved for nurses in recessed
hall areas and in nurses station, where chairs
often are taken by medical residents
Encourage early reporting and intervention
for MSDs
Femstop first to encourage this choice over
manual pressure
Obtain height adjustable cart
161
monitors or provide short staff with step stools
162 STUCKE & MENZEL

Table 2
Unit summary sheet
Patient handling task Frequency of task Stress of task Ranka
Transporting patient H H 1
off unit
Repositioning patient H H 1
from side to side
Lifting patient H H 1
to head of bed
Bathing a patient in bed M H 1
Transferring patient: M H 1
bed to stretcher
Transferring patient: L H 1
bed to chair
Making an occupied bed H H 1
Weighing a patient M L 10 (beds have built-in
scales)
Emptying catheter H H 1
drainageb
Reading chest L H 1
tube drainageb
Applying pressure M H 1
on femoral arteryb
Abbreviations: H, high; L, low; M, moderate.
a
1 indicates high risk; 10 indicates low risk.
b
Indicates high-risk task added to list in the Guide under ‘‘Other.’’

Without management support, no program in approach based on ergonomics is to encourage

ergonomics will succeed.
Prior to meeting with hospital management,
the supervisor should prepare a business case
(cost-benefit analysis) for intervening by compil-
ing information on the direct and indirect costs of
MSDs in the facility’s staff for the past 2 years.
Direct costs usually include workers’ compensa-
tion medical care and wage replacement (data
available from insurer), whereas indirect costs
include the cost of hiring replacement nurses
to cover absences, among many other consider-
ations. Indirect costs are estimated as equal to
direct costs [22]. In this facility, with a nearly
3-year record of no reported injuries, the supervisor
must recognize that there has been suppression of
reporting, based on the prevalence of MSDs the
staff described during the focus groups and their
fear of reporting. A better indication of the direct
cost of MSDs in this facility is the number of un-
scheduled absences (ie, the number of days when
nurses call in sick or take a personal day with
no prior notice). These absences translate into
costs for overtime and agency nurses. An addi-
tional cost is turnover; when a nurse feels her
health is at risk, she may move to an area
with less perceived MSD risk. This is a phenomenon
called the ‘‘healthy worker effect.’’ A management
early reporting, when intervention can be more
effective, rather than waiting until pain and dis-
ability are severe. In addition, the supervisor
should have a cost estimate for engineering
and administrative controls recommended.
The supervisor also should come prepared with
evidence that ergonomic interventions actually
reduce injuries, absenteeism, and turnover [5,23].
The supervisor can find resources at the Patient
Safety Center’s Web site [24].
Once hospital management is convinced that
there is a costly problem that can be prevented or
lessened, the facility can embark on a participatory
ergonomics program involving staff nurses in all
areas. Staff nurses’ participation is vital to the
success of any program because they must have
a say in engineering and administrative controls to
ensure they will be accepted.
Discussion
The researchers found challenges in following
the Guide’s protocol; some steps seemed out of
sequence or redundant. In particular, the unit
summary sheet in step 5 calls for a list of solutions
before risk analysis is completed or
 ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
recommendations formulated. In addition, step 4
calls for identifying high-risk tasks by ‘‘job obser-
vation, questionnaires to employees or brain-
storming sessions with patient handlers’’ before
the site visit occurs in step 5, which implies two site
visits. The protocol’s list of high-risk tasks in step 4
seems most appropriate for a nursing home
setting, not critical care. Judging from missing or
inappropriate responses, some questions on the
Pre-site Visit Unit Profile form were difficult for
the supervisor to understand. The protocol should
be edited to make it more generic and easier to
follow. Finally, it should be expanded to include
gathering information on other risks that affect
MSD incidence, such as the average number of
hours a nurse works, the facility’s climate for
reporting work-related injuries and other signs
that lifting burdens may be too great, such as staff
turnover.
The researchers noted the following differences
between MSD risks in this MICU and nursing
homes.
1. In this MICU, almost all patients were
completely dependent. In nursing homes,
some proportion of residents can assist at
least partially.
2. Nursing home patients almost always are
ambulated or transferred to wheelchairs
daily. In this MICU, patients are not trans-
ferred out of bed as frequently.
3. Bed transport is frequent in MICU, infre-
quent in nursing homes.
4. Staff are all RNs in MICU; the majority are
certified nursing assistants in nursing homes.
5. Medical procedures are performed more fre-
quently at bedside in MICU.
6. MICU patients have much more equipment
attached to them than those in nursing homes.
7. Nurse-to-patient ratio is 1:2 in MICU; it may
be 1:12 or more in nursing home.
8. MICU patients do not require feeding very
often; caregivers often must feed nursing
home patients (awkward postures).
The data were obtained from one CCU in one
hospital during one shift in one city, so the
findings are of limited generalizability. They do
indicate, however, that MSD risks are present in
critical care environments. To preserve the valu-
able resource of highly skilled practitioners safe
and at the bedside, hospital administrators must
begin to pay attention to the special risks they
face and provide effective interventions. The
163
nurses who work in these areas also should
demand these protections. A major nurse union,
United American Nurses, is a cosponsor with
the American Nurses Association for the Handle
with Care campaign to eliminate manual patient
handling. It also passed a resolution to take
political action to seek federal and state legislation
to protect nurses from the hazards of manual pa-
tient handling [25].
Recommendations
Judging from this small study and a search of
the articles published in critical care nursing
journals, critical care nurses are only minimally
aware of the MSD risks they are exposed to during
their shift. During the focus group interviews in
the MICU, nurses were able to articulate the
importance of properly arranging patients and
necessary equipment before procedures are per-
formed to prevent awkward positioning of their
bodies. Most nurses were unaware, however, of
the special equipment available to assist them in
preventing musculoskeletal injuries, when trans-
ferring patients, for instance. Critical care nurses
must be educated about the urgent need for
assistive equipment in their specialty areas, so
they can demand this equipment and safer work
practices. Nurses seeking to change employers
should inquire about ergonomic protections avail-
able in their potential new workplaces and refuse
to work where they do not exist.
It is necessary for critical care nurses to change
their paradigm from patient focus to the nurse/
patient safety dyad. Nurses need to be aware that
although they need to provide safe care to their
patients, they also need to protect their own safety
and that of their peers. The men in the study
reported that they were asked more frequently
than female staff members to help with patient
movement, thereby increasing their exposure to
hazardous tasks. With the current nursing
shortage, retention of critical care nurses is vital,
especially with the elderly population growing at
such a fast rate. Two younger nurses in the focus
groups recognized they are at risk for muscu-
loskeletal injuries by stating they currently do not
have back pain but realize they probably will in
the next few years. This resigned way of thinking
must change to one of optimism for a long career,
given proper workplace protection from the
hazards of manual patient handling, awkward
postures, and repetitive motion leading to cumu-
lative trauma.
164 STUCKE & MENZEL
Even with the safe patient handling initiatives
that have been introduced during the past few
years, critical care nurses still are unaware of
the alarming statistics regarding MSDs in health
care. Dissemination of new knowledge is pre-
sented to the nursing community at conferences
through poster presentations and oral presenta-
tions. Many nurses may not attend conferences
and, therefore, miss the information presented.
Another method for distribution of new knowl-
edge is through articles published in clinical and
research journals. When nurses read professional
journals, it usually is a journal in their field of
practice and expertise; therefore, publishing
articles related to musculoskeletal injuries (such
as this one) in critical care journals (such as this
one) is one way to reach this specialty. Some
nurses may not read journal articles, howeverd
a dissemination dead end.
Another way to distribute information to
critical care nurses is through their professional
organizations. Local chapters of professional
organizations, such as the American Association
of Critical Care nurses, are a good venue for
disseminating information to nurses who special-
ize in critical care. For instance, chapters have
meetings and educational offerings at local facil-
ities that are more convenient for nurses to attend
than national conferences, especially if continuing
education credits are offered.
A change in paradigm may create some re-
sistance, especially when the change involves
something that has been accepted and done the
same way for many years. Lewin’s model of
planned change describes a three-step framework
for instituting change. The initial step is the
unfreezing stage or preparation for change [26].
During this step, unions and professional organi-
zations inform nurses about MSD statistics in
health care, MSD hazards from manual patient
handling, critical care tasks and environmental fac-
tors that have the highest risks, actions they can
take to prevent injuring themselves, and modern
technologic assistance available to reduce the risks
that lead to MSDs. This is the step where nurses are
influenced and become interested in engaging in
change to improve their current practices.
The second step in Lewin’s model of planned
change is movement or changing. During this step,
nurses shift their behavior to a new level. They can
speak with their nurse managers regarding the
necessary changes needed to initiate a comprehen-
sive ergonomic program in their facility, including
trying out available assistive devices to determine
what equipment is most beneficial for high-risk
critical care tasks. Feedback from end users is
crucial, because they are the nurses who use the
equipment every day. Equipment that requires
distant storage or that slows down the time it takes
to deliver care is destined to be abandoned. If staff
nurses are not comfortable or satisfied with the
equipment, then the equipment goes unused and
the nurses revert to manual patient handling.
The final step in Lewin’s model of planned
change is the refreezing stage. During this step,
nurses have implemented the new changes in their
practice with the equipment they have chosen to
be most beneficial for them. Because the nurses
actively were involved with this change from the
beginning and should be experiencing the benefits
of reduced pain and fatigue, they are more likely
to accept and continue the new safe patient
handling practices.
Summary
Although the ergonomic assessment tool pro-
vided a good foundation for assessing a CCU, it
should be revised to improve its clarity, sequencing,
and applicability in a range of settings. This
qualitative study indicates that even in a critical
care area where there are no reported injuries,
MSDs can be prevalent. The critical care work
environment may involve risks in addition to those
present in all nursing workplaces by virtue of the
preponderance of dependent, obese patients; the
challenge of delivering multiple, concurrent in-
terventions to patients surrounded by a collection
of modern technology inserted into an architec-
tural space not designed to accommodate it; the
need for bed transports to centralized technology
or services; expenditures for high-tech equipment
for patient care and not worker safety receiving
budget priority; and the frequency of repetitive
tasks involving awkward postures. Hospital
administrators, professional organizations, unions,
researchers, and equipment vendors should turn
their attention to protecting critical care nurses
from manual patient handling, an antiquated
work practice unable to meet the demands of
a twenty-first century work environment.
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 ERGONOMIC ASSESSMENT OF A CRITICAL CARE UNIT
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 Crit Care Nurs Clin N Am 19 (2007) 167–175
Evaluation of Critical Care Space Requirements
for Three Frequent and High-Risk Tasks
Sue Hignett, PhD*, Jun Lu, MArch, BEng
Healthcare Ergonomics and Patient Safety research Unit (HEPSU), Department of Human Sciences,
Loughborough University, Loughborough, Leicestershire, LE11 3TU, UK
Many investigators have identified that staff
and patient safety can be compromised if in-
sufficient space is provided [1–5]. Even if sufficient
space is available, the layout and ergonomic de-
sign of workspace may restrict activities and con-
tribute to adverse events [6,7]. In the United
Kingdom (UK), there are health and safety laws
that, for example, require ‘‘every room [to] have
sufficient floor area, height and space for the pur-
poses of health and safety’’ [8]. This is a cross-
industry regulation that applies mostly to employee
activities but also to all users of a space, includ-
ing patients and visitors.
Many guidance publications are available to
assist designers (architects) in planning hospital
spaces; they include topics on health and safety,
hospital design, and clinical guidance. The recom-
mendations for bed space (single rooms or cubicles
in shared rooms) have increased since 1992, but
little empiric evidence is published to support the
proposed dimensions.
To test the space requirements for critical care
tasks, three frequent or space-critical tasks were
simulated in a full-size mock-up. The mock-up was
based on the measured dimensions from four UK
critical care units built since 2000. The selected
tasks were determined by a previous field study [9]:
washing and dressing patients and moving them
This work was supported by Grant no: B(02)13/
HUJBA from the Department of Health Estates and
Facilities Management Directorate (UK).
The views and opinions expressed in this article do
not necessarily reflect those of the Department of
Health.
* Corresponding author.
E-mail address: s.m.hignett@lboro.ac.uk (S. Hignett).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.004
from a bed to wheelchair using a lifter (bed wash/
lifter task); transferring patients from bed to an-
other bed (bed-to-bed task); and resuscitating
patients (resuscitation task).
Background
Patient bed space (room or cubicle) is the most
important and largest repeating space envelope in
a health care facility because it is the center of
nursing activity [10,11]. The design of hospitals has
been viewed as an important and integral part of
the therapeutic environment since the time of Flor-
ence Nightingale, with the effectiveness of health
care delivery determined, in part, by the design
of the physical environment and the spatial organi-
zation of work [12,13].
The first ICUs were built in the early to mid-
1950s, with open wards and no partitions except
curtains or screens. The second- and third-gener-
ation ICUs (1970s and 1980s) had individual
rooms, moving from walled cubicles to folding
or sliding doors with increased level of control. It
is predicted that the future ICUs will have in-
dividual rooms with increased privacy [14]. The
challenge is to design critical care units that facil-
itate the provision of care and also provide a low
stress environment for patients and their families
or significant others [15,16]. In the United States
of America (USA), there are recommendations
to decrease patient transfers through the use of
adaptable acuity design [17–20]. This allows pa-
tients to be accommodated in the same single
room throughout their stay with the room adjusted
for the requirements of care and treatment. The di-
mensions and configuration of the room include
a patient area, family area (including recliner bed
ccnursing.theclinics.com
168 HIGNETT & LU

and so forth), caregiver area, and hygiene area
[15,17]. The critical care bed space needs to have
working space for staff, appropriate clinical equip-
ment and furniture, and movement space for rou-
tine and emergency care [17].
There is a difference in professional space
recommendations in the USA and the UK. In the
USA, the recommended space envelope has in-
creased from 13.94 m2 (rooms) [21] in 1996 to 16.72
m2 (rooms or cubicles) [22] in 2001 and 36 m2 for
universal (acuity adaptable) rooms (Fig. 1) [18].
In the UK, the recommended space has increased
from 20.25 m2 (cubicles) [23] in 1992 to 26 m2
(rooms or cubicles) [24] in 2003. No empiric re-
search was located to support the space recommen-
dations shown in Fig. 1.
The development of evidence-based health care
has paralleled the availability of information, with
technology increasing the availability of research
findings. These concepts are starting to be seen in

2004 (Takrouri[25]: room

40
with storage [Saudi Arabia])
2004 (Takrouri[25]: cubicle
30
[Saudi Arabia])
2004 (Hendrich[18]:room
36
[USA])
2004 (Hendrich[18]:room
22.5
without family space [USA])
2003 (Sponsler[26]:room
37.16
[USA])
2003 (HBN 57[24]:
26
room/cubicle [UK])
2003 (Held[27]:cubicle
18
[Switzerland])
2001 (Gallant & Lanning[28]:
25.08
room [USA])
2001 (Stichler[29]:room
39.48
[USA])
2001 (AIA[22]: room/cubicle
16.72
[USA])
2001 (Hamilton[30]: room
33
[USA])
1999 (HermanMiller for
23.23
Healthcare[31]: room [USA])
1997 (Intensive Care
20
Society[32]: cubicle [UK])
1997 (Intensive Care
25.5
Society[32]: room [UK])
1998 (Koay[33]: room
15.75
[Singapore])

1996 (AIA[21]:room [USA]) 13.94

1995 (Wedel et al[34]: cubicle

20
[USA])
1995 (Wedel et al[34]: room
25
[USA])
1993 (Marans[35]:room
12
[USA])
1992 (HBN 27[23]: cubicle
20.25
[UK])
0 5 10 15 20 25 30 35 40 45
Area of room/cubicle in square metres

Fig. 1. Recommendations for bed space in ICUs (m2). Data from Refs. [26–35].
 EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS
health care architecture, where it is recognized
that health care architects must aim to achieve the
same high standards as clinical evidence-based
practice [36,37]. There are several narrative re-
views summarizing the literature [38–43] but no
systematic reviews looking at health care design.
As health care treatment and care procedures pre-
dominantly are evidence based, the lack of a sys-
tematic review to present a critical appraisal of
design research limits the usability of this research
for clinicians and designers (architects).
Aim
The aim is to determine the space requirements
for critical care bed space envelope (rooms or
cubicles) for three space-critical high-risk tasks:
(1) washing and dressing patients and then mov-
ing them from bed-to-wheelchair using a lifter, (2)
transferring patients from bed to another bed, and
(3) resuscitating patients.
Method
Functional space experiments (FSEs) were de-
veloped to test the space required. This method of
space testing originally was used in 1955 [44] and
has been used to recommend minimum patient
handling space requirements in bed spaces [11]
and shower or toilet rooms [45].
The importance of clinical staff participating in
health care building design is highlighted by
several investigators [7,10,46–48]. The use of
mock-ups as part of the participatory design
process is recommended by several investigators
to enable staff to experience all aspects of the de-
sign, including getting the feel of the space, evalu-
ating various aspects, and providing feedback
[10,49–53].
The templates for the FSEs were derived from
four UK hospitals built or refurbished since 2001.
The bed spaces (defined by boundaries of walls or
cubicle curtains) were measured in each ICU, as
shown in Table 1. As more recent guidance rec-
ommends that rooms and cubicles need the same
amount of space for clinical activities [22,24]; no
allowance is made for room and cubicle space
envelopes in these experiments.
Participants
Participants were recruited from the cardiac
ICU of a large regional hospital (with more than
11,500 total staff on three sites). A poster
169
Table 1
Critical care unit bed space templates
Layout Date Width (m) Length (m) Area (m2)
1 (room) 2002 5.28 5.10 26.93
2 (room) 2001 6.12 4.10 25.09
3 (room) 2002 4.64 4.37 20.28
4 (cubicle) 2001 3.30 4.00 13.20
advertising the FSE and seeking participation
was displayed on the cardiac ICU notice board
for several weeks before the start of the FSEs.
Eighteen nurses were recruited, including seven
registered nurses, eight health care assistants, and
three student nurses. Their experience working in
critical care ranged from 6 months to 20 years,
with an average of 5.3 years. Participating nurses
were given an information sheet and signed
a consent form at the FSE.
Tasks
Patient rooms are described in terms of four
zones: patient area, family area, hygiene area, and
caregiver area [15,17]. This experiment looked at
the patient (bed, bedside table, and chair) and
caregiver areas but excluded the family and hy-
giene areas and in-room storage.
Data from a previous observational study was
used to determine the tasks to be used in the FSEs
[9]. Three task scenarios were chosen: (1) washing
and dressing patients and then moving them from
bed to wheelchair using a lifter (bed wash/lifter),
(2) transferring patients from bed to another bed
(bed to bed), and (3) resuscitating a patient; the
techniques and equipment used for the three tasks
were based on recommendations for practice by
the Royal College of Nursing [54].
The task scenarios were reviewed with the help
of expert nursing staff in prepilot and pilot stages
to determine, for example, how many participants
were needed for a task, what equipment would be
used, the start and end points of the task, the
mock-up design, and camera locations.
Six groups of nurses tested the layouts by
performing the three tasks repeatedly. Different
colored tapes were used to mark the laboratory
floor to represent the boundaries of the bed space
templates with additional parallel lines at 20-cm
intervals on both sides of a boundary line to record
and measure the exact space required for nursing
tasks (Fig. 2). The mock-up used in this FSE used
a module rail (gantry), as the bed space templates
had gantry systems rather than headwall services.
170
Fig. 2. Link analyses for bed-to-bed transfer (a), bed wash/lifter (b), and resuscitation (c).
A 17-kg fully articulated mannequin was used as
the patient in all the FSEs.
Data were collected using video recording for
detailed frame-by-frame analysis. Link analysis
was used to record the movements of components
(ie, nursing staff, equipment or device, and furni-
ture) and the participants’ (nurses’) movements
between equipment or device, furniture, and pa-
tient. Links were defined as movements of position
and components [55,56]. AutoCAD was used to
draw the link diagrams as output to convey spatial
information.
Ethical issues
Ethical approval for this study was granted by
Loughborough University and National Health
Service (MREC 04/MRE09/31 and LCPRA
HIGNETT & LU
05/Q2501/45). Research governance was granted
by the participating NHS Trusts and honorary
contracts were issued to both researchers.
Results
The multidirectional video data (from four
cameras) were analyzed frame by frame using link
analysis. The movement of each nurse was plotted
individually and then overlaid with that of their
colleagues for each task and template to give 48
data sets of the composite link analyses; Fig. 2a
shows the bed-to-bed transfer, Fig. 2b the bed
wash/lifter, and Fig. 2c resuscitation. The average
space occupied was measured for each trial and
an average calculated for each task; Fig. 3 shows
the area, Fig. 4 the width, and Fig. 5 the length.
 EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS 171

35
32.5

27.38
30

26.16
25.65
24.45
27.5

23.26

23.31

22.87
22.36
24

21.45
25

21.13

21.3
20.08
19.52

19.48
22.5
20
17.5
15
Bed Wash/lifter Bed-to-bed Resuscitation

Layout 1 (26.93m2) Layout 2 (25.09m2) Layout 3 (20.28m2)

Layout 4 (13.2m2) Average

Fig. 3. Bed space envelope dimensions: area (m2).

The complexity of the task scenarios was empha- investigate the spatial requirements further, the
sized during the link analysis where the movement average dimensions for width and length also
of individual nurses could be plotted from the mul- were determined.
tidirectional data before combination with the The results of width analysis found that the
data for the other nurses. The overlaid diagrams resuscitation task needed an average of 4.89 m
(see Fig. 2) are detailed but give a true reflection (see Fig. 4), followed by the bed-to-bed transfer
of the complexity of the working activities. task (4.87 m) and the bed wash/lifter task (4.81
The bed-to-bed transfer task occupied the most m). Again, layouts one (5.28 m) and three (4.64
space, with an average area of 23.26 m2 (see m) accommodated all the tasks. Layout two
Fig. 3), followed by the resuscitation task (22.87 (6.12 m) just accommodated the tasks, with the
m2) and the bed wash/lifter task (22.36 m2). full width used for the resuscitation task. There
Only layout one (26.93 m2) accommodated all was concern that the data from layout two might
the average spatial requirements for all the tasks. skew the results. This was checked in detail from
Layout two (25.09 m2) was exceeded for the bed- the video recording and it was concluded that
to-bed task but accommodated the bed wash/lifter nursing task behavior was unchanged when com-
and resuscitation tasks. Layout three (20.28 m2) pared with the other three layouts. Layout four
accommodated the bed-to-bed and resuscitation (3.3 m) was exceeded for all three tasks.
tasks but not the bed wash/lifter task. Layout The results of length analysis (see Fig. 5) found
four (13.2 m2) was exceeded for all the tasks. To that the bed-to-bed transfer task needed an average
5.93

5.85

6
5.5

5.5
5.04
4.97

4.89
4.87
4.81

4.81

5
4.57
4.54

4.34
4.24

4.3

4.5
4.19

3.5

3
Bed wash/lifter Bed to bed transfer Resuscitation

Layout 1 (5.28m) Layout 2 (6.12m) Layout 3 (4.64m)

Layout 4 (3.3m) Average

Fig. 4. Bed space envelope dimensions: width (m).

172
5.5
4.92
4.73
5
4.66
4.61
Length (m)
4.36
4.5
3.5
3
Bed wash/lifter
Layout 1 (5.1m)
Layout 4 (4.0m)
Fig. 5. Bed space envelope dimensions: length (m).
of 4.80 m, followed by the resuscitation task (4.67
m) and the bed wash/lifter task (4.66 m). Most of
the resulting dimensions approximated to square
shapes. Layout one (5.1 m) accommodated all the
tasks. Layouts two (4.1 m), three (4.37 m), and
four (4.0 m) all were exceeded for all three tasks.
Discussion
The average spatial requirement from all the
FSEs was 22.83 m2 (average width of 4.68 m and
length of 4.71 m), similar to the recommendation
from Hendrich and colleagues [18] for a room
area of 22.5 m2, excluding family space. The result
is within the current UK recommendation (26 m2)
but greater than the guidance [23] that would have
been used for all the benchmark sites (20.25 m2).
One of the limitations of the FSEs was the exclu-
sion of space considerations for family, hygiene,
and in-room storage areas and it is likely that an
additional 3 m2 would be needed to accommodate
these areas. In comparison, recommendations for
adaptable acuity rooms usually include storage
and services, giving space recommendations of
36 m2 (of which 13.5 m2 is family space) [18]
and 40 m2 (of which 10 m2 is storage space) [25].
The shape of the bed space envelope was impor-
tant. The average spatial dimensions for the three
tasks differed. The limiting factor was found to be
the length for layouts two (bed-to-bed transfer
task) and three (bed wash/lifter task) where the
average area was insufficient for the specified
tasks. The shape of the layout for all the tasks
HIGNETT & LU
5.09
4.91
4.85
4.79
4.8
4.68
4.67
4.66
4.49
4.41
Bed to bed transfer Resuscitation
Layout 2 (4.1m) Layout 3 (4.37m)
Average
resulted in a greater width than length, with the
resuscitation task needing 20 cm more width
than length and the bed wash/lifter task 15 cm
more width than length.
The three tasks offered frequent (bed wash/
lifter and bed-to-bed transfer) and safety critical
(resuscitation) challenges to the spatial require-
ments. The resuscitation task required the greatest
width to accommodate the increased number of
staff (up to six were available for the FSEs) and
the equipment and circulatory space around the
bed. It was anticipated that the bed-to-bed trans-
fer and bed wash/lifter might require greater space
than the resuscitation task because of the addi-
tional equipment (second bed and lifter). The
length requirements are less surprising, with the
bed-to-bed transfer requiring the largest dimen-
sion to accommodate the access and egress of the
second bed. It was expected that the resuscitation
task might require a greater length than the bed
wash/lifter task. A previous pilot study on adult
acute ward bed space envelopes identified that
width was the critical spatial factor when using
a lifter, whereas length was the critical factor for
resuscitation (bed-to-bed transfer spatial require-
ments were not investigated) [11]. The results from
the critical care environment suggest that width is
equally important for the resuscitation task and
requires more space than when using a lifter.
This presents a challenge to hospital designers:
Should a bed space envelope be designed for the
safety critical task, giving a larger envelope
(23.80 m2)? Or for the frequent tasks, 23.23 m2
or 22.27 m2? The location of openings (doorways)
 EVALUATION OF CRITICAL CARE SPACE REQUIREMENTS
within a layout was found to affect the results. For
example, in layout two, the doorway was close to
the patient bed head and services (electrical
points, oxygen, air, and so forth) and perpendicu-
lar to the bed. When the nurses wanted to move
the mobile lifter, the resuscitation trolley, second
patient bed, or any other big equipment or furni-
ture into the bed space from outside, a lot of space
was needed between the door and bed to maneu-
ver the equipment without difficulty. It is sug-
gested that this might be the reason the architect
had to design the width of 6.12 m and why the
data from this layout seemed to skew the results.
It was important to give the results with
specific dimensions (length and width) and floor
areas. For example, a 24-m2 room could be 4 m in
width with 6 m in length (or 4 m in length  6 m
in width) or 3 m in width by 8 m in length (or 3 m
in length by 8 m in width), depending on the func-
tionality and usability. This might be a problem,
as architects and clients could talk about the floor
area of a room without taking account of the
shape. This approach might work when designing
buildings, such as shops, museums, libraries, and
even residential buildings, because professional
knowledge, personal experience, and common
sense can inform the architect. But hospital build-
ing design presents different challenges and archi-
tects need to know that the lack of 0.5 m in the
length or width of a room could affect the safety
and efficiency of care and treatment.
A limitation of this research was the lack of
evaluation for the design of the provision of services
(electrical, vacuum, air, and oxygen). There are two
principal systems for the delivery of these services,
a modular rail or power column [57,58]. A rail sys-
tem has the intravenous lines, tubes, and so forth
fanning out from patients. The benefits of the rail
system (gantry) include minimal tangling, adjust-
ability for different patients, access for right- and
left-handed caregivers, and freeing floor space
with everything hanging from the rail but must
work from both sides of the bed [7,49]. The power
column (pendant) has the lines, tubes, and so forth
leaving a patient and converging in one area. This
can facilitate 360 access to patients, decrease the
amount of walking, and increase efficiency with
controls at fingertips and equipment congregated
in one area, but the lines can get tangled [17,49,59].
The choice to provide care in rooms or cubicles
needs to be considered in more detail to look at
the risk balance for safety and social issues. Two
studies report that isolated patients (in single
rooms) were visited half as often as nonisolated
173
patients (5.3 versus 10.9 visits per patient) [60] and
were twice as likely to have adverse events (31 ver-
sus 15 events per 1000 patient days) [61]. Two
studies looking at patient stressors in ICUs (with
six bed units) found that lack of privacy was not
considered a priority [62] and ranked only four-
teenth as a stressor [16].
Summary
The provision of functional space in a critical
care environment is recognized as important for
patient and staff safety. This research provides
empiric data to support a spatial requirement of
22.83 m2, as the average task space based on the
average length (bed-to-bed transfer) and width
(resuscitation) dimensions are given as 4.8 m
and 4.89 m. The method of link analysis was
found effective for plotting the movements of
the nurses and accounting for the complexity of
the tasks. This method, in combination with ob-
servational field studies, provides a simple but ef-
fective way of determining the functional space
requirements for nursing activities.
Summary of important points
 There has been a gradual increase in the rec-
ommended dimensions for critical care bed
spaces since 1992.
 Empiric data are lacking to support the rec-
ommendations from professional guidelines
for critical care bed space envelopes.
 The use of mock-ups with systematic FSEs
provides a simple but effective method for de-
termining the spatial requirements.
 An average bed space envelope requirement
of 22.83 m2 is recommended to accommodate
frequent and safety critical tasks in ICU
environments.
Acknowledgments
The authors would like to thank Jonathan Mill-
man (Department of Health Estates and Facilities
Management Division) for his support during the
project; and Moira Durbridge and Allison Godfrey
Vallance and the staff from the Cardiac ICU at
University Hospitals of Leicester NHS Trust for
facilitating access and participating in the project.
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 Crit Care Nurs Clin N Am 19 (2007) 177–186
Technology Solutions for High-Risk Tasks
in Critical Care
Andrea Baptiste, MA (OT), CIE
Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL 33612, USA
Critical care units present a unique set of
challenges to nurses and health care professionals
who work with this patient population. These
challenges come in various forms, ranging from
job requirements, work organizational issues, en-
vironment, and equipment. This article focuses on
potential technological solutions in critical care.
Before understanding the solutions to high-risk
tasks in critical care, the job content and the
physical demands of specific tasks that place
critical care nurses under stress should be un-
derstood. The job requirements of intensive care
nurses are different from those of other specialties,
resulting in different occupational hazards for
intensive care or critical care nurses. A study in
The Netherlands analyzed the relationship be-
tween the physical and psychologic work-related
risk factors and musculoskeletal complaints of
nurses from operating rooms and intensive care;
x-ray technologists; and nonspecialized nurses.
Results indicate that intensive care nurses per-
ceived fewer prolonged neck-shoulder complaints
than nonspecialized nurses and that an ergonomic
environment seems predictive for low back com-
plaints (odds ratio 1.11; 95% CI, 1–1.24) [1].
The findings of this study explained further
that intensive care nurses perceive force exertion
and dynamic loads as high. Force exertion is
defined in this study as ‘‘lifting, pushing and
pulling, carrying, forceful movements with arms,
high physical exertion, lifting with loads above the
chest, lifting with bad grip, lifting with very heavy
loads, short force exertion, or exerting great force
in hands.’’ Dynamic load is described as ‘‘trunk
movements, movements of the neck, shoulders or
E-mail address: andrea.baptiste@va.gov
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.011
wrists, reaching, make sudden and/or unexpected
movements, pinching, working under, at or above
shoulder level’’ [1].
Ergonomic environments predictive of low
back complaints is consistent with feedback
from nurses and can be seen by analyzing the
use of technology in critical care environments.
The reasons for these challenges are because not
all units have the same patient population and
require the same patient handling tasks. Types of
transfers vary and dependent on the needs of
patient populations. For example, in nursing
homes, the demand for lateral transfers is greater
than in critical care units, because of the medical
conditions of critical care patients. The medical
status of patients is a determining factor in
considering which type of equipment should be
used to perform patient transfers. Types of trans-
fers typically performed in critical care units vary
but most include the following high-risk tasks:
Lateral transfers
Repositioning patients up or side to side in bed
Bed-to-chair or -wheelchair transfers
Pericare of bariatric patients
Toileting in bed
Sustained limb holding for dressing wounds
Patient transport
Lateral transfers
Lateral transfers can be a physically demand-
ing task performed by nursing staff. Because of
the frequency of this task, technological solutions
offer a means to perform this labor-intensive task
with little or no impact on patients or caregivers.
Lateral transfers can be performed more safely
ccnursing.theclinics.com
178
through use of mechanical lateral transfer devices,
ceiling lifts, air-assisted devices, and friction-
reducing devices (FRDs).
Mechanical lateral transfer devices
There are many technological solutions for
performing lateral patient transfers safely, but
unfortunately many caregivers still do this task
manually, subjecting themselves and patients to
risk for being injured. The best, most preferable
solution to making lateral transfers safer is via the
use of an engineering solution, such as using
a mechanical device, such as a ceiling lift or
mechanical lateral transfer aid. Both of these
technologies diminish the manual labor typically
used by caregivers in such a task.
The mechanical lateral transfer device consists
of a rod that is rolled into a sheet and powered.
Patients lie on this sheet and two retractable
straps are attached from the base unit to the rod
in the sheet. Pressing a button on the base unit’s
control panel retracts the straps, thus pulling
patients across to the destination surface without
caregivers moving patients manually. Fig. 1
depicts the use of this type of mechanical lateral
device.
Ceiling lifts
An alternate solution to accomplish lateral
transfers is via use of a ceiling lift with a supine
sling (Fig. 2). Ceiling lift systems function by
using an overhead track, which is mounted to
Fig. 1. Mechanical lateral transfer device. (Courtesy of VISN 8 Patient Safety Center of Inquiry, Tampa FL; with
permission.)
BAPTISTE
the ceiling. The track typically is positioned over
a patients’ bed but may extend into the washroom
if needed. There are two types of tracks: a single-
track design allows the lift to run along that ded-
icated track only, whereas an X-Y track allows
more versatility as two tracks intersect, permitting
the lift to change directions and allowing more
coverage in the room or bathroom.
If a ceiling lift is used for a lateral transfer, the
track has to be perpendicular to the direction of
the bed or stretcher to safely move a patient
horizontally. In this case, a supine sling or sling
covering the length of the entire body is placed
under the patient while the subject is lying on
a bed or stretcher. The patient then is elevated off
the bed, using the ceiling lift, then moved across to
the destination surface and then lowered. Care-
givers’ manual work is reduced drastically during
the lateral transfer using this method. This
method still requires caregivers to position the
sling manually under a patient, however, which
still is a physically demanding task. There needs to
be solutions that eliminate sling insertion and
removal, because these two tasks are deemed
high-risk tasks. One might ask, ‘‘Why not leave
the sling under the patient?’’ Although there is no
evidence or literature on leaving slings under
patients, the following questions need to be
considered:
Does the patient have compromised or thin
skin?
How breathable is the material of the sling?
 TECHNOLOGY SOLUTIONS IN CRITICAL CARE
Fig 2. Ceiling. lift track. (Courtesy of Liko, Franklin,
MA; with permission.)
Does the sling present rough, uneven edges
that can produce pressure points on the
patient?
Can the sling be left under a patient and tucked
into the mattress when not in use?
Currently, manufacturers are working on ex-
panding the types of slings that can be left under
patients to address these questions.
Air-assisted devices
If there is no mechanical solution (lift system
or mechanical aid) available, then the next best
choice to perform a lateral transfer of critical care
patients is the use of an air-assisted device. These
systems are composed of special mattresses, which
have no weight limit, often are radiolucent, and
are constructed with material that offers reduced
friction during a transfer. The system consists of
a portable electric air pump, a hose, and an
inflatable mattress. Air is pumped into the mat-
tress via the hose by pressing a button. Once
a mattress is filled with air, patients (lying on the
mattress) can be pulled onto the destination
surface with little effort. The reduced effort is
due to the holes underneath the mattress, which
allow air to escape, and in doing so, provide
a reduction of friction between the underside of
the mattress and the bed.
Air-assisted devices were rated most preferable
in a study in critical care units where eight devices
were evaluated for lateral transfers. Caregivers
179
reported that the air-assisted products were best in
overall comfort, ease of use, effectiveness in
reducing injuries, time efficiency, and patient
safety [2]. Because of the lack of weight restric-
tions, caregivers may be more likely to use these
products than others in transferring heavier
patients.
Friction-reducing devices
These products offer a remarkable, low-cost
solution to performing lateral transfers when the
preceding two solutions are not possible. The
primary purpose of FRDs is to transfer patients
from bed to stretcher. These products also are
used, however, to reposition patients up or side to
side in bed. The size, shape, and function of these
products determine how well they can perform
a transfer. For example, a FRD designed for
lateral transfers may be able to reposition patients
in a chair but may not perform this task well
because of the physical length of the device. When
patients are pulled up in a chair, they slide back
down if the FRD is not removed quickly because
of the low friction of the material. It is important
that each product is used in its intended way to
promote and maintain safety for all participants
involved during transfer tasks.
FRDs are made from a slippery-type material
that reduces friction, making it easier to move
patients. Some products are made with two
separate sheets, where one slides over the other,
whereas others are designed with one tubular
piece of material that rolls over itself. Some of
these devices have handles or extended pull straps
making gripping easier and reducing reaching,
respectively. FRDs with extended pull straps are
proved effective in reducing the biomechanical
stress at the low back, thus reducing the risk for
injury [3].
Significant factors that affect the performance
of a lateral transfer device are caregiver and
patient characteristics, device design and features,
and organizational and environmental factors.
Repositioning
Repositioning patients up in bed
Ceiling lifts predominantly are used for vertical
transfers (bed to chair) in long-term care facilities;
however, in critical care, there is a greater need to
reposition patients up in bed or turn them on their
side. Fig. 3 indicates the typical posture used by
caregivers who have to move patients up in bed
180 BAPTISTE

Fig. 3. Manual repositioning of a patient up in bed. (Courtesy of VISN 8 Patient Safety Center of Inquiry, Tampa FL;
with permission.)

manually without any assistive devices. As seen in use of such devices can reduce musculoskeletal
this illustration, caregivers use a forward bent injuries associated with patient handling tasks.
position at the waist, the shoulders are extended, The purpose of this study was to test the effect
and the wrists are under the armpits of the of a best practices program, which involved use
patient. This constitutes a poor posture and places of patient handling equipment, on staff injuries,
caregivers at a risk for potentially injuring their workers’ compensation costs, and lost workday
wrists, shoulders, low back, or neck. injuries. The study found that a best practices
Fortunately, there are several technological musculoskeletal injury prevention program con-
solutions to assist in the task of repositioning sisting of mechanical lifts and repositioning aids,
patients up in bed. The first solution involves use a zero lift policy, and employee training on lift
of repositioning aids. usage significantly reduced resident handling
Repositioning patients in bed can be injury incidence, workers’ compensation costs,
performed safer and more efficiently by use of and lost workday injuries after the intervention.
these aids. These devices vary in style, size, and For further information on repositioning
function. Some are made of a material that has devices, refer to the Web site, http://www.visn8.
friction-reducing properties to allow caregivers to med.va.gov/patientsafetycenter/resguide/Technolo
slide patients up in bed easily. Some devices have gyResourceGuide.doc#RepositioningDevices [5].
the ability to engage a specific area on the sheet
itself to introduce friction and prevent patients
from sliding back down.
Another type of repositioning device is one
that attaches to a hospital bed. A sheet is fed from
a roller at the foot of a bed to a roller at the head
of a bed. A caregiver turns a handle manually,
which activates the roller, and moves the patient
to the head of the bed. The handle can be
detached from the head end and reattached to
the foot end to facilitate repositioning in the
opposite direction if needed (Fig. 4).
The benefit of using repositioning aids can be
seen in a study by Collins and colleagues [4];
friction-reducing sheets were used to reposition Fig. 4. Repositioning device on bed. (Courtesy of EZ
patients in bed. There is evidence showing that Way, Inc., Clarinda, IA; with permission.)
 TECHNOLOGY SOLUTIONS IN CRITICAL CARE
This link describes supine repositioning devices and
those used for repositioning patients in sitting.
Repositioning patients on the side
Technological solutions continue to improve
and expand as health care manufacturers realize
that the manual effort of caregivers needs to be
eliminated. This realization is evident in a reposi-
tioning product, which can replace or work with
a bed sheet as it is placed under a patient and can
remain there when not in use. This sheet can be
used to turn or move patients up in bed. These
two tasks are accomplished by using an overhead
ceiling lift system and an appropriate spreader
bar. There are two versions available, one that
accommodates up to 440 lb and another for
larger, bariatric patients (up to 1100 lb). If the
latter sheet is used, it is essential that the lift used
has the capacity to accommodate up to the same
weight as the sheet. Fig. 5 shows an example of
a repositioning sheet used for turning patients in
bed.
Changing the type of lift, sling, and spreader
bar is another way to move patients up in bed or
on their side. Fig. 6 shows a supine sling in
Fig. 5. Repositioning sheet used for turning a patient.
(Courtesy of Liko; Franklin, MA; with permission.)
181
conjunction with a floor-based lift that is used to
lift patients up off of a stretcher.
To accommodate turning patients to the side,
the boom of the floor-based lift has to be high
enough to accomplish turning.
Another mechanical device used to make this
task of repositioning in bed easier is the use of
a ceiling lift in conjunction with a supine sling. By
using the mechanical lifts (floor based or ceiling
lift), caregivers do not have to exert any effort
manually except to place a sling under a patient.
Sling insertion and removal is a high-risk task
element for caregivers and research is lacking in
this area. These forces affect the upper body joints
(wrists, elbows, and shoulders) and neck, in
addition to caregivers using an awkward posture,
which in turn, affects the low back negatively.
Mechanical equipment should be used if avail-
able, as it can assist greatly in reducing injuries for
caregivers during the various repositioning tasks.
Use of such equipment also benefits patients,
because there is no dragging or pulling of patients
manually on a bed sheet to the head of a bed or
across to the side of a bed. As a result, frictional
forces are eliminated, which protects the skin
integrity of patients.
McGill and Kavcic [6], in 2006, looked at the
effect of a friction-reducing assistive device on
low back mechanics. They quantified and com-
pared three lateral transfer devices by measuring
the coefficient of friction, muscle activity of care-
givers, and spinal loading during the lateral trans-
fer. Results showed that during a lateral transfer
of a mannequin (72.7 kg) on a cotton sheet, the
coefficient of friction was 0.45. In comparison to
this standard condition, the three assistive devices
reduced the coefficient of friction to 0.18 to 0.21.
Consequently, there is evidence to prove the ben-
efit of using FRDs for caregivers and for patients.
Frictional force studies are lacking and there
needs to be more research regarding the effect of
transferring patients manually across surfaces and
the direct impact on patients’ skin, especially
concerning pressure ulcers.
Bed-to-chair transfers
One transfer task common to critical care units
is bed-to-chair transfers or vertical transfers.
Moving patients who have been in bed for
a prolonged period of time from a lying position
(bed) to a seated position in a chair can be
a difficult task. This in part is because of the
182
Fig. 6. Supine sling with floor-based lift. (Courtesy of Arjo; Roselle, IN; with permission)
awkward posture used by caregivers and the
mass of the patients. This type of transfer can be
unpredictable, as the functional strength and
mobility of such patients is poor, as they usually
are weak from inactivity. There are several
solutions, however, to making this transition
easier. The ideal way is to eliminate the manual
work of this task by using a mechanical lift
system.
The choice of lift used is dependent on
patients’ level of assistance, weight-bearing capa-
bility, physical condition, level of cooperation,
and comprehension.
For bed-to-chair transfers, three solutions are
offered: floor-based lifts, ceiling lifts, and sit-
to-stand lifts.
Floor-based lifts
Floor-based lifts have served well in reducing
caregiver effort in transferring patients from bed
to chair or vice versa. The original floor-based lift
worked by activating a pump manually, which
raised and lowered a boom arm while the legs of
the lift also were operated manually by a lever.
These lifts have been replaced by electric floor-
BAPTISTE
based lifts, which operate by pressing a button
that elevates and lowers the boom and opens and
closes the legs. To transfer patients from a bed to
a chair, caregivers apply a sling (appropriate for
the patients) while patients are lying in bed.
Patients are log rolled and the sling is inserted
under them, the legs on the lift are opened for
stability, and the boom then lowered enough to
attach the sling to the spreader bar. Patients are
raised off the bed by pressing a button on the
control panel. The lift then is moved over a chair
and patients then lowered. Once patients are
positioned properly in the chair, the sling then is
removed.
Floor-based lifts are useful in critical care for
bed-to-chair transfers, picking patients up from
floor level, and lifting a limb for a sustained
period of time when performing wound dressing
changes.
Ceiling lifts
The second solution to bed-to-chair transfers is
the use of a ceiling lift (discussed previously). The
steps for transferring patients via a ceiling lift are
similar to using a floor-based lift, except that the
 TECHNOLOGY SOLUTIONS IN CRITICAL CARE
ceiling lift is the existing infrastructure hanging
above on the rail. A sling is inserted under
a patient, the lift is lowered, and the sling is
attached. Then, a caregiver presses a button and
the patient is raised, guided on the track, and then
positioned over the chair. The caregiver then
lowers the patient into the chair and the sling is
removed.
Sit-to-stand lifts
Sit-to-stand lifts are useful provided patients
meet the criteria for using such a lift. Patients
should be able to weight bear partially, under-
stand and follow simple commands, and hold
onto the handles of a lift. This type of lift can be
used in rehabilitation when teaching someone
how to transfer from sitting to standing. Using
a sit-to-stand lift requires some leg and arm
strength from patients but support still is provided
in the event of patients losing their balance. A sit-
to-stand lift works by attaching a sling around
patients’ back and waist, then placing their legs on
a stand while they are sitting on the edge of the
chair or bed. A caregiver then presses a button to
raise a patient up off the chair or bed and into
a standing position. The patient is moved to the
destination surface and lowered by pressing a but-
ton on the lift, and the sling then is removed from
the patient. Sling insertion and removal remain
a challenge and efforts are being made to design
slings that can be left under patients without
compromising patients’ sling integrity or increas-
ing their risk for developing or aggravating
existing pressure ulcers.
Pericare of bariatric patients
Pericare of obese patients presents a challenge
because of the amount and weight of redundant
tissue, weight, and size of patients’ legs and the
difficult access of perineal area. Currently,
pericare is performed manually after bowel move-
ments and urination and for patients who have
indwelling catheters. Pericare can be accom-
plished without turning patients by spreading
apart the legs of patients for access to the genital
area. This task requires caregivers to lean over
a bed for a sustained period of time while moving
redundant tissue to gain access and provide the
ability to clean the genitals. This task can be
made easier with use of an abdominal binder,
183
limb straps, and an expanded capacity ceiling lift
system.
Abdominal binders can be used to hold some
of the redundant tissue from the leg together more
compactly, thus providing easier access to the
genitals. Limb straps can be attached to the ceiling
lift, to lift and separate the legs and hold them in
a sustained position while a caregiver cleans the
genitals. This solution eliminates lifting and hold-
ing of a heavy leg for a long period of time and
allows caregivers to concentrate on cleaning
patients more effectively and comfortably.
Another approach to this problem is using
a floor-based lift. The advantage of using a ceiling
lift is that there is no storage needed for this lift, as
it is stored on the track overhead. The process of
using a floor-based lift is the same as discussed
previously except that the limb straps are con-
nected to the floor-based lift versus the ceiling lift.
Toileting in bed
In critical care units, patients present a wide
array of dependency levels. If patients need to
toilet and are able to lift their buttocks, caregivers
slide a bedpan under patients’ buttocks. If
patients are unable to turn independently, care-
givers turn patients to the side manually, then
place a bedpan in position and turn patients back
onto a bedpan with knees slightly bent. Once
toileting is complete, caregivers have to turn
patients on their side to clean them while ensuring
bedpans do not spill. After toileting is completed,
patients are turned back to the supine position.
The physical effort needed to turn dependent
patients manually makes this a high-risk task.
The manual turning involved in this task can be
eliminated by using an overhead ceiling lift with
turning straps. Straps are positioned under the
heaviest parts of a patient, typically the torso and
upper legs. The straps used should be wide enough
so they do not cut into patients’ skin. Once in
place, these straps are attached to a ceiling lift via
a spreader bar. The ceiling lift is used to raise and
lower patients in preparation for toileting. Once
patients finish their bowel movement, the lift is
raised and bedpan removed. Caregivers should
not have to move the straps to access the genitals
to clean patients because of properly placing the
straps of the correct width beforehand. Straps are
available in various widths and can accommodate
up to 1000 lb. It is important that patients’ weight
184
does not exceed the capability and weight limit of
the straps or the ceiling lift.
Sustained limb holding for dressing wounds
The sixth high-risk task discussed in this article
is holding a heavy limb for a sustained period of
time while dressing a wound. This task is consid-
ered a high-risk task for many reasons. Some of
these include the weight of the limb, position of
a caregiver’s hand while gripping that limb, and
the posture of caregivers during this task.
Typically, caregivers bend at the waist, leaning
over the bed, extending one arm to hold the limb,
and using the other hand to clean the wound and
apply a dressing.
A preferable, alternate solution to assist care-
givers in sustained limb holding for dressing
wounds is the use of limb straps with a ceiling
lift system or floor-based lift (Fig. 7).
As shown in Fig. 7, a special sling used for
holding limbs is placed under a patient’s leg and
attached to a lift to suspend the leg in place.
This task can be accomplished with the use of
a floor-based lift or a ceiling lift. The benefit of
using these special straps is that they are available
in different widths, and proper placement of the
straps on the affected limb can allow easier access
to dress a wound. The advantage of using either
lift (ceiling or floor based) is that the weight of
the limb is held by the lift, which allows caregivers
to use both hands, if needed, to take care of
patients.
To illustrate the physical demands placed on
someone holding a leg for a period of time, a study
Fig. 7. Limb sling for dressing wounds. (Courtesy of
Liko, Franklin, MA; with permission.)
BAPTISTE
was conducted simulating this task. This research
study was conducted in the biomechanics labora-
tory at the VISN 8 Patient Safety Center of
Inquiry (James A. Haley Veterans’ Hospital) and
evaluated the physical demands of patient transfer
tasks performed by nurses in a controlled labora-
tory setting. Fifty-three tasks were analyzed and
broken down into subtasks to quantify the peak
force required to perform each subtask. One of
these tasks was limb holding for a sustained
period of time. A 200-lb mannequin was used to
simulate a dependent patient. The anthropometry
and weight of the mannequin’s limbs were compa-
rable to that of a human being. Results indicated
that the amount of force required to lift and hold
one leg is comparable to the force needed to pull
a draw sheet through from under a patient (200
lb) who is lying on the side. In addition, use of
a ceiling lift device to raise and let down the lower
leg requires significantly less force than the force
needed to perform this task manually. These find-
ings indicate the benefit of using a floor-based lift
or ceiling lift to suspend a limb and avoid manual
limb holding. Use of such technologies should
result in less strain on the upper body joints, im-
proved posture in the low back, and reduced
risk for injury to caregivers.
Patient transport
The last high-risk task in critical care does not
involve handling patients directly but is related to
patient movement. Transport of patients has
been and continues to be a difficult task physi-
cally because of the push forces required (weight
of transport vehicles plus patients), the working
condition (steering, castors, and brakes) trans-
port devices (beds or stretchers), and confined
spaces in transport routes. The excessive load in
addition to the frequency of the task and posture
used by transporters all contribute to an in-
creased risk for injury. To alleviate the physical
demands of this task, many facilities have started
using powered transport technologies. These
devices are available commercially in different
types.
The first type is a stand-alone, detachable, or
independent device that attaches to a bed, linen
cart, or trolley (Fig. 8). Once the unit is attached
securely to a bed or object to be powered, an
operator is able to move and steer the device.
A bed mover is powered by batteries and
enables the device to move forward or backward.
These devices have a wide range of weight
 TECHNOLOGY SOLUTIONS IN CRITICAL CARE 185

Fig. 8. Powered bed mover. (Courtesy of Ergotech, Danbury, CT; with permission)

capacities (up to 2500 lb). The disadvantage of to quantify the push forces required when using
using such a device is that it may not fit into the occupied beds and wheelchairs manually on differ-
elevator when attached to a bed, so careful ent surfaces. This evaluation is designed to com-
measurements and planning should be taken pare the biomechanical factors required to
before purchase. The advantage of using a detach- perform transport tasks manually versus using
able, powered device, however, is that it can be powered devices (described previously). Patient
attached to many items, such as linen carts,
trolleys, or beds. The cost of these detachable
units is cheaper than the alternate type of powered
technology that is integrated into beds.
The second type of transport technology is one
that is incorporated into beds and powers them by
unplugging a bed, releasing the brakes, and
pressing two buttons. Use of powered transport
devices is beneficial especially when moving
heavier patients, because there is minimal force
exerted to initiate movement of a bed.
Another type of patient transport device is
a powered wheelchair mover. This device (Fig. 9)
is designed to be attached to a standard manual
wheelchair via a securing hitch. Once connected,
a caregiver is able to operate and steer the device
by toggling a lever. This powered wheelchair
mover has two variable speeds and an emergency
stop button.
Use of these powered transport devices is
becoming popular in health care facilities, as
they reduce the risk for caregiver injury. To
date, there is no literature found regarding the
use and benefit of patient transport technologies.
Currently, a research team at the VISN 8 Patient
Safety Center of Inquiry (James A. Haley Vet- Fig. 9. Wheelchair mover. (Courtesy of Dane Industries,
erans’ Hospital) is conducting a laboratory study Minneapolis, MN; with permission.)
186 BAPTISTE
transport can be made safer for caregivers
through the proper use of powered patient trans-
port technologies.
Summary
There are several high-risk nursing tasks in the
critical care environment discussed in this article.
These tasks include lateral transfers, repositioning
patients up or side to side in bed, bed-to-chair
or -wheelchair transfers, pericare of bariatric
patients, toileting in bed, sustained limb holding
for dressing wounds, and patient transport. There
are, however, technological solutions available to
perform these tasks more safely. Evidence-based
research currently is in development to prove that
patient handling technology works for suggested
high-risk tasks. Although there are few studies
that currently provide objective data regarding
use of technology in reducing caregiver injuries,
the aforementioned patient handling equipment is
promising. There are reports of improved job
satisfaction and employee morale among health
care staff when using these technologies. Using
these technologies properly is the only true way to
realize the benefits these devices provide. Techno-
logical solutions are available and should be
implemented in critical care to promote the safety
of all involved in patient care.
References
[1] Bos E, Krol B, van der Star L, et al. Risk factors and
musculoskeletal complaints in on-specialized nurses,
IC nurses, operation room nurses and x-ray technol-
ogists. Int Arch Occup Environ Health 2007;80(3):
198–206 [E-published ahead of print, 2006 June 24].
[2] Baptiste A, Boda S, Nelson A, et al. Friction-reducing
devices for lateral patient transfers: a clinical evalua-
tion. AAOHN J 2006;54(4):173–80.
[3] Lloyd J, Baptiste A. Friction-reducing devices for lat-
eral patient transfers-a biomechanical evaluation.
AAOHN J 2006;54(4):113–9.
[4] Collins JW, Wolf L, Bell J, et al. An evaluation of best
practices musculoskeletal injury prevention program
in nursing homes. Inj Prev 2004;10:206–11.
[5] Department of Veterans Affairs (VHA). Technology
resource guide. Accessed August 31, 2006. Available
at: http://www.visn8.med.va.gov/patientsafetycenter/
resguide/TechnologyResourceGuide.doc#Reposition
ingDevices.
[6] McGill SM, Kavcic NS. Transfer of the horizontal
patient: the effect of a friction reducing assistive de-
vice on low back mechanics. Ergonomics 2006;48(8):
915–29.
 Crit Care Nurs Clin N Am 19 (2007) 187–196

Justification for a Minimal Lift Program

in Critical Care
Arun Garg, PhD, CPEa,*, Suzanna Milholland, MS, OTRb,
Gwen Deckow-Schaefer, MS, OTRb, Jay M. Kapellusch, MSb
a
Center for Ergonomics Industrial & Manufacturing Engineering University of Wisconsin-Milwaukee,
P.O. Box 784, Milwaukee, WI 53211, USA
b
Industrial & Manufacturing Engineering University of Wisconsin-Milwaukee,
P.O. Box 784, Milwaukee, WI 53211, USA

Back and shoulder injuries are a major and
serious problem for nursing personnel in all areas
of patient care, including hospitals, long-term
care, and home health care. According to the
Bureau of Labor and Statistics [1,2] nursing assis-
tants led all other occupations in overexertion in-
juries in the United States in 1993. The rate of
overexertion injuries among nursing assistants
was four times higher than the average rate for
all other private industries. This overexertion
rate continued to be four times higher through
1995. In 1995, the Bureau of Labor and Statistics
[3], reported home health care workers’ injury
rates that were double, and hospital health care
workers’ injury rates were nearly double that of
injury rates in private industry. In 2000, the Bu-
reau of Labor and Statistics [4] reported that the
injury incidence rate for nursing personnel was
the second highest in the United States for nonfa-
tal occupational injuries. Furthermore, these in-
juries were severe enough to require medical
treatment or produce lost workdays. With these
high injury rates come significant costs. Direct
costs including medical treatment, medications,
therapies or surgeries have been estimated to
range between $9,000 and $30,000 per injury.
One example can be cited by Dunn and De Peralta
[5]. They documented that 17 injuries occurred on
a spinal cord unit in 2002 resulting in $162,815.53
of direct costs. Meanwhile, the indirect costs
* Corresponding author.
E-mail address: arun@uwm.edu (A. Garg).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.002
(ie, replacement personnel, training, insurance
premiums) of these injuries are estimated to be
four to ten times greater still [5]. These injuries
were all attributed to patient-handling tasks. The
Bureau of Labor and Statistics [4,6], in 2001
stated that among full-time hospital workers, in-
juries were 8.8 per 100 full-time hours and 13.5
per 100 full-time hours among nursing home
workers. This compared with all other industry
work injuries and illnesses including rates of 4.0
per 100 full-time workers in mining, 7.9 per 100
full-time workers in construction, and 8.1 per
100 full-time workers in manufacturing. Nursing
aides and orderlies were surpassed only by truck
drivers and nonconstruction laborers when rank-
ing lost day injuries [1]. These nursing personnel
injuries do not appear to be isolated to the United
States. The Health and Safety Executive [7] in
London cited that approximately 70% of work-
place injuries involved health care workers associ-
ated with patient-handling tasks [6]. Another
study cited that nurses in Israel ranked first in
low back injury rates compared with most other
occupations, including light and heavy industry
workers, farmers, bus drivers, and others [7]. In
Sweden, the National Board of Occupational
Safety and Health reported the highest frequency
of back injuries was among bath attendants and
nursing aides [8]. Injuries among nurses are
largely unreported. French and colleagues [9]
sent a questionnaire to 47 nursing personnel in
an acute care hospital. They reported that
80.9% had back pain at some time during their
ccnursing.theclinics.com
188 GARG
career; however, more than 90% never reported
any back pain to their employer. In 1995 Vasilia-
dou and colleagues [10] conducted the first ever
study on prevalence of back pain among Greek
nursing personnel. They administered a question-
naire to 407 nursing personnel in a tertiary care
facility in Athens. Of the participants, 63% re-
ported work-related low back pain within the pre-
vious 2 weeks and 67% within the previous
6 months. Prevalence was higher in conjunction
with heavier physical duties. Although it is diffi-
cult to directly compare these studies in various
countries, the statement can be made that all of
the nursing positions were classified as high-risk
occupations for low back injury.
Causes
Although the exact mechanism of injury is not
clearly defined, many of the injuries to nursing
personnel have been attributed to patient-
handling tasks. Overall, many studies cite patient
lifting and transferring as the most common cause
of back injuries [9–21]. Owen [22] stated that as
many as 89% of low back injury reports filed by
nurses in a hospital setting indicated that a pa-
tient-handling task was the precipitator of their
injury. Kumar [23] suggests that cumulative load
exposure predisposes the spine to pain or injury.
Cumulative spinal loading can be defined in three
ways: (1) accumulated demands on the spine dur-
ing a single patient-handling task, (2) additive ef-
fects of lifting loads over a workday, or (3)
accumulation of loads throughout the lifetime.
Others have added the risk factors of frequent
bending, twisting, carrying, and pushing of beds
as contributors to musculoskeletal complaints
[24–26]. Still others have added that forward flex-
ion, lateral bending, twisting of the spine, or an in-
creased horizontal distance of the load from the
body during lifting further increases the chances
of low back injury [27–29]. A study performed
in Hong Kong by French and colleagues [9] not
only cited transferring patients and lifting patients
as two major causes of back pain but also in-
cluded the static posture of stooping during vari-
ous patient care tasks as contributing to pain.
Others have cited bad work technique or lack of
training as contributors [30,31]. Hignett and Ri-
chardson [32] add that unpredictable patient fac-
tors such as shape and size, disability, and
capacity for compliance may interfere with the
use of safe handling techniques. Many also state
et al
that any previous history of back pain has shown
to be a risk for future episodes of back pain
[33,34]. It has been noted that nurses perceive
that their low back symptoms were caused by or
exacerbated by work [35].
Biomechanical evidence
Garg and colleagues [26,36,37] conducted lab-
oratory studies to evaluate five different manual
techniques and three different mechanical hoists
for transferring patients to and from bed to wheel-
chair, wheelchair to shower chair, and wheelchair
to toilet. Static biomechanical evaluation showed
that estimated compressive forces ranged from
1973 N to in excess of 5000 N and shear forces
ranged from 442 N to more than 900 N. These
studies also reported that less than 40% of female
workers have sufficient muscle strength to per-
form manual lifting and transferring tasks even
when using two nursing aides. The studies found
that estimated compressive forces exceeded the
National Institute Of Occupational Safety And
Health (NIOSH) recommended acceptable limit
of 3400 N. The studies also found that use of
a walking belt in combination with a pulling tech-
nique, rather than lifting, produced less biome-
chanical and perceived stresses on the nursing
personnel, and the patients found it to be more
comfortable and secure than the manual lifting.
Further, two of the older hoists were perceived
by the nurses to be more stressful than the use
of walking belts with pulling technique. Also, pa-
tients found the older hoists to be less comfortable
and less secure than the walking belt.
Marras and colleagues [38] estimated compres-
sive and sheer forces on the low back using an
electromyograph-assisted biomechanical model
for transferring a 50-kg, non-weight–bearing co-
operative woman. They also studied the probabil-
ity of membership in the high-risk low-back group
(LBD) by using a lumbar motion monitor. The
patient transfer tasks studied were transfers be-
tween bed and wheelchair and between toilet chair
and hospital chair. The estimated compressive
forces ranged from 4463 N to 6408 N, anterior-
posterior shear force ranged from 913 N to 1116
N, and LBD risk ranged from 76.9% 93.8%, de-
pending on patient transfer technique used and
number of nursing personnel involved in the
transfer. The study concluded that patient han-
dling is an extremely hazardous job. The task of
patient handling has substantial risk of causing
 JUSTIFICATION FOR A MINIMAL LIFT PROGRAM
a low back injury whether one or two nursing per-
sonnel are used for patient handling.
Winkelmolen and colleagues [39] studied repo-
sitioning patients in bed (moving upwards toward
the head of the bed). Passive patients between
55 kg and 75 kg were used to study five different
techniques (Australian lift, Orthodox lift, barrow
lift, through-arm lift, and under-arm lift). Using
a two-dimensional, static biomechanical model,
the estimated compressive force on the low back
ranged from 3315 N to 4003 N for the 55-kg pa-
tient and 3869 N to 4487 N for the 75-kg patient.
The authors concluded that for almost all trans-
fers, the compressive forces exceeded the NIOSH
acceptable limit of 3400 N.
Skotte and colleagues [40] studied low back
loading for nine patient-handling tasks including
turning, lifting and repositioning a male stroke
patient using a dynamic three-dimensional Biome-
chanical model. The main compressive force
ranged from 1618 N to 4433 N, peak anterior-pos-
terior shear force ranged from 106 N to 661 N,
and ratings of perceived exertion on the Borg
CR-10 scale ranged from 0 to 8. The study con-
cluded that the peak compression during two
tasks involving lifting the patient was significantly
higher than all other tasks. The four tasks involv-
ing repositioning the patient in bed had lower
peak compression than the two tasks involving
lifting the patient. The task involving turning the
patient in the bed had the lowest compressive
force. The study further concluded that, based
on peak compressive force or peak moment on
the low back, the patient-handling tasks can be
classified into three groups: (1) lifting tasks, (2)
repositioning tasks, and (3) turning tasks.
Ulin and colleagues [41] studied six different
patient transfer methods, three manual and three
mechanical, to transfer two totally dependent pa-
tients weighing 56 kg and 95 kg, respectively. The
study concluded that peak compressive forces
were greater than 10,000 N for manual transfer
methods, exceeding the NIOSH maximum limit
of 6400 N. When mechanical lifts were used, the
back compressive forces ranged from 437 N to
719 N, well below the NIOSH recommended limit
of 3400 N. The study reinforced the need to use
a mechanical lifting device when transferring
totally dependent patients.
A preliminary study by Lloyd and Baptiste
[42], working to develop new patient transfer tech-
nologies, reported that initial push and pull forces
required to manually transport an unoccupied
hospital bed over a smooth flat surface were
189
146 N and 134 N, respectively, whereas an occu-
pied bed required push and pull forces of 189 N
and 196 N. The forces encountered over a thresh-
old, such as the opening of an elevator, for an
empty bed were 151 N and for an occupied bed
were 198 N. Hospital beds found in medical-
surgical units are typically heavier and require
more transport. Therefore, the investigators state
that forces required to transport these types of
beds come close to or exceed strength capabilities
of most female workers.
Zhuang and colleagues [43] conducted a biome-
chanical evaluation of nine battery-powered lifts,
a sliding board, a walking belt, and a manual
method for transferring nursing home patients
from a bed to a chair. The study concluded that
transfer method and patient weight affect a nurs-
ing assistant’s low back loading. The use of me-
chanical lifts (portable or overhead devices)
reduced low back compressive forces by approxi-
mately two thirds compared with the baseline
manual lift method.
Daynard and colleagues [44] reported that use
of new assistive equipment resulted in higher com-
pliance with interventions. This was particularly
true when the perceived risk of injury during pa-
tient handling increased because of an increase
in patient size or a reduction in patient physical
capability. The study found that use of new assis-
tive handling equipment reduced spinal loading in
several tasks.
Several other studies have confirmed that
patient-handling tasks result in high compressive
forces on the low back [43,45–51]. Considering
these and other biomechanical studies collectively,
it appears that patient-handling tasks requiring
a vertical lift produce the highest compressive
forces on the low back, followed by patient-
handling tasks that require repositioning patients
in a bed or lateral transfers; whereas, turning pa-
tients in bed produces the least amount of com-
pressive force on the low back.
Nursing personnel perception
Insufficient staffing of nursing units can con-
tribute to work overload, which, in several stud-
ies, has been reported to contribute to feelings of
stress among nursing personnel [52,53]. Cato and
colleagues [52] reported that 73% of nurses with
low back problems reported feeling overly stressed
at work compared with those nurses without low
back problems. Ore [54] reported that 35% of
190 GARG
nurses responding to a questionnaire considered
changing jobs related to their idea that low staff-
ing levels would contribute to a higher risk of in-
jury caused by patient-handling tasks. Along these
lines, a study by Yassi and colleagues [51] found
that overly stressed staff perceived the inability
to obtain and use correct assistive lifting equip-
ment because of time constraints. Yet another
study by Yassi and colleagues [19] found that
nursing personnel with low back injuries perceived
that the cause of their injuries was inadequate
training in patient-handling techniques. Job satis-
faction is another factor that may predict low
back health according to a prospective study by
Ready and colleagues [55].
Perceived stresses
Many studies have found that nurses rated
perceived stresses on the low back and shoulder as
high during patient lifting and repositioning tasks
[56,57]. Winkelmolen and colleagues [39] studied
perceived stresses for repositioning patients
weighing 55 kg and 75 kg in bed. The perceived
stresses on the Borg scale (rating scale of 6-20)
ranged from 13 (somewhat hard) to 19 (extremely
hard). The perceived comfort ratings ranged from
3.3 to 4.3 on a six-point scale (rating scale of 0-5).
Studies addressing nurses’ perceived stresses were
also conducted by Owen and colleagues [57,58]
and Garg and Owen [56]. In all studies, nursing
personnel using assistive devices reported de-
creases in perceived physical exertion to the shoul-
der and low back during performance of all
patient-handling tasks. Yet another study by
Garg and colleagues [36] showed that perceived
stress ratings for the whole body, including shoul-
der and upper and lower back, were lower for pa-
tient-handling techniques based on pulling
methods rather than lifting methods. Owen and
Fragala [59] found similar results of decreases in
perceived exertion during a specific transfer task
that involved a pulling rather than lifting motion.
Yassi and colleagues [51] conducted a study in-
volving nursing personnel on medical, surgical,
and rehabilitation units. Each unit was assigned
to one arm of the study. One unit served as the
control group and received instruction in body
mechanics and lifting only on request. The ‘‘safe
lifting’’ unit was supplied with transfer belts in
each room and one mechanical lift for the unit.
The ‘‘no strenuous lifting’’ program unit received
new assistive equipment for patient-handling
et al
tasks. The equipment was supplied based on the
needs of the patient population on the unit.
Both the ‘‘safe lifting’’ and ‘‘no strenuous lifting’’
units were also given education on back care and
handling techniques in addition to training in the
use of assistive devices. Perceptions improved in
both the ‘‘safe lifting’’ and ‘‘no strenuous lifting’’
units, including perceptions of work fatigue, back
and shoulder pain, safety, and frequency and in-
tensity of physical discomfort. However, the nurs-
ing personnel on the ‘‘no strenuous lifting’’ unit
showed greater improvement.
Education and training
Historically the approach to decreasing low
back injuries in nursing personnel has been to
provide education and training in body mechanics
and lifting or transferring techniques [33,51,
60,61]. A few studies have shown a decrease in
compressive force on the low back with the proper
use of training and correct body mechanics
[44,62]. However, manual patient-handling tasks
are intrinsically so hazardous that no amount of
training alone can make the job safe. Also the
compliance with use of proper body mechanics
and techniques is lower when relying on education
and training alone [44,63]. Pheasant and Stubbs
[64] showed that there was an initial reduction in
back injury occurrence immediately after proper
training in patient-handling techniques; however,
this effect only lasted 18 months before the injury
rate climbed back to the original level.
There has been evidence to suggest that edu-
cation and training alone, without work modifi-
cations, does not decrease the number of
occupational low back injuries [33,56,65–72]. La-
gerstrom and Hagberg [60] conducted an educa-
tion program for nursing personnel including
training on transfer technique, physical fitness
and exercise, and stress management techniques
over a 3-year period in a Swedish hospital. Al-
though most participants expected that participa-
tion in this program would lead to a decrease in
injuries, the results did not show any decrease in
neck, shoulder, or back symptoms. Videman and
colleagues [33] compared nurses that did and did
not participate in an extensive training program
and their incidence of low back pain. Similarly,
the investigators found no significant differences
in occurrence of low back injury between groups.
In summary, ‘‘although instruction on manual
lifting and transferring patients is widely believed
 JUSTIFICATION FOR A MINIMAL LIFT PROGRAM
to have prophylactic value, there is no scientific
evidence that it alone is effective in reducing the
frequency or severity of back pain, especially in
nursing practice’’ [56].
Intervention programs
The focus of education and training programs
has been to change the way nursing personnel
perform the task instead of changing the task itself
[57]. As previously discussed, although this ap-
proach has not been able to show a reduction of oc-
currence in low back injury, an ergonomic approach
to patient handling has shown success [58,61,
73–75]. In an ergonomic approach to patient han-
dling the physical demands of the job are assessed
and then changed to decrease the risk factors that
may contribute to low back or shoulder injuries.
The changes to decrease the risk of injury are met
by developing alternate methods of performing
tasks to decrease stresses to the body and then apply-
ing them to the job through education and training.
Owen and colleagues [57] conducted a 5-year
follow-up study on nursing personnel after train-
ing and incorporation of several assistive lifting
devices in one of two hospitals. The second hospi-
tal served as a control and the personnel were
given only a 1-hour in-service on proper lifting
techniques. By introducing the assistive devices,
in effect, the physical job demands were changed.
This study also showed a postintervention de-
crease of back injuries of 40%. This study con-
firmed results found earlier in a study by Garg
and Owen [56] conducted in a long-term care facil-
ity. Compressive force on the low back and
strength requirements were significantly decreased
with the introduction of lifting devices, making
the job of patient-handling tasks safe for 83% of
female workers versus only 41% before interven-
tion. Furthermore, lost work days also decreased
significantly showing a decrease in severity of
injury.
Silverstein [61] stated that, with a systematic
and thorough approach to initiating zero lift pro-
grams in nursing homes, decreases in injuries
could be seen for nursing personnel and patients
alike. This is with the caveat of engaging manage-
ment commitment through the entire process.
Klebenow and colleagues [74] also showed a de-
crease in number and severity of injuries with
the institution of a minimal lift program in a hos-
pital setting and long-term care facility. The au-
thors also reported positive by-products of an
191
improved safety image to the public, an increase
in productivity, and an increase in recruitment
and retention of nursing personnel.
Collins [76] reported on a long-term study in-
stituting a minimal lift program in six long-term
care facilities. Results showed that low back in-
juries caused by patient lifting and transferring
decreased steadily after implementation of the
program from 47 injuries immediately after inter-
vention to 16 injuries after 5 years of the program.
Severity of injury was also reduced as the lost
work days decreased from 488 before intervention
to 229 after intervention. Injuries caused by trans-
fers in and out of bed, and during toileting and
picking patients off the floor were reduced by
50%. Injuries caused by turning or rolling resi-
dents in bed were also reduced by 50%. A 35%
reduction was seen in injuries attributed to
repositioning patients in bed. Worker’s Compen-
sation costs were decreased by approximately
50% over the same follow-up period.
Evanoff and colleagues [77] introduced me-
chanical lifts in acute care hospitals and long-
term care facilities. After training in proper use
of the assistive devices, the follow-up period lasted
approximately 3 years. Within that time period,
the results showed a decrease in musculoskeletal
injuries and lost workdays caused by injury. In-
jury reduction was greater in long-term care facil-
ities compared with acute care hospitals. Also,
injury reduction was greater on nursing units
that reported more consistent use of the assistive
lifting equipment. Another implementation of
a ‘‘no lifting’’ standard in England reiterated the
previous study findings in that there was reduction
of injuries and lost work days after introduction
of assistive devices on the nursing wards [78].
Others have suggested that the development of
a lift team responsible for all patient handling
with proper mechanical assists reduces low back
injuries [72,79,80]. Donaldson [80] conducted
a study in acute, subacute, and extended care units
of a 296-bed hospital. Acute care consisted of
telemetry, medical-surgical, intensive care, and
oncology units. Low back injuries and Workers’
Compensation costs for nursing personnel showed
significant decreases over the 6.5 years after the in-
stitution of the lift team. Similarly, Charney [79]
found that during a 1-year follow-up to the lift
team program, although the team performed
3,188 lifts, there was only one injury reported
with no lost time for the team members. Two
modified duty days were reported for that specific
injury. This substantially decreased injury costs.
192 GARG et al

Critical care specialized beds to care for patients in excess of

700 pounds. In addition to lifting the entire
Although there has been an abundance of
patient weight, certain surgical procedures require
research in the area of physical stresses from
lifting or supporting a limb of the patient for
patient handling in hospitals and long-term care
a prolonged period. Depending on the weight of
facilities, there is virtually no published literature
the patient and the body posture used, lifting
dealing with stresses to nursing personnel in
a patient limb could be hazardous to nursing
critical care settings. Based on informal discus-
personnel, producing large compressive forces on
sions with nurses and other operating room
the spine along with the possibility of producing
personnel, several observations were made. These
large torques on the shoulders. Some limbs of
are discussed below.
obese or bariatric patients’ may weigh in excess of
Patients require critical care in operating
50 pounds alone. The Revised NIOSH Lifting
rooms for preoperative preparation and during
Equation [81] recommends a maximum weight of
perioperative and postoperative care. They re-
51 pounds under ideal lifting conditions for
quire critical care in emergency rooms, intensive
a smooth, continuous lift. If a nurse has to reach
care areas, cardiac care areas, and on many other
horizontally about 20 inches away from the ankles
hospital units. Lifting and repositioning patients
during lifting, then the recommended weight
to and from hospital bed, to and from an
limit significantly decreases to approximately
operating room bed, on and off stretchers, and
25 pounds. Certainly, when reaching for and lift-
in and out of cardiac chairs, are frequent occur-
ing a limb of an obese or bariatric patient, it is
rences. Patients are transferred from stretchers,
quite likely that the nursing personnel could ex-
transport carts, and beds to operating room tables
ceed the recommended weight limit from NIOSH.
and back to stretchers, transport carts, and beds,
Further, the recommended weight limit does not
both before and after surgery. Patients may need
account for holding a limb of the patient for a pro-
to be transported for medical imaging (eg, com-
longed period, which often may be the case during
puted tomography scan, magnetic resonance im-
a surgical or diagnostic procedure. It is well estab-
aging, ultrasound scan, x-rays) or any number of
lished that a person’s ability to hold or support
other diagnostic procedures. Nursing personnel
a weight decreases nonlinearly with an increase
face a serious risk of musculoskeletal injuries, in
in holding time. For example, Garg and col-
particular back and shoulder injuries, when han-
leagues [82] have shown that endurance time for
dling patients in these environments. Some of
holding a weight of 10 pounds or less with one
these patients are completely dependent because
hand is less than 60 seconds. They also showed
of general anesthesia, stroke, or sedation. They
a significant accumulation of fatigue in the shoul-
may be unconscious or comatose and cannot help
der girdle during such a task.
during transfer tasks. Nursing personnel, along
A few studies have recognized the high risk
with perioperative team members, are often re-
associated with patient-handling tasks in preop-
quired to manually lift patients or patients’
erative patient-handling tasks. For example Owen
extremities.
[83] identified several high-risk perioperative
As stated earlier, manual lifting of a normal
tasks. Some of these included transferring patients
patient is considered hazardous to health care
on or off operating room beds, repositioning pa-
workers. Lifting and handling of patients requir-
tients in operating room beds, lifting and holding
ing critical care is an even greater hazard for
patients’ extremities, and holding retractors for
several reasons: (1) these patients often are totally
extended periods. Wicker [84], in the United
dependent, and their entire body weight must be
Kingdom, stated certain unique aspects of high-
lifted; (2) depending on the patient’s injury and
risk patient-handling tasks associated with preop-
illness and type of surgery performed, it may be
erative limb preparation, supporting limbs during
necessary to maintain a patient in a dependent
surgical procedures, and patient handling during
position (eg, hips cannot be moved because of
postoperative recovery. Wicker stated that nurs-
surgery); and (3) there may be equipment attached
ing personnel have to raise a limb to prepare it
to the patient such as oxygen, intravenous line,
for surgery. The nursing personnel may have to
respirator, catheters, or casts. Some of these
hold a limb manually during the entire time
patients may be obese or bariatric, weighing in
needed for skin preparation. Wicker also raised
excess of 400 to 500 pounds. For example,
concerns regarding fatigue and pain from static
a hospital in Milwaukee, Wisconsin is purchasing
posture during surgical procedures. In addition
 JUSTIFICATION FOR A MINIMAL LIFT PROGRAM
to patient handling, there is also concern regard-
ing pushing and pulling of heavy equipment
such as operating room tables, imaging machines,
microscopes, beds, or instrument trays. Some of
the patient-handling tasks may require lateral
transfer of a patient lying in a supine or prone po-
sition from stretcher to operating room bed and
vice versa. These tasks may require moving the
patient from a prone position to a supine position
or supine position to prone position. Some perio-
perative tasks may require positioning and reposi-
tioning a patient on the operating room bed in
a supine position. Other perioperative tasks may
require positioning and repositioning the patients
in a semi-Fowler’s position, lithotony position, or
lateral position. Other tasks may require lifting
and holding of a patient’s leg, arm, or head.
Unlike patient handling in long-term care
facilities that mostly requires vertical transfers
(eg, from bed to wheelchair), most patient han-
dling in critical care requires lateral transfers (eg,
supine position to supine position from stretcher
to operating room bed) and lifting and holding
of a patient’s limbs such as leg, arm, or head.
Therefore, ergonomists need to pay more atten-
tion to patient transferring devices that would be
able to perform lateral transfers such as from
operating room bed to stretcher for patients in
need of critical care. Also, ergonomists need to
pay attention to devices that would be able to lift
and support patients’ limbs. Creativity and in-
genuity are needed to develop devices that will
turn patients from one position to another posi-
tion such as from supine to prone and vice versa.
Regarding lateral transfers, many patient
transferring devices are commercially available.
Some of these devices have been used successfully
by long-term care facilities and hospitals. It is
recognized that when dealing with patients re-
quiring critical care, some of these devices may
need to be modified. Regarding lifting and sup-
porting a patient’s limb, currently both ceiling
hoists and portable hoists are designed to lift the
entire patient. With appropriately designed slings
or with some creativity, these mechanical devices
can be used to lift and support patient’s limbs
during perioperative care. Regarding reposition-
ing of a patient in an operating room bed, such as
from supine to supine position, semi-Fowler’s
position to semi-Fowler’s position, or lithotony
position to lithotony position, it is quite possible
that some of the devices that are commercially
available for repositioning a patient in a supine
position in bed may be useful. Another option for
193
repositioning a patient in these positions would be
to use battery-operated hoists with properly de-
signed slings that are capable of lifting a patient
while maintaining the desired position. The issue
of turning a patient from a supine to a prone
position or from a prone to a supine position as
well as supporting a patient in a semisupine
position is difficult, because currently, there is
a lack of commercially available devices to ac-
complish this. In this regard, principles of bio-
mechanics can be used to make the job easier. For
example, working with biomechanical principles,
it is often less stressful to the body to pull a patient
toward you rather than to lift a patient. Similarly,
supportive wedges or pillows can be used to make
the job easier on the critical care worker and more
comfortable for the critical care patient. These
recommendations are consistent with Owen’s [83]
observations. Owen [83] conducted her study in
medical-surgical units. She concluded that her
findings could be useful to perioperative nurses
because the type of horizontal transfer performed
in the operating room and medical-surgical units
are similar.
It is clear from the above discussion that
patient handling in critical care settings is a serious
hazard. It is also clear that no amount of body
mechanics and training in safe lifting and patient
transferring techniques will make the job safe.
Therefore, the only safe solution for patient
handling in critical care settings is with incorpo-
ration of the use of patient handling and assistive
devices to eliminate or minimize lifting and
supporting of patient weights as much as possible.
These programs have worked extremely well in
long-term care facilities as well as in hospitals, and
there is no reason to believe that they would not
be successful in reducing musculoskeletal disor-
ders in critical care settings.
Summary
Numerous studies and statistics clearly show
that low back injuries are commonplace among
nursing personnel. The prevalence of work-related
low back pain is higher in this population than
almost all other working groups. Shoulder pain is
also an issue for nursing personnel that is often
overlooked. The primary causes of injuries are
thought to be patient-handling tasks, specifically
lifting and transferring of patients. Repositioning
of patients is also reported to be as physically
stressful as lifting. Biomechanical studies show
194 GARG
that compressive and shear forces exceed accept-
able levels of exposure. The strength requirement
of the job also exceeds the physical capabilities of
most female workers. Therefore, patient-handling
tasks are inherently very hazardous and pose
a high risk for injury.
Training in body mechanics and lifting technique
is not enough to reduce low back and shoulder
injuries. Several epidemiologic studies have shown
that ergonomic interventions are effective in re-
ducing the risk of injury and the severity of injury.
Critical care poses a very challenging environ-
ment because patients are usually more debilitated
and unable to assist during transfers. Therefore,
the needs of this population as a whole are greater
than some other patient or resident populations.
Also, the risk of injury is also greater to nursing
personnel caring for this population. The only
long-term solution is to introduce assistive devices
into this specialty area of nursing care. This may
require some ingenuity in using current commer-
cially available devices as well as creativity to
design new and improved equipment.
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 Crit Care Nurs Clin N Am 19 (2007) 197–204
Sustaining Staff Nurse Support for a Patient Care
Ergonomics Program in Critical Care
Linda L. Haney, RN, MPH, COHN-S, CSPa,*,
Laurette Wright, RN, MPH, COHN-Sb
a
Diligent Services, ARJO, Inc., 711 North Tenth Street, Wausau, WI 54403, USA
b
Diligent Services, ARJO, Inc., 1200 Theodore Lane, Durham, NC 27713, USA
Approximately 70% of all change initiatives
fail, according to Beer and Nohria [1] of the Har-
vard Business School. Ergonomic change initia-
tives, such as safe patient handling in critical care
units, certainly are not immune from this discour-
aging fact. Managers have only to look at past
purchases of patient equipment to find it languish-
ing in the back of a storage room. Moving to a safe
patient handling environment, with the purchase
of appropriate equipment, in any setting requires
nothing less than a cultural change demonstrated
as new and consistent use behaviors of nurses.
From the beginning of their training nurses are
taught to lift and move patients using ‘‘body me-
chanics’’ with the implication that if a task simply
is done properly it is safe for patients and care-
givers. This notion is reinforced through in-service
trainings and managers who give well-meaning re-
inforcement. A significant body of literature dis-
putes the safety of body mechanics alone as an
effective way to prevent injuries [2].
As research becomes available, nurses have
supported and rallied around evidence-based
practice for patient care. Malloch and Porter-
O’Grady [3] define evidence-based practice as the
application of the best possible research with evi-
dence from clinical expertise channeled toward the
needs of patients. Partly for complex historical
and sociologic reasons, nurses tend to be self-sac-
rificing and slow to move to evidence-based
This work was supported through funding by
ARJO, Inc.
* Corresponding author.
E-mail address: lhaney@dwave.net (L.L. Haney).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.003
practice for themselves. The research is clear
that safe patient handling programs can achieve
safety goals for caregivers, although there is
a dearth of research on the issue of improved pa-
tient safety as a result of the programs [4]. The an-
ecdotal evidence, however, strongly indicates
reduced patient falls and increased comfort during
patient lifts and transfers when a safe patient han-
dling program is in place. Additionally, there is
beginning recognition among rehabilitation pro-
fessionals that safe patient handling equipment
can be used to further rehabilitation goals [5].
In spite of training, education and research to
the contrary, caregivers in general do not appear
to view mobility, such as sitting on the edge of
a bed or transfer to a chair, as clinical issues.
Positioning of patients relative to lung function
clearly is seen as a clinical issue in critical care
units, however [6]. The general belief regarding
mobility is important especially in critical care
units where the major focus is on life-threatening
conditions, not the sometimes devastating after-
math of immobility. Physicians routinely write or-
ders for patients to be ‘‘out of bed,’’ although
informal discussions with critical care nurses vali-
date the belief that these orders often are unrealis-
tic given patients’ condition. As a result, they do
not carry the same criticality as most other orders.
The average age of a nurse is expected to rise to
45.4 years by 2010, as compared with 41.9 in 2000
[7]. Older caregivers who now predominate in the
workforce remember earlier practice mandating
lengthy enforced bedrest after open-heart surgery.
It is now widely accepted that patients do consid-
erably better when they are mobilized quickly
after surgery, usually within several hours. The
ccnursing.theclinics.com
198 HANEY & WRIGHT
conclusion is that mobility is just as much a clinical
issue as correct medication, procedure, or diet.
There are many reasons, therefore, why mobility
and transfer tasks should be made as safe as
possible.
Sustaining staff support for a safe patient
handling program implies that support was present
at one point or for some period of time. Exploring
the nature of change, how it happens, how people
are motivated to accept it, what barriers prevent
it, and how it is sustained all are inextricably
linked. Society actively seeks quick fixes and
engages in limited long-term planning. Cultural
change, expressed as new and different behaviors,
occurs slowly. Consider only the initiative to use
gloves to understand the difficulty. Wearing gloves
consistently and appropriately has taken nurses
more than 15 years even with the knowledge and
evidence of an associated frightening disease
(AIDS) and a federal law (Bloodborne Pathogens
Standard) [8]. Safe patient handling programs are
not associated with a frightening disease, although
the toll of musculoskeletal injuries may be far in
excess of AIDS, and there is no a federal regulation
specific to the problem, although several states are
have enacted safe patient handling laws, with more
expected to come. Thus, it is important to under-
stand that the change to an environment of safe
patient handling may take many years.
The natural question is why change initiatives
are so difficult to maintain and fail so frequently.
Field discussions with managers and employees
attest to the fact that beginning a change initia-
tive, although sometimes difficult, can be done
with relative ease compared with sustaining or
cementing a change. There is a significant amount
of literature that provides insight, particularly in
the business and management realm, on change
management. As Harrington states, ‘‘[Permanent]
change is not a simple process. It requires a lot of
thought, a well-developed plan, a sophisticated
approach, and unfaltering leadership’’[9].
Other articles elsewhere in this issue address
the rationale and assessment of need for a safe pa-
tient handling program. The remainder of this ar-
ticle focuses on some of the issues related to
change management and communicating and
maintaining a successful safe patient handling
program in critical care units.
Change process models
Change is about seeking new and improved
ways of doing things. Weick and Quinn [10] de-
scribe two slightly different models of change,
based on the classic work of Kurt Lewin. Episodic
change follows the sequence of ‘‘unfreeze, transi-
tion, refreeze,’’ whereas continuous change is
framed as ‘‘unfreeze, rebalance, refreeze.’’ The
United States Army uses the PMOC model, devel-
oped from the work of an early French engineer,
Henry Faylol. It consists of planning (setting goals
and the process for achievement), motivating
(providing incentives for a group to work toward
the goal), organizing (how best to group activities
and resources), and controlling (monitoring and
correcting ongoing activities toward the goal) [11].
Experience shows that there are two basic
approaches. The first is a common onedheavy
handed, top down, and ‘‘holding people account-
able’’ with concomitant strictly applied punitive
measures for those who do not comply, particu-
larly if there is a written policy in place. The
second approach is one of a softer and more
relaxed approach of building trust and emotional
commitment through a planned approach of
communication. Proponents believe this is the
more effective approach, although they acknowl-
edge that this approach does take more time. Beer
and Nohria [1] make the case that the most effec-
tive approach is a combination of the two basic
approaches that includes setting direction from
the top and engaging people from below. Change
imposed only from the top down tends to result in
minimal compliance if not outright evasion.
More recently, Kotter [12] developed an 8-step
process-of-change model. He emphasizes that the
role of leadership is more important than that of
management, although increasing leadership
does not mean decreasing management:
1. Create urgency.
2. Build the guiding team.
3. Get the vision right.
4. Communicate for buy-in.
5. Empower action.
6. Create short-term wins.
7. Do not let up.
8. Make change stick.
All change models require organizations and
individuals to move from one entrenched position
to another one. All typically encompass variations
of the following and are similar to the familiar
nursing process [13]:
1. Recognizing a problem or an opportunity Assess
2. Assessment of the current situation Assess
3. Development of possible
ideas to solve the problem Diagnose
 NURSE SUPPORT FOR A PATIENT CARE ERGONOMICS PROGRAM
4. Selection of best approach Plan
5. Identification of barriers Plan
6. Communication, Implement
7. Implementation Implement
8. Monitoring results Evaluate
9. Maintenance
Covey [14] includes the following as one of his
seven habits of highly effective people: ‘‘begin with
the end in mind.’’ This is true especially when be-
ginning a program with the goal of behavioral
change. Kirkpatrick [15] provides a useful model
for determining the effectiveness of training, using
five tiered levels of evaluation. His work, adapted
to effectiveness of a change initiative, suggests that
behavioral-change end goalsdcost-effective and
consistent use of devices to reduce injuries for
patients and staffdand the planned step-by-step
objectives to achieve those goals are essential to
success.
Communication
Critical care nurses are familiar with the pro-
cesses of assessment, diagnosis, and planning.
They may not be as familiar with the business
literature on communication processes. How well
communication is planned and delivered through-
out the change process has critical implications
for the successful implementation and mainte-
nance of the new behaviors. Every change man-
agement model includes or implies the importance
of effective planning and communication about
the proposed change. Duck [16] states that man-
aging a successful change initiative means manag-
ing the communication between those who seek
the change, those who are expected to implement
it, the context of the change within the organiza-
tion, and the emotions that go along with the
change. She goes on to say that because people
need time to hear the message, integrate it into
their thinking, and believe it, change proponents
need to talk about the change over and over and
over. She expresses it well: ‘‘When you are so
sick of talking about something that you can
hardly stand it, your message is finally starting
to get through. Until managers have listened,
watched, and talked enough to know that the an-
swer to all of the following questions is yes, they
haven’t communicated at all: did they hear it, do
they believe it, do they know what it means,
199
have they interpreted it for themselves and have
they internalized it?’’ [16].
Social marketing is a new concept that aids in
communication. It is defined by the Social Mar-
keting Institute as the planning and implementa-
tion of programs designed to bring about social
change using concepts from commercial market-
ing [17]. The goal of social marketing is to initiate
and sustain a change in behavioral action in indi-
viduals and society through application of mar-
keting principals of communication and
persuasion [18]. The Centers for Disease Control
uses social marketing in their public health efforts
and participates in the Turning Point Social Mar-
keting National Excellence Collaborative spon-
sored by the Robert Wood Johnson Foundation
and housed at the University of Washington
School of Public Health and Community Medi-
cine. The collaborative provides resources for
social marketing, collaborative leadership,
performance management, information technol-
ogy, and public health law modernization to en-
courage the use of social marketing at state and
local levels. A helpful resource is the Turning
Point CD-ROM Toolkit available at no charge.
It includes a wide and extensive variety of innova-
tive tools, worksheets, and resources, including
‘‘The Basics of Social Marketing,’’ ‘‘Guidebook
for Performance Measurement,’’ and ‘‘Manager’s
Guide to Social Marketing’’ [19]. Change that is
preceded and supported by ongoing social mar-
keting seems to have a better likelihood of an
effective outcome.
The act of communicating and persuading
people to move from one way of thinking and
behaving to the adoption of another way is
important in all social settings. It allows progress
to be made and permits research to move to reality.
Various means of changing behavior have been in
vogue since the industrial revolution. Classic
Theory X and Theory Y approaches, developed
by McGregor, attempted to categorize manage-
ment believed as either one of work being a nega-
tive (X) or a positive (Y) for workers [20]. Newer
thinking and changing social demographics have
moved management science to a more collabora-
tive model, although the heavy-handed approach
with workers remains surprisingly common.
Duck [21] states that the new management style
recognizes that change ultimately is about feelings.
Emotions must be recognized and addressed if
facilities or units want employees to contribute
their heads and their hearts to their work. Fournies
[22] emphasizes the importance of explaining the
200 HANEY & WRIGHT

cause/effect relationship in detail between the in-
tended actions and the expected results.
The Social Marketing Institute and Turn Point
literature, based on the work of Weinreich, states
there are several key concepts associated with so-
cial marketing, including action as the objective,
focus on the target audience, understanding that
the exchange is critical, analyzing the competition
(in this case, for time, but also possibly for budget
dollars), flexibility and monitoring (the change),
and use of the 4 Ps (Table 1) [23]:
Create an enticing product (ie, the package of
benefits associated with the desired action).
Minimize the price the target audience believes
it must pay in the exchange.
Make the exchange and its opportunities avail-
able in places that reach the audience and fit
its lifestyles.
Promote the exchange opportunity with crea-
tivity and through channels and tactics that
maximize desired responses.
Training
New behaviors require initial and ongoing
training. Some object to the term, training,
although it is in widespread use, preferring the
term, facilitating learning. Educating caregivers
should not be a one-time exercise but a process,
particularly if the scope of the information is
extensive. Nin writes, ‘‘There are very few human
beings who receive the truth, complete and
staggering, by instant illumination. Most of
them acquire it fragment by fragment, on a small
scale, by successive developments, cellularly, like
a laborious mosaic’’ [24]. Education in isolation
rarely achieves goals. Benner [25], in her classic
book, From Novice to Expert, expresses the same
beliefs when she states that nursing practices and
skills develop through experiences and are con-
veyed through experiences. She states that the
learning derived from those experiences are
learned most easily and safely when based on
a good educational foundation. Too often, educa-
tion is an isolated process with little follow-up,
little monitoring, and limited review [26]. Adher-
ence to the generally recognized principles of adult
learning and Kirkpatrick’s model help to insure
that real learning takes place and achieves the
stated goals rather than training merely for the
purpose of compliance.
The purpose of training is change and action,
but it is not sustainable without an analogous
change in the supporting management process,
according to Harrington [8]. He states that man-
agers must direct action within the first week after
a class by applying the information presented to
them. If they cannot or will not apply the infor-
mation quickly, there is only a 20% chance that
they ever will use the techniques or methods that
were taught [8]. In short, behaviors change in
large measure because of what managers do or
do not do.
Motivation
Herzberg’s [27] classic article on change re-
viewed the various factors that motivate em-
ployees. His research concludes that motivation
occurs when people are given interesting work,

Table 1
Applying social marketing to safe patient handling
Target population Product Price Promotion Place
Caregivers within Slide sheets Perceived barriers: Evidence-based Facility newsletter
critical care to reduce friction when Too much time to apply literature Unit bulletin
units moving patients Requires two people Staff meetings board
within a bed to use Success stories Signs for location
Other perceived Naming of of the sheets
benefits: campaign Pay roll stuffers
Task made Task force
physically easier Incentives
Symptom
Reduces total reductions
fatigue for shift
Reduces potential
for back/shoulder
injuries
 NURSE SUPPORT FOR A PATIENT CARE ERGONOMICS PROGRAM
challenges, and increasing responsibility. Coombs
[28] suggests that the following factors are neces-
sary for motivation for intensive care nurses:
pay conditions, clinical requirements, organiza-
tional requirements, interaction, autonomy/re-
sponsibility, and prestige/status. Controversies
exist about whether or not it is even possible for
one individual to motivate another, although the
consensus seems to be that a leader’s responsibil-
ity is to create the conditions where individuals
‘‘own’’ their motivation. Three short case studies,
although not all specific to critical care, serve to
emphasize the key role of leadership:
Case study 1
After extensive review, a large university-based
system made the decision to create a safe patient
handling environment and selected a critical care
unit to pilot the project, because this nursing staff
had the best compliance with equipment use.
When looking at the salient factors, the following
was discovered: a unit manager was committed to
the change and took the time to take pictures of
her staff in the equipment; a poster placed in
a prominent location on the unit where staff and
patients could see it easily; a small weekly
newsletter for the staff with a regular column
on the safe patient handling initiative; and
a manager who stated regularly that her staff
were absolutely terrific and she was very proud of
them. The enthusiasm and compliance with the
program resulted in no staff or patient injuries
related to patient handling for more than a year.
When this manager subsequently left because of
personal health reasons, compliance went down
to the level of other units in the hospital.
Case study 2
In a critical care unit of one hospital, a single
personal care technician who had sustained a pre-
vious back injury readily saw the benefits for
herself and others on her unit of a safe patient
handling program. She became a peer leader,
defined as unit champion, and the driving force
for the use of slide sheets to transfer patients from
bed to stretcher. With the support of her manager,
she insisted that they be placed on all of the beds
and doggedly pursued the goal of compliance on
the unit. It was not long before she was called
‘‘Purple Sandy’’ because of her advocacy of the use
of the purple slide sheets. This individual played
a strong role in creating an acceptance for the
change in behaviors on the unit.
201
Case study 3
One hospital, part of a 200-bed health care
system, approached the change to a safe patient
handling environment in a different way. The
entire system put together a task force that
created a baseball theme for the change to
a safe patient handling program. The initiative
included baseball shirts for unit champions,
themed posters and newsletter inserts, game score
cards, and initially used incentives to capture the
excitement after the training. The task force
continues to keep the initiative alive and the
hospital has seen sustained dramatic reductions
in staff injuries over 2 years.
Bringing motivation factors to life requires an
enthusiastic walk-the-talk attitude and the ability
to lead others to a better way. Modeling the
behavior is one important way for managers to
express their commitment to the change by in-
dicating graphically that they not only say that they
want a change but also are demonstrating their
commitment. Modeling may mean actually doing
the task, such as using a new ergonomic piece of
equipment, giving positive reinforcement when the
equipment is used, including the desired perfor-
mance in performance evaluations, and even pro-
moting those who exhibit the desired performance.
One of the best methods is for managers, on
a weekly basis, to round the units and randomly
request various employees to put a manager in the
equipment and demonstrate its use. Another rec-
ommendation is to discuss the status of individual
compliance periodically during informal coaching
sessions and formally at the time of performance
reviews. Employees intuitively know that if an issue
does not appear in their performance evaluations it
is not important. When managers walk the talk they
build predictability. Duck [16] states that predict-
ability leads to trust, and trust and competence
are necessary to achieve change. If managers ignore
behavior that does not reflect the desired change,
they have sent a powerful message that the change
is not important or a priority, and caregivers are
not expected to change their actions. And, if this
is the case, it is difficult for the initiative to succeed.
Incentives
Human behavior research, beginning with
Skinner [29], asserts that people do things for
which they are rewarded and do not do things
for which there is no reward. Performance that
is rewarded increases in frequency; the reward re-
inforces the behavior. Behavior psychologists,
202 HANEY & WRIGHT
such as Daniels, are applying theories and practi-
cal applications to the fields of safety, health, er-
gonomics, and change management. Daniels’
work indicates that if a change within an organi-
zation is to be successful, leaders need to reward
it in a way that causes people to increase their ef-
forts, cooperation, and quality of their work [30].
Beer and Nohria caution that incentives should be
used to reinforce change rather than drive it [1].
Using behavior analysis techniques to examine
the antecedent of the behavior (what comes
before), the behavior, and the consequence
(what happens after) is the cornerstone for be-
havioral change. According to Daniels, anteced-
ents have limited control over behavior. Their
function is to get a behavior to occur once or at
best a few times. Positive consequences, alterna-
tively, are the key to getting a behavior to occur
again and again. Daniels [30] succinctly summa-
rizes by saying, ‘‘If performance is not improving,
reinforcement is not occurring.’’ Fray [26] puts it
a slightly different way: ‘‘In reality a continuous
input of motivation is required to keep the change
process moving. Personal experience has shown
nonmonetary or low monetary incentives to be
the most effective. A simple smile, pat on the
back, or personal note can serve as powerful
and inexpensive incentives. Selecting the right in-
centive to motivate behavior may be individual;
it is determined best simply by asking the
employee, ‘What motivates you?’’’
Peer leaders/unit champions
Coaching implies an expertise in a specialized
area. It generally is acknowledged that unit-based
coaches or peer leaders for safe patient handling
are useful, although the evidence-based literature
is sparse. Safe patient handling coaches have
various names, such as transfer mobility coaches,
back injury resource nurses, and ergocoaches
(Netherlands). Peer leaders are defined as staff
colleagues who work alongside new staff or those
learning new skills to assist with the transfer of
knowledge (learned in a class) to skills (ability to
apply the knowledge) in the real world [31]. With
strong management support, specialized training
for this these individuals serves to extend the
reach of managers on units as it relates to safe pa-
tient handling behaviors. Unit champions can be
a strong factor in changing behaviors in support
of the goals. Cook [32] states that effective coach-
ing moves learners from thinking only of them-
selves to thinking about what is best for units or
organizations. The ideal ratio of coaches, allowing
caregivers to have ready unit-based access to
a coach at all times, is 1 to 2 per shift per unit.
Coaches for safe patient handling typically
incorporate this role into their existing responsi-
bilities on a unit. Training includes the following
basic skills: ergonomics, introduction of equip-
ment to patients and families, problem solving,
techniques for improving compliance on a unit,
review of patient handling injuries that have
occurred, and thorough knowledge about the
available equipment and coaching skills. Backed
by regulatory reinforcements and national fund-
ing, the Netherlands has a long and successful
history of changing the culture of health care
providers to one of safe patient handling. Their
ergocoaches are supported through national con-
ferences, specialized training, and their own Web
site. A large, 600-facility–based study soon will be
underway to examine the value of ergocoaches in
a systematic way [33].
Resistance to change
Change and resistance are linked closely. Plan-
ning needs to identify possible barriers to the
change initiative and determine a plan to reduce
them. There may be many reasons why there is
resistance to a safe patient handling environment,
including distraction as the result of too many
initiatives happening simultaneously, the belief
that the change is unnecessary, a feeling that the
initiative has been tried unsuccessfully before, and
a lack of appropriate communication. Sometimes
managers themselves are skeptical about projects
and do not participate in senior-level change di-
alog. Their skepticism about the project can affect
their team’s response. Dym [34] sees resistance as
an attempt by the organization to regain equilib-
rium and as feedback about the disruptions.
Resistance may be observed in individual
behavior showing apathy, skepticism, denial,
anger, helplessness, incompetence, or lack of
follow through. It also can appear in a phrase,
such as, ‘‘I don’t have time to use the equipment.’’
Examined more closely, the caregiver may be
saying, ‘‘I don’t believe this is a priority in the
time that I have available.’’ Ultimately, change is
a highly personal endeavor because it requires
individuals to think about their behavior, make
a decision about whether or not they are going to
change, and then act differently [16].
Resistance also may come as the result of
impatience. When projects, such as safe patient
 NURSE SUPPORT FOR A PATIENT CARE ERGONOMICS PROGRAM
handling, do not communicate realistic expecta-
tions, people become impatient and conclude that
the change is not a good one. Clear and practical
timelines reiterated repeatedly and a strong com-
mitment to persistence are needed. Dym [34] pro-
vides a 5-step approach to management of
resistance: (1) anticipate resistance; (2) explore
the problems for which resistance provides feed-
back; (3) join and validate the resistance, thus em-
powering those who resist; (4) form a partnership
to solve the problem addressed by the resistance;
and (5) problem solve.
Combining plenty of communication, persis-
tence in the message, unwavering modeling of the
behavior, problem solving, and rewards for the
desired behavior are effective.
Summary
The ultimate goal of a safe patient handling
program actually is ‘‘no program,’’ and the pro-
cess may take years. When safe patient handling
practices become so embedded in education and
practice that they no longer are considered ‘‘a
program,’’ change has occurred and the culture is
one where patients and caregivers are safe during
lifts, transfers, and mobility activities. The change
may not occur solidly until the current generation
of caregivers leaves the workforce and the new
generation provides the bulk of care. A safe patient
handling program with its associated benefits is
too important to be left to change or a ‘‘good
effort’’ only to see the initiative die. Sustainable
patient handling change requires a change in
beliefs about the value of mobility tasks and the
unswerving belief of the importance of protecting
caregivers and patients during those tasks.
The ability to see that a safe patient handling
environment makes sense and has advantages
requires individual thought and strong leadership.
Sustaining the change requires a thoughtful plan
from the beginning with input from those who are
affected, a realistic attitude about the time it will
take, repeated communication, positive reinforce-
ment, and dogged persistence. Change and a com-
mitment to the sustaining the change do result in
goal achievement.
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 Crit Care Nurs Clin N Am 19 (2007) 205–211

Safe Patient Handling Program in Critical Care

Using Peer Leaders: Lessons Learned
in The Netherlands
Hanneke J.J. Knibbe, MSc, RPTa,*, Nico E. Knibbe, MSca,
Annemarie J.W.M. Klaassen, RN, MScb
a
LOCOmotion, Research in Health Care, Brinkerpad 29, 6721 WJ Bennekom, The Netherlands
b
Project ErgoCoaches, RegioPlus Foundation, Zoetermeer, The Netherlands

An ergonomic approach in acute care
In the Netherlands, the ergonomic approach is
advocated as the most effective way to prevent
musculoskeletal disorders among health care
workers. In the literature, this is referred to as
a nonlifting or minimal lifting approach, and there
is evidence of the effect of such an approach and of
the lack of effect of other approaches [1–3]. The
primary objective is to eliminate or substitute all
potentially harmful actions. For this purpose,
guidelines were developed mainly based on the Na-
tional Institute of Occupational Safety and Health
(NIOSH) guidelines for manual handling of loads
[4]. Patients or objects in excess of these limits
should not be lifted or transferred manually. This
approach has been enhanced over the past 4 years
through working environment covenantsdsigned
agreements ensuring commitment by a range of na-
tional parties. The initial drive for these covenants
originates from the European Union guidelines for
promoting safe work practices. In nearly all health
care sectors (acute and critical care, nursing homes,
home care, psychiatric care, and care for the hand-
icapped) employers, workers (unions), and govern-
ment have, on the basis of these convenants,
worked together to decrease the exposure of nurses
to physical overload. The focus of the convenants
is not restricted to a nonlifting approach, but all
major sources of physical overload (lifting and
transferring patients, pushing, pulling, postural
* Corresponding author.
E-mail address: j.j.knibbe@wxs.nl (H.J.J. Knibbe).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.009
load, reaching, prolonged standing, and so forth)
are taken into account.
This article briefly overviews the implications of
this development for critical care in hospitals. In the
Netherlands, this applies to a group of 110 hospitals
across the country, which has a total population of
approximately 16 million people. For the purpose
of this article, the group of eight academic teaching
hospitals has been excluded, which, as a group,
have taken a slightly different approach.
This article provides insight into the develop-
ment of the guidelines, the implementation pro-
cess, and preliminary results.
Analysis of the ergonomic situation in acute
and critical care
The first step was to assess the exact nature of the
ergonomic problems encountered in critical care.
For this purpose, research material from different
sources was collected and the conclusions were
combined. Methods used were surveys, observa-
tions, and direct measurements of exposure.
Prevalence of musculoskeletal disorders
In a survey of 4129 nurses from a convenience
sample of 27 hospitals (average nurse response
rate 68% [50%–100%] per hospital; hospitals
evenly distributed across the country), it was clear
that there are back pain problems but also that
the back pain prevalence differs widely between
hospital wards [5]. The average 12-month back
pain prevalence of all nurses responding was
63%. This is high compared with the average for
ccnursing.theclinics.com
206 KNIBBE
the Dutch general population (42%) but slightly
lower than the Dutch average for home care in
that period (67%). Preventive action, therefore,
was considered relevant and necessary. It also
was clear that there were large differences between
different specialties in a hospital. Surgery, cardiac
critical care units, ICU, emergency departments,
cardiology in general, orthopedics, and neurology
reported a higher prevalence, the latter two rank-
ing first and second. Alternatively, specialties,
such as gynecology, pediatrics, and internal med-
icine, reported prevalence lower than the hospital
average. Acute and critical care were in the mid-
range: not as high, for example, as nurses working
on orthopedic units report but higher than the av-
erage for the general population (50%–62% de-
pending on the ward). It also seemed that for
acute and critical care, back pain was not the
only problem, with an elevated prevalence of mus-
culoskeletal disorders. Nurses working in critical
care also reported a relatively high prevalence of
neck and shoulder problems. Over a third
(35%–55%) of the critical care nurses in the 27
hospitals included in the survey reported having
had neck or shoulder pain in the 3 months before
the survey.
These data underline that for critical care, there
is sufficient reason to undertake preventive action.
Exposure to physical load
Registration by means of a self-administered
log (the so-called ‘‘Lift Counter’’ or ‘‘Lift Ther-
mometer’’1) [2] in 12 of the 27 hospital revealed
that lifting and transferring dependent patients
occurred frequently. On average, 5.2 transfers
were performed per patient per 24 hours. Nearly
half of these patients (46%) were almost or totally
passive.
For acute and critical care, this percentage was
higher, with an average of 64%. Either they were
not able or were not allowed to move themselves
or assist in the transfers. An additional 26% were
limited in their mobility level and the remaining
10% were able to assist substantially or to move
independently or with only verbal guidance. The
weight of the patients (average 71 kg), their
dependency level, and the type of transfer per-
formed indicated that these transfers provided
a health risk for the nurses if these transfers were
1
This tool is a practical but validated assessment
tool that assesses exposure to physically demanding
tasks and compliance with the use of preventive
equipment.
et al
performed manually. The criteria for ‘‘safe,’’ in
these cases, were derived from the revised NIOSH
guidelines for the manual handling of loads. More
specific assessments of the actual load were
performed with the 3 Dimensional Static Strength
Prediction Program (3D SSPP) software program
from Chaffin [6], which also refers to the NIOSH
guidelines [4].
It seemed that 39% of the patients were
transferred with the help of two nurses, implicat-
ing an occupational health risk for both nurses. It
did not make much difference if these transfers
were performed with one nurse or with two
nurses. In both cases, the resulting load still was
in excess of safe limits for manual handling set by
the NIOSH guidelines (3400 N) [4]. In spite of the
fact that dividing the weight of the patients be-
tween the two nurses made the transfer lighter,
a biomechanical analysis by means of the 3D
SSPP program revealed that it did not make the
transfer safe. This is in line with other research in-
dicating that manual transfers of dependent pa-
tients should be avoided [1–3]. The conclusion,
therefore, was that lifting with two nurses was
not a structural solution and the guidelines for
practice now state explicitly not only that one-
person manual lifts should be avoided but also
that two-person lifts and transfers should be
avoided.
Alternatively, the frequency with which nurses
in acute and critical care lift and transfer patients
is not as high as in other wards or in nursing
homes and homes for the elderly. There, the
frequency per patient can be more than 12 per
patient per 24 hours.
Also, the type of transfers was specific to acute
and critical care when compared with other spe-
cialties or situations in nursing homes. It seemed
that more than half of the transfers were performed
within a bed itself, which is higher than in nursing
homes, where they often are a third or less.
Examples of these types of transfers are reposition-
ing in bed, up the bed, or sideways; rolling over; and
so forth. This means that solutions, such as mobile
or overhead ceiling lifters, are not sufficient to solve
transfer problems. A well-designed, high-low pow-
ered bed and the use of sliding sheets help to solve
these problems and, therefore, have become part of
the guidelines for practice. Another 10% consisted
of horizontal transfers: from a supine position (bed,
stretcher, and so forth) to another supine position
(bed, examination table, stretcher, and so forth).
This type of lateral transfer occurs in less than 5%
of the transfers in nursing homes.
 LESSONS LEARNED IN THE NETHERLANDS
It also seemed that other causes of physical
load, besides transfers, added to the total expo-
sure level of nurses and increased their risk of
developing musculoskeletal disorders. The static
or postural load especially was high. This may
occur during daily routines, such as tending to
patients in bed or elsewhere (wound care, tending
to drains, removing or placing needles, changing
intravenous lines, or medical checks) and during
periods of assisting doctors or colleagues with
treatments or other types of interventions. During
those activities, prolonged stooping over patients
occurs. Besides static load during the periods of
direct patient-nurse interaction, there is a consider-
able amount of static load during other activities,
such as reading out the data on monitors and
other types of electronic displays (often not in
ergonomically ideal positions), keeping records,
sorting out medication supplies, and cleaning and
disinfection routines. This static load often is
underestimated but may provide an (additional)
explanation for increased levels of sick or personal
leave. Jansen and colleagues [7] found, for exam-
ple, that longer exposure to static load (with
a trunk flexion over 45 ) was related (relaltive
risk, 3.18) especially to more serious, disabling
back pain among health care personnel.
Finally, pushing and pulling also seemed to be in
excess of safe values. Pushing and pulling occurred
during maneuvering heavy objects, such as during
the transportation of beds or heavy (diagnostic)
equipment. Special types of ICU beds or special
mattresses in particular resulted in loads in excess
of the safe values of 200 N considered safe.
Nurses reported these problems (transfers,
static load, and pushing and pulling) not only in
the logs and direct measurements but also in the
survey. They reported them subjectively as major
problems they would like to have solved. The
conclusions of subjective data and objective
measurements converged, underlining the validity
of the results. In addition, some nurses reported
the frequent use of computer terminals and other
devices and electronic patient files as unfavorable
ergonomic conditions and stated that this added
to their risk profile for developing musculoskele-
tal disorders.
Observations and expert walk-through
Finally, observations (expert walk-through
on all wards in 12 hospitals) pointed to a wide
range of small and large practical ergonomic
problems. Some were general problems, occurring
207
in practically all the hospitals, and some were
specific to some hospitals. Patient rooms, exami-
nation rooms, and bathrooms generally seemed to
have insufficient space for maneuvering beds and
heavy equipment. Some locations did have suffi-
cient space, but the space (eg, in ICUs) often was
taken up completely by diagnostic and control
devices. It was difficult for nurses to put themselves
in an ergonomically ideal body position during
transfers or nursing activities. They often were
working in awkward positions. For example,
some of the bags with body waste or treatment
fluids were placed in difficult places and were heavy
(when full) and difficult to detach without good
vision (sometimes hanging under a bed or bed rail).
There often was not enough equipment in place.
In some cases, nurses would have to go looking for
the equipment and did not do so. They considered
this as too time consuming and not efficient. In
other cases, the equipment was not maintained
properly or it was unclear if it was maintained
properly at all (eg, no records kept). This resulted in
wheels that were clean but no longer rotated easily.
No maintenance records were kept for slings from
lifting devices (either ceiling or mobile patient
lifters) as a rule. This implied that it was unclear
when the last strength test was performed and
whether or not a sling was in good working order.
From a patient and nurse safety perspective, this
situation needed improvement. At times, the type
of equipment was not optimal. In some hospitals,
high-low beds were present but operated partially
hydraulically instead of electrically. Apart from
other disadvantages, this meant that patients were
not able to operate their beds themselves, leading to
unnecessary dependence and lack of mobility. In
addition, nurses had to move the headrests up and
down manually, an activity experienced as heavy,
especially with dependent patients in the bed.
Another problem occurring frequently was that
mobile lifters often were present but frequently
were not used because of lack of space. Overhead
ceiling lifters rarely were in place. When they were
present, their reach often was limited to one room
and access to another room or the hall way was
limited or absent.
Guidelines for practice
After this first research phase, a national task
group was formed consisting mainly of nurses and
physical therapists. It was their task to develop
practical guidelines as a response to the major
problems the studies (described previously)
208 KNIBBE et al

pointed out. They were supported in this by

human movement scientists.
This task group developed the guidelines in
several stages during nearly 7 months. At each
stage, they consulted with their own hospitals and
their direct colleagues there. The purpose was to
develop guidelines that would be simple, under-
standable, and practical for use in critical care itself.
Although this was a time-consuming process, it was
considered necessary to ensure commitment, prac-
ticality, and quality of the guidelines. This process
meant that from the beginning the nurses them-
selves were empowered to develop and produce
guidelines and implement them.
Once this national group of 15 representatives
had reached consensus, the final version was offered
to the national covenant committee, in which
Fig. 1. Repositioning in bed. (Courtesy of Knibbe JJ,
unions, employers, the health and safety inspector- Knibbe NE, Geuze L. Beter, Werkpakket Fysieke Be-
ate, the inspectorate of quality of care, and two lasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,
government departments (health and social affairs) Utrecht, 2003; with permission.)
participated. These guidelines were signed by these
parties to become official. After this, it was agreed
that the guidelines for practice would form the basis Lateral transfers (bed bed, bed stretcher,
for future inspections of the health and safety and so forth)
executive. Nationally, as of summer 2006, the final For all patients who are passive or nearly
stage has been reached, in which the health and passive and who need lateral transfers, a sliding
safety is starting their inspection process. board, sliding sheets, or a lifter with a horizontal
For the purpose of the article, an outline of the stretcher frame must be used in combination with
guidelines is given. For details, the authors may be a powered high-low bed (Fig. 3).
contacted. The guidelines for practice cover the
major sources of physical load identified in the Transfers from bed, wheelchair, and so forth
research. For hospitals, this means they covered bed or wheelchair
five groups. In summary the guidelines are as
follows. For all patients who are passive or nearly
passive, patient lifters or hoists have to be used,
either passive lifters or active lifters (Fig. 4).
Repositioning in beds, on stretchers, and so forth
Static or postural load during patient care
For all patients who are partially or totally
and so forth
passive and who need repositioning in bed, the use
of a powered high-low bed in combination with For any activities lasting longer than 1 minute
the use of sliding sheets is necessary (Fig. 1). that require a back inclination or rotation of more
For patients who have the capacity to assist or
move themselves, the use of a powered high-low
bed and smaller aids (monkey pole, ladder, and so
forth) may be relevant and may help them to
maintain or improve their independence.
When diagnostic tests need to be performed
(for example, X-ray cassettes that need to be
placed under a patient), a double-layer sliding
sheet needs to be used to avoid having to lift
a patient. When patients need to be positioned Fig. 2. Positioning for treatment. (Courtesy of Knibbe JJ,
carefully for treatment or diagnostic reasons, Knibbe NE, Geuze L. Beter, Werkpakket Fysieke
special sets of sliding sheets must to be used Belasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,
(Fig. 2). Utrecht, 2003; with permission.)
 LESSONS LEARNED IN THE NETHERLANDS 209

Fig. 3. Lateral transfer. (Courtesy of Knibbe JJ, Knibbe

NE, Geuze L. Beter, Werkpakket Fysieke Belasting Zie-
kenhuizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;
with permission.)

than 30 , additional equipment needs to be used

(Fig. 5). This may include powered high-low de-
vices, sitting supports, or supports for patient
limbs (wound care). If this is not possible, pro-
longed tasks (longer than 1 minute) need to be al-
ternated frequently among nurses, or more breaks
or microbreaks need to be used. Nurses in these
cases must be informed about the risks they may
experience and the options they have to prevent
musculoskeletal disorders.
If patients use antiembolism stockings (AES),
special devices need to be used to avoid postural
stress and excessive pulling forces in fingers and
arms.
Fig. 4. Lifter. (Courtesy of Knibbe JJ, Knibbe NE,
Maneuvering with heavy material Geuze L. Beter, Werkpakket Fysieke Belasting Zieken-
huizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;
If the force required to maneuver an object with permission.)
exceeds 200 N, a powered pulling or pushing
(transportation) device must be used (Fig. 6).
To encourage nurses to use optimal techniques
and develop their techniques with sometimes new
material and equipment, special educational ma- expected to be a complex process, a choice was
terial (step-by-step leaflets) was developed. This made to train and install so-called ’’Ergo-
information did not replace the information that Coaches.’’ On every ward, one or two nurses
manufacturers offer with their equipment. In- needed to be appointed and trained to become
stead, it provided additional and practical sugges- an ErgoCoach (also called peer leaders, lifting
tions to use the equipment or aids safely for nurses co-coordinators, back injury resource nurses
and patients. This was considered necessary be- [BIRNs], lifting specialists, mobility coaches, and
cause some manufacturers suggest that sliding so forth) [1–3,8]. In short, this ErgoCoach–nurse
sheets could be used for transfers out of bed to is responsible for starting the ergonomic process
a wheelchair. The task group considered this an and keeping it going. These ‘‘ergonomic ambassa-
unsafe procedure for patients and nurses, so this dors’’ are available for questions, problem solv-
technique was advised against. ing, introduction training, updates on new
equipment, and so forth. ErgoCoaches can iden-
tify problem areas, can perform assessments, are
Implementing change in acute and critical care
consulted easily (they work on wards like any
After this stage of guideline development, the other nurse), and are trained and specialized in er-
implementation process started. As this was gonomics. Theoretic advantages are that they are
210 KNIBBE et al

Fig. 5. Wound care. (Courtesy of Knibbe JJ, Knibbe

NE, Geuze L. Beter, Werkpakket Fysieke Belasting Zie-
kenhuizen, Sectorfondsen Zorg en Welzijn, Utrecht, 2003;
with permission.)

nurses (‘‘one of us’’), they speak the same ‘‘lan-

guage,’’ and they ‘‘know what it’s like,’’ but
most of all they interact frequently with their
colleagues.
For acute and critical care, this is of vital
importance, as this highly specialized setting is
from time to time complex and, as the research
points out, the problems are diverse in nature. It
was considered that anyone outside this setting
not present on the ward itself and not matching
the expertise level never would be able to generate
the necessary impulse for a preventive policy. In
addition, the presence of and dependence on
outside experts would make the process inefficient Fig. 6. Transportation device. (Courtesy of Knibbe JJ,
and expensive. This makes the ErgoCoach phe- Knibbe NE, Geuze L. Beter, Werkpakket Fysieke Be-
nomenon an essential and potentially effective lasting Ziekenhuizen, Sectorfondsen Zorg en Welzijn,
drive behind the ergonomic message, especially Utrecht, 2003; with permission.)
in acute and critical care.

would have forced these hospitals to plan this

Preliminary results
Nationally, the percentage of nurses on sick
leave has decreased from 5.6% in 2002 to 4.7% in
2005 (2003: 5.1%; 2004: 4.8%) [9]. Monitoring of
all the hospitals revealed that the implementation
process demonstrated a typical implementation
pattern [10]. Early innovators were in the lead,
followed by a mid range of hospitals underway.
These hospitals had made some changes and
were planning for more but were not working
according to the guidelines at this stage. The rea-
sons often were oriented financially. For example,
if a hospital had a collection of hydraulic high-
low beds, there was an obvious need to re-invest
in new powered beds. Budgetary constraints
over a period of 5 years or more. Another major
reason for a slow implementation process was
a difference in priorities. The national approach
meant that the time frame of the whole process
was a national one. Local hospitals may have
made different plans already. There was, for ex-
ample, one hospital that made the implemen-
tation of a policy aimed at protecting their
workers against aggressive and sometimes violent
patients and their relatives as their first priority.
Finally, there also was a group of hospitals that
had not started at all yet. An approximate divi-
sion can be made of 20%/60%/20% for these
three groups. The latter group now is ‘‘gently
but firmly’’ pushed into taking action with some
 LESSONS LEARNED IN THE NETHERLANDS
pressure from the Health and Safety Inspectorate.
Among others, they look for the presence of
ErgoCoaches. In 2005, monitoring revealed that
ErgoCoaches were present in 56% of the hospi-
tals, whereas there were few (!10% of the hos-
pitals) ErgoCoaches 4 years ago. Long-term
monitoring will have to demonstrate if a higher
national implementation degree will be in place
and be effective.
On a hospital level, especially in the acute care
situation, the hospitals that are in the lead
demonstrate a variety of changes: smaller ones
(such as better wheels under some of the equip-
ment and having a longer line on the stethoscopes
so that postural stress is avoided) and bigger ones
(making a plan for investing in new beds that
comply with the guidelines and the specific de-
mands of acute and critical care) [10].
In conclusion, ergonomic changes in acute and
critical care are relevant. The general guidelines
also are relevant for this specific group of nurses
and patients, but the diversity and medical com-
plexity of this setting indicate that tailor-made
solutions often are necessary. Interventions are
successful but take up considerable time. A time-
frame of more than 2 years is average. To
implement this, strong professional stakeholder-
ship from nurses themselves is essential. Working
with ErgoCoaches on these types of wards can
facilitate empowerment of the nurses themselves
in this implementation process and can ensure and
stimulate commitment.
211
References
[1] Hignett S, Crumpton E, Ruszala S, et al. Evidence-
based patient handling. London: Routledge; 2003.
[2] Knibbe JJ, Friele D. The use of logs to assess expo-
sure to manual handling of patients illustrated in an
intervention study in home care nursing. Int J Ind
Ergon 1999;24:445–54.
[3] Nelson AL, editor. Safe patient handling and move-
ment. A practical guide for health care professionals.
New York: Springer Publishing Co., 2006.
[4] Waters TR, V Putz-Anderson. Scientific support
documentation for the Revised 1991 NIOSH Lifting
Equation. Cincinnati (OH): National Institute for
Occupational Safety and Health; 1991.
[5] Knibbe JJ, Hooghiemstra F, Knibbe NE. Ergonomic
problems in hospitals [in Dutch]. In: Arboconvenant
Ziekenhuizen, Stand der Techniek, Eindrapport.
Doetinchem (The Netherlands): Elsevier; 2001. p.
1–95
[6] Chaffin DB. 3D SSPP (Static Strength Prediction
Program), version 5.04. Ann Arbor (MI): University
of Michigan; 2005.
[7] Jansen JP, Morgenstern H, Burdorf A. Dose-
response relations between occupational exposures
to physical and psychosocial factors and the risk of
low back pain. J Occup Environ Med 2004;972–9.
[8] Knibbe JJ, Knibbe NE, Geuze L. ErgoCoaches in
beeld [in Dutch: a view of ErgoCoaches]. Bennekom
(The Netherlands): LOCOmotion; 2005.
[9] Available at: www.vernet.nl. Accessed March 30, 2007.
[10] Vree F van, Petersen A van, Knibbe NE. Monitor
Arboconvenant Ziekenhuizen, Eindmeting (Moni-
tor Follow Up), [in Dutch]. Leiden (The Nether-
lands): Research voor Beleid, LOCOmotion, 2005.
 Crit Care Nurs Clin N Am 19 (2007) 213–222

Creating a Culture of Change Through

Implementation of a Safe Patient Handling Program
Karen Stenger, RN, MA, CCRNa,
Lou Ann Montgomery, PhD, RN-BCb,*,
Eric Briesemeister, MSc,1
a
Department of Nursing Services and Patient Care, University of Iowa Hospitals & Clinics, Intensive and Specialty
Services 5JPP, 200 Hawkins Drive, Iowa City, IA 52242, USA
b
Department of Nursing Services and Patient Care, CNO T100 GH, University of Iowa Hospitals & Clinics,
200 Hawkins Drive, Iowa City, IA 52242, USA
c
BT 1000 GH, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA

Nelson and Baptiste [1] stated in 2004, ‘‘Nurs-
ing can no longer afford the ‘human sacrifice’ ap-
proach to patient handling defined as replacing
the steady stream of injured nurses with newly re-
cruited nurses.’’ Clearly something more must be
done to protect bedside care providers and their
patients.
Risks when handling patients manually
The statistics are telling. The Occupational
Safety and Health Administration (OSHA) has
calculated that nearly half of all health care
workers suffer at least one work-related musculo-
skeletal injury during their career [2]. More than
half of all nurses (52%) complain of chronic
pain and 38% of registered nurses (RNs) have suf-
fered occupation-related back injuries severe
enough to require time away from work [3,4].
Twelve percent of RNs consider leaving the pro-
fession because of lower back pain [3] and in an
American Nurses Association (ANA) survey,
* Corresponding author. Department of Nursing
Services and Patient Care, University of Iowa Hospitals &
Clinics, Intensive and Specialty Services 5JPP, 200
Hawkins Drive, Iowa City, IA 52242.
1
Previously held position of Safety Manager,
Department of Safety and Security, 2002–2006.
E-mail address: lou-montgomery@uiowa.edu
(L.A. Montgomery).
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.007
almost 60% of nurses list disabling back injuries
as one of the top three health safety issues [5].
In 2000, health care injuries caused time away
from work for nearly 11,000 RNs and nearly
45,000 nursing assistants, orderlies, and atten-
dants who said that ‘‘re-exertion and overexertion
in lifting’’ were the cause of the events [6].
The National Institute for Occupational Safety
and Health (NIOSH) is the federal agency re-
sponsible for conducting research and making
recommendations for the prevention of work-
related injury and illness. For 90% of men and
75% of women, the maximum weight limit for
lifting, under ideal conditions, is 51 lb [7]. Ideal
conditions include the presence of handles for
grasping, keeping the load close to the body,
avoiding twisting of the trunk, and minimizing
the distance a load is carried. Clearly, patient han-
dling in clinical settings occurs in less than ideal
conditions. Zuidema and colleagues [8] reported
that the maximum weight limit for lifting several
times throughout the day under less than ideal
conditions ranged from 22 to 33 lb for men and
15 to 22 lb for women.
Health care workers may perform many man-
ual patient handling tasks daily or during their
careers that exceed these recommendations [9]. An
overexertion injury may occur if the forces applied
to a nurse’s musculoskeletal system exceed its me-
chanical strength [10]. For example, a nurse may
reposition a 200-lb patient in bed manually that
ccnursing.theclinics.com
214 STENGER
results in an overexertion back injury. By con-
trast, overuse injury may result when the rate of
cumulative damage exceeds a structure’s capacity
for healing and repair [10]. The wear and tear
that occurs daily in lifting and working manually
in a bent and twisted position cause cumulative
damage and increase the risk for musculoskeletal
injury [10]. For example, a nurse who has spent
20 years lifting critically ill patients manually
one day may suffer an injury when doing a routine
manual lift. This acute insult may be superim-
posed on the long-term cumulative effects of over-
use injuries.
To protect health care providers and patients
from injuries related to patient handling, ergo-
nomics has been investigated and researched to
reduce the incidence and severity of job-related
injuries related to patient handling tasks. The
University of Iowa Hospitals and Clinics (UIHC)
embarked on a safe patient handling program in
2001. The UIHC is a 725-bed comprehensive
tertiary-care academic medical center. There are
more than 2500 staff in the Department of
Nursing Services and Patient Care, approximately
1400 of whom are RNs. There are more than 100
radiology technicians and 20 inpatient physical
therapists and physical therapy assistants.
The purpose of this article is (1) to describe how
this institution created a culture of change through
implementation of a safe patient handling pro-
gram, as guided by the Iowa Model of Evidence-
Based Practice to Promote Quality Care (Iowa
Model) [11,12], in order to decrease lost workdays
and reduce workers’ compensation costs and (2)
to share lessons learned in the process.
Iowa Model of Evidence-Based Practice
to Promote Quality Care: considering
a practice change
The Iowa Model [11,12] served as a guide to
use evidence for improvement of patient care
(Fig. 1). Following is a detailed description of
the key components used to translate the evidence
into safe patient handling practice.
Problem- and knowledge-focused triggers
A change in practice is considered as a result of
assessing the impact of factors in an environment.
In 2001, several factors, or triggers, served as
catalysts for motivating UIHC to question the
practice of handling patients manually and mov-
ing toward safe patient handling. Problem-
et al
focused triggers include clinical problems seen
repeatedly in practice. The end results of these
problems often are seen in risk management data.
At UIHC, there were an average of 121 nursing
incidents per year related to patient handling from
1997 to 2000. These injuries involved mainly the
back and shoulder. With this volume of exertion
injuries, the units were faced with the need to re-
place staff in direct patient care activities on
a more frequent basis and for longer periods of
time. An increasing number of nurses, often expe-
rienced nurses, found themselves unable to give
direct patient care because of the patient handling
injuries they had suffered. Staff noticed that their
peers were becoming injured and were concerned
for their welfare and their own possible potential
risk for becoming injured.
In addition, several knowledge-based triggers
or newly recognized information, such as stan-
dards and practice guidelines available from
national agencies and organizations, became
available. In 1992, the United Kingdom published
manual handling operation regulations. These
regulations govern regulatory and compensatory
aspects of patient lifting and require a risk assess-
ment to be made for handling tasks and risks to be
reduced to the lowest level reasonably practicable
before patient lifts occur [13]. Although these reg-
ulations were in existence for several years, UIHC
had no knowledge of them until the year 2001.
In October 2001, the Web site, www.
patientsafetycenter.com [14], became recognized
more widely as a resource mecca for the work of
Dr. Nelson [15] from the Tampa, Florida, Vet-
erans Administration Medical Center Patient
Safety Center of Inquiry. The downloadable,
128-page, Patient Care Ergonomics Resource
Guide: Safe Patient Handling and Movement, be-
came available to serve as a resource to those in-
terested in reducing the incidence and severity of
job-related injuries.
As UIHC continued to develop a safe patient
handling program, more knowledge-focused trig-
gers occurred. In 2002, the draft of the Ergonom-
ics OSHA Guidelines for Nursing Homes [16,17]
was published. These guidelines were designed
to help nursing homes reduce musculoskeletal
injuries but also are applicable to acute care hos-
pitals. In June 2002, the ANA adopted a statement
called, ‘‘Elimination of Manual Patient Handling
to Prevent Work-related Musculoskeletal Disor-
ders’’ [18]. This statement provided support for
action and policies that result in the elimination
of manual patient lifting. In November of that
 CREATING A CULTURE OF CHANGE 215

The Iowa Model of

Evidence-Based Practice to Promote Quality Care

Problem Focused Triggers Knowledge Focused Triggers

1. Risk Management Data 1. New Research or Other Literature
2. Process Improvement Data 2. National Agencies or Organizational
3. Internal/External Benchmarking Data Standards & Guidelines
4. Financial Data 3. Philosophies of Care
5. Identification of Clinical Problem 4. Questions from Institutional Standards Committee

Is this Topic
Consider No a Priority
Other For the
Triggers Organization?

Yes

Form a Team

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Is There
Yes a Sufficient No
Research
Base?

Pilot the Change in Practice

1. Select Outcomes to be Achieved
2. Collect Baseline Data Base Practice on Other Types of Evidence: Conduct
3. Design Evidence-Based 1. Case Reports Research
Practice (EBP) Guideline(s) 2. Expert Opinion
4. Implement EBP on Pilot Units 3. Scientific Principles
5. Evaluate Process & Outcomes 4. Theory
6. Modify the Practice Guideline

Is Change
Continue to Evaluate Quality No Appropriate for Yes
Institute the Change in Practice
of Care and New Knowledge Adoption in
Practice?

Monitor and Analyze Structure,

Process, and Outcome Data
Disseminate Results
• Environment
• Staff
• Cost
• Patient and Family

= a decision point

Fig. 1. The Iowa Model of Evidence-Based Practice to Promote Quality Care. (Reproduced with permission from Mar-
ita G. Titler, PhD, RN, FAAN, Iowa City, IA. For permission to use or reproduce the model, please contact Dr. Titler.)
216 STENGER
year, ANA released their ‘‘Handle with CareÒ’’
initiative [19]. This campaign’s purpose was to
seek profession-wide effort to prevent back and
other musculoskeletal injuries through greater ed-
ucation and training and increased use of assistive
equipment and patient-handling devices.
Is the topic considered a priority
for the institution?
The next step in the Iowa Model is to decide if
the topic is a priority for the organization [11,12].
Safe patient handling was considered a priority
for UIHC, triggered especially by the 121 average
number of annual injuries to staff (discussed pre-
viously). Hospital administration charged the
UIHC Environment of Care Subcommittee with
forming an ergonomics task force to begin to ad-
dress how to improve the process of lifting and
moving for staff to minimize their risk for injury.
Form a team
The ergonomics task force was a multidisciplin-
ary team chaired by the institution’s safety man-
ager with representation from nursing, physical
therapy, the health protection office, and the
workers’ compensation office. The goal of the
group was twofold: (1) to reduce injuries to direct
caregivers while maintaining patient safety and (2)
to minimize exertion injuries for staff in nondirect
patient care activities, such as food, nutrition, and
environmental services. The task force met on
a monthly basis but it became apparent after
approximately 1 year that there could be more
impact if the group was separated into direct
patient care and nondirect patient care subgroups.
Although injuries to workers in each group were
similar, the processes and resolutions would differ.
Assemble, critique, and synthesize relevant
research and related literature
The Iowa Model’s next step is to gather
evidence from research-related literature to de-
termine if a change in practice is warranted
[11,12]. The remainder of this article describes
the process and outcomes achieved by the direct
patient caregiver subgroup of the ergonomics
task force to improve patient handling activities.
The ergonomics task force investigated litera-
ture, research findings, and expert opinion on
patient handling. Studies show that ergonomic
approaches to safe patient handling reduce staff
et al
injuries. Specifically, assessment of stressful tasks
and development of alternatives methods to
decrease the stress can reduce the number of over-
exertion injuries [15,20–22]. Also, emphasis on edu-
cation and training with a focus on body mechanics
may not be enough in controlling musculoskeletal
problems [15,23,24]. The research does not show
conclusively that proper body mechanics can be
maintained during lifting among activities. Other
variables, such as the characteristics of patients,
environment, and caregiver, interact and have an
impact on an experience. It seemed that a different
approach was needed to solve the problem.
Considering sufficiency of a research base
and the role of expert opinion
The research literature, therefore, offered an
imperfect solution. The Iowa Model suggests that
if there is not a sufficient base of evidence to adapt
a change for practice, then practice changes
should be based on other types of evidence
[11,12]. The ergonomics task force decided to so-
licit expert opinion on which to base a change.
Some of the staff wanted to explore the use of
a lift team to assist in patient lifting and moving
activities. The opinion of a consultant was sought,
who had published on lift teams. In this model,
assigned ‘‘lifters’’ are hired by an institution to lift
and move patients on an as-needed basis. The
benefits of a lift team can include (1) a possible
improvement in direct caregiver satisfaction re-
lated to not having to participate in lifts, (2)
reduction in number of mechanical devices needed
to move patients, (3) the possible result of de-
veloping a care team of lifters with expertise in
this activity, and (4) decreased costs that would
occur if all staff were trained to move and lift
patients [21]. The solution would have been an at-
tractive option if not for one factor: the hospital
occupies 3 million square feet spread over half
a mile and five pavilion buildings. There was no
feasible way that a few lift teams could respond
to staff calls for assistance adequately and eco-
nomically 24 hours a day, 7 days a week.
In 2001, the task force invited another consul-
tant, a nursing researcher, to visit UIHC, assess
the patient handling tasks, and present informa-
tion on ergonomics to the committee and nursing
management. She gave encouragement, support,
and motivation to implement a change to protect
staff and patients. The task force became con-
vinced of the need to move to a comprehensive safe
patient handling program involving all units and
 CREATING A CULTURE OF CHANGE
staff on the front lines who would be trained to lift
and move patients safely whenever a need oc-
curred. Although this option would have higher
initial capital investment for equipment and train-
ing costs, they believed it was the best solution.
Pilot the change in practice
The Iowa Model [11,12] suggests that the next
step is to pilot the change in practice. The task
force believed, however, that they had to educate
and raise awareness of staff on the hazards of man-
ual lifting and needed to secure financial support
before instituting a change. The strategies and pro-
cesses used are described in the following sections.
Collecting baseline data
Vendor fair
In 2001, one of the strategies to educate staff
and get feedback on safe patient handling was to
organize a vendor fair. This vendor fair was held
in a large open meeting room and available for
staff to visit between 8:00 AM and 5:00 PM. The
room was separated into four major sections so
that equipment could be displayed in a meaningful
fashion: total assist devices, stand assist devices,
repositioning aids, and beds with self- propelled
features. At midday, there was a presentation
from a physician from the Iowa Spine Research
Center. The physician provided hands-on demon-
strations of the impact of a sudden load and repet-
itive motion on the spine. This helped staff
understand the risks they were taking when mov-
ing patients without mechanical assistance. There
also were poster displays of the research con-
ducted at the VA Patient Safety Center of Inquiry
(Tampa, Florida) on safe patient handling. Staff
were asked to evaluate the various pieces of equip-
ment from the fair and provide input as to
whether or not they would be interested in cham-
pioning safe patient handling in their areas.
Unit assessments
Another important strategy for implementing
safe patient handling was to assess the need for
assistive devices in various inpatient units and
ambulatory clinics. Members of the ergonomics
task force, with the help of a vendor of choice,
visited 23 units and met with the nurse manager and
staff on each unit, asking asked them to identify
high-risk patient handling tasks and gathering
baseline data on patient handling. There were
approximately 100 patients who needed limited
assist (patient has upper body strength and can
217
bear weight but needs limited help to stand), 200
who needed extensive assist (patient has minimal
upper body strength and can bear at least 50% of
the weight on one leg), and 150 who were deemed
total assist (patient totally dependent on others to
perform movement activity).
Equipment trials
After unit clinical assessments, portable equip-
ment from three different vendors was trialed.
These vendors were chosen from the feedback
received from staff who attended the vendor fair.
These companies could meet the basic minimum
requirements of having enough equipment and
clinical support to trial on several areas. As part
of this process, vendors would bring equipment to
trial and provide education and clinical support.
For example, staff would know which days
a particular vendor would be at UIHC. The
vendor of the day would be provided with a pager,
and staff were instructed to page when they
needed assistance with a patient lift. Evaluation
tools were developed based on information in
Patient Care Ergonomics Resource Guide: Safe
Patient Handling and Movement [15]. Some of
the important criteria used to evaluate the equip-
ment were staff and patient input on overall com-
fort and ease of use, power source requirements
(battery versus electrical), design and ease of use
of slings, weight capacity, and clinical support
available for implementation success.
Ceiling lift trials were more complicated.
Ceiling lifts from the same three vendors were
trialed. One particularly successful trial had ceil-
ing lifts from two vendors installed in one clinic
for approximately 1 month. With this setup, the
clinic could compare the lifts side by side. An
unanticipated outcome from the trial was that
when the trial ended, the staff did not want the
ceiling lifts removed! They had grown accustomed
to them and wanted them to stay for patient use
and staff safety.
Securing financial support
In the spring of 2002, the ergonomics task
force submitted a capital request to the capital
budget team for a 3-year comprehensive ergo-
nomics program. NIOSH recommendations,
OSHA guidelines, and key literature findings for
safe lifting were presented [7,15,16]. The relation-
ship between the project and the institutional stra-
tegic plan was articulated. Lost workdays,
number of injuries, and workers’ compensation
costs associated with patient exertion injuries in
218 STENGER
the department of nursing were chosen as the out-
come variables. An estimated projected cost of in-
juries and a return on investment that could be
captured within 3 to 5 years were demonstrated.
Institutional support was shown when the
capital request was funded 100%. The ergonomic
project was funded for $667,116. Some of the
units of nursing had unit money available to
purchase two stand assist, three total assist, two
ceiling motors and track, and lateral transfer
devices. This was a good pilot for use of the
equipment by different vendors and the informa-
tion that was obtained in their clinical application
was used in making the decisions for standardized
capital purchased equipment. Just buying the
equipment and offering education on how to use
the equipment was not enough for the health care
providers to choose to use the equipment. There
were fears of using the equipment, lack of
confidence that the equipment made a difference,
and lack of active support from peers or manage-
ment for the health care provider to take the time
to use the equipment, especially if the equipment
was not located easily.
Designing practice guidelines and implementing
the practice change
Once a practice change is decided on, the Iowa
Model directs developing practice guidelines. The
next step is implementing the change [11,12].
In late 2002, plans ramped up to adopt and
integrate safe patient handling program into
practice throughout the institution. This phase
included selecting the equipment, developing pol-
icies and procedures, obtaining management sup-
port, and educating staff in how to use the
equipment and to coach their peers to use the
equipment. It continued with empowering key
coaches, who were all nurses and patient handling
professionals, improving the belief among staff
that moving patients with minimum lift tech-
niques is best practice for staff and patients.
Selecting equipment
In October 2002, equipment was selected,
ordered, and allocated based on data from the
unit and clinic assessments done in the spring.
Originally, it was believed that equipment might
be shared between units and clinics but in the
pilot, there was too much manual patient han-
dling occurring to depend on sharing equipment.
et al
The purchased equipment fell into five cate-
gories: minimal stand assist; stand assist; total
assist; repositioning aids, including lateral transfer
devices; and ceiling lifts. The minimal assist device
is used to assist patients who have upper body
strength and the ability to bear weight but need
assistance to get to the standing position. It also is
used to transport patients in a sitting position
a short distance. It requires no battery or electrical
source and has a 265-lb weight capacity. For
example, the labor and delivery unit in the hospital
uses these to assist new mothers recovering from
recent epidurals or who have pain management
regimes. It also is useful for patients who need
assistance getting to a bathroom quickly.
The stand assist device is used for patients who
do not have the strength in their upper body to
assist them stand but can bear at least 50% of
their weight with at least one leg. A belt is applied
around the waist and the machine helps support
the patient stand. It has a 420-lb weight capacity.
The machine has a commode attachment so that
patients can be raised and lowered on a commode.
This lift feature makes it easier for caregivers to
provide necessary hygiene after toileting. Patients
find this device helpful. One patient, who had
been diagnosed with a recent stroke, requested
this ‘‘purple pooping machine,’’ because it did
not require him to have to use a bedpan and
gave him some privacy during bowel movements.
This machine also is used as a bridge to indepen-
dence when patients need short-term assistance in
standing up as strength is built up. Physical ther-
apists use the device for patients who are taking
their first steps after a period of immobility.
Two kinds of portable total assist devices were
purchased. The device used most commonly has
a 440-lb weight capacity and can be used to move
patients from laying-down, sitting-up, and on-the-
floor positions. Patients do not have to follow
instructions and can depend totally on the lift. The
total assist also has a scale that has proved helpful.
The other total assist device was developed to
assist patients getting out of a car. The emergency
department and guest services department have
found this device invaluable in getting patients out
of a car. A sling is placed behind a patient,
wrapped around the patient’s legs, and then
attached to the machine, which moves the patient
out of the car. Patients note that using the machine
to get them out of the car is less painful compared
with manual movement. This portable dependent
lift also is used in clinic areas, as it folds up and
requires less room to store. It can be used in the
 CREATING A CULTURE OF CHANGE
same situations as the other total assist lift except
that it has a lower weight capacity, at 308 lb.
Lateral transfer devices are used to reposition
patients in bed and transfer patients from one
horizontal surface to another, such as bed to cart.
A lateral transfer kit was purchased that included
two 6-ft slippery sheets with handles and a small
orange tube. The sheets are placed under patients
to reduce friction when moving in bed. There are
many applications for these devices, including
sliding patients up in bed, turning them, pronating
them, and transferring them from a cart to bed.
An air lateral transfer device is helpful when
moving patients of size up in bed or laterally to
another surface. An electrical motor supplies the
power to expand the attached mattress with air.
The result is the creation of an air mattress that
reduces the friction greatly beneath patients dur-
ing lateral transfer. There is no reduced friction
when the air is not in the mattress, so patients may
lay on them safely, when the head of a bed is up,
without sliding down. This apparatus is used
frequently under surgical patients of size for easier
transfer to and from perioperative surfaces.
Ceiling lifts are total assist devices that can be
used with many patient handling tasks. Assisting
patients from a wheelchair to a cart was a difficult,
high-risk manual patient handling task before
ceiling lifts were installed.
Developing policies and procedures
A policy guideline was developed addressing
how the program would run and how the equip-
ment would be used. The policy comes short of
mandating equipment use. We allow choice by the
caregiver, but do follow-up, counsel, and poten-
tially address disciplinary actions if injury occurs
and equipment is not used.
Educating staff and obtaining management support
By December 2002, the initial order was placed
for equipment and the task of extensive educating
staff begun. At the same time as the equipment
was purchased, a 3-year contract for clinical
support was signed. The clinical consultant as-
signed to the hospital by this vendor presented to
the hospital management staff and nursing leader-
ship to map out the proposed education imple-
mentation process. She also offered a 2-hour
meeting at several different times and days for
nurse managers to attend to provide an overview
of the proposed safe patient handling program
and outline the key role nurse managers would
219
play to change culture on their units. Nurse
managers were asked to identify staff that would
serve as transfer and mobility coaches, or key
coaches. These key coaches would be instrumental
in implementation of the safe patient handling
program. They included managers, staff nurses,
advanced practice nurses, nursing assistants, nurs-
ing units clerks, and physical therapists. What is
important is that they have passion to create the
culture of change and eventually role model safe
patient handling skills in their respective units.
The institution chose to roll out the equipment
and educate on the equipment by divisions of
nursing (ie, adult intensive care and specialty
services, medical and surgical services, women’s
and children’s services, and behavioral health and
perioperative nursing areas). Key coaches were
taught by the clinical consultant in an 8-hour
training session the week before divisional staff
training. Four 8-hour classes of key coach training
were offered. Ten to fifteen staff members serving
as key coaches were trained each day on ergo-
nomic and coaching principles. The clinical con-
sultant worked with the nursing education center
to develop competency-based orientation check-
lists for staff to use. One of the first responsibilities
of key coaches was to sign off, with return
demonstration, the staff on their unit as having
trained on all the equipment.
The rest of the staff, who were not key coaches,
attended a 2-hour training session added to the
annual mandatory competency sessions. This
strategy was a convenient way to educate staff
on a day when they were not responsible for direct
patient care. The clinical consultants taught the
2-hour class with content on risks of manual lifting
and how to use the new equipment. To assure
the ability to train individuals adequately, up to
6 rooms of classes were running simultaneously so
that no more than 15 staff members were in a room
at one time. By the end of March 2003, all nursing
units had key coaches and staff trained. All
equipment was distributed to the units.
Evaluating the outcomes
Once a practice change is infused, the Iowa
Model directs evaluating the process and outcomes
[11,12]. The outcomes were selected to monitor
the number of injuries, lost workdays, and cost.
Staff outcomes
Anecdotally, the staff have been impressed
favorably. One staff member left a picture of the
220 STENGER
stand assist device on the door of her unit nurse
manager, reading, ‘‘Please hire 6 of these folks!’’
Another nurse noted, ‘‘I was going to have to
leave this unit because of all of the lifting, now
with the equipment, I can stay.’’ Another said,
‘‘We had to pick a patient up off the floor. We
went and got the (total assist). I think we saved
four back injuries.’’ Staff on one unit, who were
caring for a paraplegic patient, commented posi-
tively on the ceiling lift. The staff previously
would try to lift the patient manually to see all
of his wounds. This was a difficult and risky task
for staff and embarrassing for the patient. With the
new ceiling lift available, they were able to use the
machine to provide the necessary wound assess-
ment while maintaining the patient’s dignity.
Specific indicators used to analyze the effec-
tiveness of this project included lost workdays,
workers’ compensation costs, and the number of
OSHA recordable patient exertion injuries within
the Department of Nursing Services and Patient
Care (Table 1). From 2002 to 2004, lost workdays
decreased from 2881 to 529, a 76% reduction. In
addition, the cost of replacing an injured em-
ployee in the workplace can be substantial. If
UIHC replaced every one of the 2352 lost work-
days with another employee, it would be equiva-
lent to the hiring of nine full-time employees.
The cost estimated for nine RN full-time em-
ployees salaried conservatively at $66,000 per
year (including benefits) would be approximately
$600,000. From 2002 to 2004, workers’ compensa-
tion costs fell from $559,610 to $84,880, indicating
an 85% reduction. In 3 years, UIHC reduced
workers’ compensation costs by more than
$475,000. UIHC also has seen a reduction in the
number of OSHA recordable patient exertions.
From 2004 to 2006, recordable exertions de-
creased by 18%, from 92 to 75. It seems that the
institution recovered the initial investment and
noted a reduction in the number of claims.
Although the OSHA recordable rates do not
continue to decline, there has been a decrease in
Table 1
Annual report of patient handling figures
Annual report 2002 2003 2004
Number of claims 92 83 75
Lost workdays 2881 1020 529
Workers’ $559,610 $245,677 $84,088
compensation
costs
Equipment d FY2003 d to be reported to hospital administration through
expenditures $667,116
et al
severity, something Dr. Nelson said likely would
occur (Audrey Nelson, RN, personal communi-
cation, 2004). Building a culture of safety often
resolves the musculoskeletal injury underreport-
ing problem that has plagued nurses for years.
Effective programs are more likely to see a possible
increase in injury rates but a significant decrease
in severity of injuries (fewer lost workdays and
lower workers’ compensation costs). Most of the
current injuries seem related to moving patients
up in bed or moving and lifting obese patients. In
many of these situations involving obese patients,
proper technology and equipment do not exist or
are in early stages of consumer use.
Patient outcomes
Several patients have commented favorably
about the ergonomic equipment. Some of the
comments included, ‘‘Please use the machine
instead of lifting yourself’’ and ‘‘Since I have
had bone cancer, I haven’t been moved this
painlessly.’’ A patient had been in one of the
adult ICUs for a long time before being trans-
ferred to an intermediate care unit. He weighed
400 lb. He had not been out of bed, because the
staff could not move him. Physical therapy had
convinced him to try the stand assist device. He
did so and eventually was able to progress to full
mobility. His story eventually was included in the
UIHC annual report, because the patient wanted
to tell others that ‘‘I would have never got out of
bed if it wasn’t for that machine’’ [25].
Disseminating the results
The final step of the Iowa Model [11,12] is to dis-
seminate results. UIHC is dedicated to keeping as
many people as possible updated and aware of their
work. Injury data is shared on a monthly basis at
the UIHC’s Environment of Care Committee,
which reports directly to the Hospital Advisory
Council. On a quarterly basis, two of the authors
(Stenger and Montgomery) make rounds of the
nursing shared governance committeesdincluding
the nursing administration council, advanced prac-
tice nurse council, and staff nurse councilsdto
share injury data trends, training plans, equipment
issues, and previous and current challenges and
successes. Annually, the work was and continues
yearly reports or project summaries.
 CREATING A CULTURE OF CHANGE
Lessons learned
Some valuable lessons have been learned in the
course of overseeing this project. It was essential
to partner with the Joint Office for Marketing and
Communication to get the word out through
flyers, broadcasts, and internal media to any
department affected even remotely by the project.
Secondly, it is important to partner with preferred
vendors. They can be excellent sources to assist
with trouble shooting, maintenance and replace-
ment of equipment, and product growth. Third,
key coaches are great change agents at the local
unit level. They are truly the ones who affect
practice and change the cultural mindset of peers
and patients. Monthly key coaches meetings are
essential to keeping this group empowered and
updated regarding safe patient handling practice.
Units that have active key coaches have a higher
compliance of using the ergonomic equipment.
Fourth, it is important to know upfront that safe
patient handling skills take time to develop and
persistence to sustain. In this case, initial compe-
tency activities and related documentation took
a year for 1500 employees. Fifth, as any new
practice, there is a need to constantly re-educate
staff and re-infuse the desired practice. Coordina-
tors have to keep this goal continually on every-
one’s radar. Sixth, share the ‘‘numbers’’ and
stories with shared governance councils and lead-
ership. It is essential that managers in key units
know how the program is progressing so that
they can role model necessary practice improve-
ments for staff and keep the practice changes go-
ing. Seventh, be prepared to make adjustments
in current equipment or any purchased in the fu-
ture. The ergonomic equipment purchased must
interface safely with other hospital equipment.
For example, one lift purchased did not fit under
some of the beds. The bed casters were too low to
the floor. These casters had to be changed out to
larger ones. Such findings were commonplace in
remote areas of radiology, for example, so be pre-
pared. Eighth, ‘‘think ergonomics’’ when planning
construction and renovation projects. It is easier
to build with these needs considered upfront in-
stead of trying to retrofit equipment into existing
plans, especially ceiling lifts. Step up and suggest
that ergonomics considerations be added to every
construction renovation plan in your institution.
Ninth, a consistent process for ongoing education
of new health care providers is vital. Return dem-
onstration here assures check-off lists are com-
plete. Content in annual competency sessions
221
also is important to portray the importance of
safe patient handling and assist staff in feeling
comfortable and proficient in use of the equip-
ment. Tenth, include other health care providers,
such as radiologists, on the task force. They
have many high-risk tasks that can be performed
in a safe manner with the use of the equipment.
Finally, if the initial ordering were repeated,
more portable and ceiling total assist lifts would
have been purchased. The need for these in this in-
stitution was grossly underestimated.
Are you moving patients safely?
Most back injuries are the result of physiologic
illnesses that develop over a period of weeks,
months, or years as a result of prolonged me-
chanical stressors imposed on the musculoskeletal
system. Research indicates that lifting more than
51 lb under ideal conditions is not recommended
[7]. Nurses, however, routinely believe 100 lb is
lightdbut it is not. All health professionals are
asked to stop and consider this fact carefully be-
cause every one of us is too valuable to risk being
injured as a result of not taking time to plan ahead
and move patients safely using lifting and moving
equipment.
Acknowledgments
We would like to acknowledge the following
staff for their assistance in developing this man-
uscript: Linda Q. Everett, RN, PhD, CNAA, BC,
FAAN, Associate Director, University of Iowa
Hospitals and Clinics and Chief Nursing Officer,
and Linda K. Chase, RN, MA, CNAA, Senior
Assistant Director–Nursing Administration, for
administrative support; Becky Hurt, Secretary III,
Nursing Clinical Education Center, and Shellee
Laubersheimer, Secretary IV, Nursing Adminis-
tration, for clerical support; and David Hack-
barth, Safety Engineer, Health Protection Office,
for data analysis support.
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 Crit Care Nurs Clin N Am 19 (2007) 223–240

Handling of the Bariatric Patient in Critical Care:

A Case Study of Lessons Learned
Marylou Muir, RN, COHNa,*,
Gail Archer Heese, BEd, OTR, BMRa,
Daria McLean, RN, COHN(C)a, Sheila Bodnar, RN, BNb,
Betty Lou Rock, RN, BNc
a
Winnipeg Regional Health Authority (WRHA), Occupational and Environmental Safety & Health Unit,
Health Sciences Centre Site, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
b
Medical Intensive Care Unit and Coronary Care Unit, Health Sciences Centre,
820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
c
WRHA Critical Care, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada

Literature review the increase growth in the population at an

epidemic proportion [8]. The current trend of
The World Health Organization [1] has identi-
treating these patients through bariatric surgical
fied that the obesity epidemic is increasing at
interventions has contributed to increased admis-
alarming rates across all developed nations. Seen
sions into critical care units because of postopera-
as one of the most significant worldwide health
tive complications [8]. One study identified that up
problems, it is estimated that more than 1 billion
to 24% of bariatric surgery patients required ad-
adults worldwide are overweight and 300 million
mission to a critical care unit [9]. Nonsurgical ad-
are obese [2,3]. In the United States (US) alone,
missions of bariatric medical patients to critical
the incidence of obesity has doubled in the past
care areas also is increasing. Unfortunately, there
decade to 38 million, 9 million of whom are cate-
is a high mortality rate for these patients because
gorized as severely obese. This increase is occurring
of patient delay in accessing treatment. It is be-
in both genders and across age groups, races, and
lieved that one reason patients delay access to
educational levels [4]. The obesity epidemic costs
treatment is the inability of communities to ac-
the US health care system $70 billion per year [5].
commodate patients with expanded capacity
The direct medical costs attributable to adult
equipment needs in medical clinic settings [9]. Of
obesity in Canada were estimated at $1.8 billion
patients currently who are admitted to critical
in 1997 or 2.4% of total direct medical costs [6].
care units, the prevalence of (US) patients who
Bariatrics is the science of providing health
have extreme obesity ranges between 1.4% and
care for the proportion of the obese population
7% [10–12]. The mortality of those who are obese
considered to suffer from extreme obesity. Bari-
in ICUs has a reported odds ratio of 2:1 compared
atric patients are described by the following
with patients within normal weight ranges [13].
definitions: overweight by more than 100 to 200
Nurses are challenged when caring for bariat-
lb and body mass index (BMI) greater than 40, or
ric patients, because tasks require increased time
body weight greater than 300 lb [7].
and additional patient handling solutions and
The increased number of bariatric patients
skills [14]. Inappropriate equipment or staffing
requiring hospitalization and critical care matches
levels are identified as contributing factors that
lead to staff reluctance to provide care [7]. A sur-
* Corresponding author. vey of the University Health System Consortium
E-mail address: mmuir@hsc.mb.ca (M. Muir). reports that 39% of reported accidents or
0899-5885/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccell.2007.02.010 ccnursing.theclinics.com
224
equipment-related problems are related to bariat-
rics [15]. The same survey reports further that
55% of nursing personnel report injury claims re-
lated to providing patient care. Patients them-
selves also report claims, 18% of which are
related to equipment inadequacies [15]. Overall,
data addressing bariatric patients who are criti-
cally ill are scant and information on patient han-
dling issues is even less available. There are too
few publications dealing specifically with patient
handling techniques and recommendations to as-
sist with strategic management of these patients.
The emotional task of caring for these patients
also is affected by the high rates of morbidity and
mortality in a young population. Several studies
have documented health care worker and physi-
cian negative attitudes and stereotypes, including
fear of injury, disgust, or anger, which has
a negative impact on patient care [16,17].
Health Sciences Centre, Winnipeg, experience
The Health Sciences Centre (HSC) is a teaching,
tertiary care facility in the core area of Winnipeg,
Manitoba, Canada, which has a population of
600,000. The facility does not have a bariatric sur-
gical program, yet receives an average of 30 to 40
bariatric admissions per year. The definition used
to identify bariatric patients in this facility is weight
over 350 lb. The most common weight range of ad-
missions to the facility during the past 5 years was
in the 400- to 450-lb weight range (Fig. 1). During
a 5-year period (2001–2005), nurses requested
assistance consultations on patient handling
techniques for 78 bariatric admissions (54 men
and 24 women). These patients were admitted for
medical issues needing treatment, with approxi-
mately 37% admitted to critical care units.
30
25
Number of
Patients
20
15
10
5
0
300 350 400 450 500 550 600 650 700 750
Lbs Lbs Lbs Lbs Lbs Lbs Lbs Lbs Lbs Lbs
With Weight Above
Fig. 1. Bariatric patients assessed on admission from
2001 to 2005. (Courtesy of the Health Sciences Centre
and the Winnipeg Regional Health Authority, Winni-
peg, Manitoba, Canada; with permission.)
MUIR et al
Bariatric patient handling resources
Over the past 10 years, the HSC has evolved in
its provision of supports for bariatric admissions.
The facility has made provisions to assist nurses
with the necessary knowledge that is outside the
nurses’ usual knowledge base. Equipment and
patient handling guidelines, access to patient
handling education, and corporate policies are
some of the ways HSC can ensure health care
nursing personnel provide sensitive and dignified
patient care in a safe manner for themselves and
patients. Details of tools in place include
 Bariatric patient handling policy: identifies
admission process, current list of and access
to equipment, team members, and method
of consulting (Fig. 2).
 Patient handling education: all new em-
ployees receive a 3.5-hour class on minimal-
lift patient handling. Nursing personnel are
asked to contact the trainers in the event of
bariatric admissions or transfers to assist
with specific bariatric patient handling tech-
niques and equipment needs.
 Bariatric patient handling algorithms (Figs.
3–7): each unit has access to a binder that
has algorithms for safe patient handling tech-
niques. These algorithms were adapted from
the patient care and resource guide from the
Veterans Affairs (VA) Patient Safety Center
of Inquiry in Tampa, Florida, directed by Au-
drey Nelson. There are five algorithms specific
to bariatric patient handling tasks. These
tools assist nursing personnel in identifying
the safest methods for patient handling tasks
based on patient assessment and equipment
available.
 Bariatric patient assessment tool: a tool used
to identify the equipment and procedure for
providing care to patients (Fig. 8).
 Bariatric safe patient handling work proce-
dures: these are provided to nursing personnel
in a written format. They describe the step-
by-step procedures for the associated patient
handling tasks when repositioning or transfer-
ring bariatric patients using slider sheets.
 Bariatric equipment pool: the patient equip-
ment services department provides expanded
capacity equipment to the units on request.
Items available are lifts, slings, friction-reduc-
ing devices (sliders), beds, wheelchairs,
stretcher chairs, footstools, commode chairs,
and walkers.
 BARIATRIC PATIENT CARE: LESSONS LEARNED 225

Fig. 2. Patient care policy and procedural manual of the Winnipeg Regional Health Authority. (Courtesy of the Health
Sciences Centre and the Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; with permission.)
226 MUIR et al

Fig. 2 (continued)
 BARIATRIC PATIENT CARE: LESSONS LEARNED
Fig. 2 (continued)
 Injury prevention training supports: resources
are available for staff concerning any patient
handling or mobility difficulties from various
disciplines. Allied health, including physio-
therapy, occupational therapy, and patient
handling trainers from the occupational and
environmental safety and health unit are
available for consultation. Most commonly,
staff request hands-on participation from the
trainers, especially during difficult patient
handling tasks. Most requests are made in
the early stages of admission or until they
feel proficient to manage the techniques
independently.
Process for the management of admission
When bariatric patients are admitted, corpo-
rate patient care policy requires that a nurse
227
identify the equipment and training needs for
the unit and the health care needs of the patients.
The nurse consults the patient handling manual
on the unit that identifies available equipment
with its weight capacity, safe patient handling
algorithms, safe work procedures, and a patient
assessment tool template. Additionally, the nurse
determines if the space assigned is adequate for
patients’ care and their specific equipment needs.
If patients require expanded capacity equipment,
the policy allows a two-patient bed space to be
converted to a one-bed space. The nurse also
determines the need to consult the appropriate
resources for any assistance required. Team mem-
bers who may be consulted include, but are not
limited to, the following: physician, ergonomist,
occupational health nurse, safety technician, phys-
iotherapist, occupational therapist, wound care
specialist, dietician, maintenance technician, and
unit manager.
228 MUIR et al

Fig. 2 (continued)
 BARIATRIC PATIENT CARE: LESSONS LEARNED 229

Fig. 3. Bariatric patient handling algorithm #1. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
230 MUIR et al

Fig. 4. Bariatric patient handling algorithm #2. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)

Case study his illness, he was employed part time, able to

ambulate one block with a cane before becoming
History
fatigued, and independent with hygiene, meals,
Mr. B was a 42-year-old man. His admission
and laundry. He lived with his stepmother in
weight was 697 lb, height 6 ft 2 in, BMI 91. Until
a bungalow. His father had passed away 3 weeks
 BARIATRIC PATIENT CARE: LESSONS LEARNED 231

Fig. 5. Bariatric patient handling algorithm #3. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
232 MUIR et al

Fig. 6. Bariatric patient handling algorithm #4. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)
 BARIATRIC PATIENT CARE: LESSONS LEARNED 233

Fig. 7. Bariatric patient handling algorithm #5. (From Patient Safety Center of Inquiry. Patient Care Ergonomics Re-
source Guide: Safe Patient Handling and Movement. Tampa, FL: Veterans Health Administration and the Department
of Defense; 2001. Available at: http://www.visn8.med.va.gov/patientsafetycenter/resguide/ErgoGuidePtOne.pdf.)

before his admission. His medical history included
a diagnosis of rheumatoid arthritis, gout (mostly
affecting his knees), and type 2 diabetes mellitus.
Three days before his admission, he experienced
shortness of breath on minimal exertion. He called
an ambulance and on arrival at the emergency
department was unable to bear weight or maintain
a sitting position. He was admitted because of
coffee ground emesis and abdominal pain, de-
creased blood pressure, and decreased level of
consciousness. He was given blood products and
intubated for respiratory ventilation. He pro-
gressed to develop bacteremia, acute renal failure,
and elevated liver enzymes. Because of fluid
retention, his weight elevated to 712 lb. He
remained in the ICU for 95 days.
Admission
When Mr. B was admitted, the unit contacted
the patient handling team to assist in applying
234 MUIR et al

Patient: Weight: Height:

Ward: Room#
Assessed by: Date assessed:
Position of Assessor: Strong side: Right Left

Staff has reviewed Large Patient Handling Guidelines

Requires the Following Large Patient
Capabilities of Patient:
Equipment (Equipment Pool # 5031):
Ambulatory Total Body Mechanical Lift
Ambulatory with assistance (large Wheelchair
walker)
Non weight-bearing Stretcher
Can move in bed without assistance Commode
Can move in bed with assistance Slider Board
Cannot assist movement in bed at all Step Stool
Walker
Armchair and footstool
Reclining stretchair
Bed
Slider sheets
Is the bed on the ward appropriate for this patient?
Yes No, large person bed has been requested

Patient Handling Requirements (Review Large Patient Handling Guidelines):

# of Staff Members Type of Equipment
Task Required Required

Bed Boost

Bed Turn
Side to Side Movement in
Bed
Bed to Stretcher Transfer
Bed to Chair/Commode
Transfer
Transport Within the
Hospital
Comments:

Fig. 8. Large patient assessment checklist (for nursing care plan). (Courtesy of the Health Sciences Centre and the
Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; with permission.)

techniques required to reposition, weigh, sit up,
and transfer the patient. Medical problems, such
as diabetes, cardiovascular disease, hypertension,
stroke, certain types of cancer, and osteoarthritis,
commonly associated with bariatric patients, can
contribute to difficulties during patient handling
tasks [17,18]. The patient assessment of Mr. B
identified several medical problems that required
attention during patient care and handling
activities.
 BARIATRIC PATIENT CARE: LESSONS LEARNED
Respiratory status. The patient required intuba-
tion, resulting in a tracheostomy and ventilation.
Elevation of the head of the head of the bed was
recommended to facilitate breathing compro-
mised by the weight of the chest wall, and
impingement of the thoracic cavity by the large
abdomen and fat deposits in the intercostals and
diaphragm [7,19]. Lowering of the head of the bed
was limited to short intervals during turns and re-
positioning, as the patient could tolerate the flat
position for only 5 to 10 minutes.
Central nervous system. There were times when
the patient was semicomatose and confused be-
cause of sepsis. At times he was not able to assist,
follow directions, or assist with repositioning.
Gastrointestinal and genital urinary. The patient’s
nutritional needs were met with tube feeds for
most of his admission in the ICU. His weight
reduced from 697 lb to 550 lb during 13.5 weeks of
his stay in the ICU. Because of tube feeds, the
patient had frequent diarrhea. He was incontinent
of urine and spent time in renal failure. A Foley
catheter and Bardex rectal tube were in place to
assist in monitoring output and assist in prevent-
ing further skin breakdown.
Immune system. Isolation was required because of
poor immune response, partly from pancytopenia.
A private room was provided.
Musculoskeletal. The patient had severe weakness
and poor strength in arms and legs. He was able
to assist with upper body strength during turns
using the overhead trapeze bar when he was
conscious. His legs were weak and he was unable
to move them independently or turn his body
from side to side.
Skin integrity. Skin integrity was compromised
from the excessive skin folds and poor nutritional
status, including diabetes. He had a pressure ulcer
on the coccyx and thigh and leg ulcers. A low air-
loss pressure reduction mattress and friction-
reducing devices during turns, with close attention
to skin integrity, were required.
Psychosocial. The patient was grieving the recent
death of his father. He had some family members
and co-workers visit during his admission but
often was too ill for social visits. Despite his
situation and isolation, he did not demonstrate
a depressed mood often. He always was thankful
for his care.
235
All of these medical conditions are not un-
common for bariatric patients and are well
documented in the bariatric literature [7,14,19].
The critical care unit
The critical care area in this case study is
located at the HSC. The unit is a 10-bed care unit
specializing in care for critically ill patients and
also houses a 6-bed unit for intensive coronary
care. Most nursing personnel follow a 12-hour
shift rotation.
Annual training refresher courses and new
employee orientation are provided on patient
handling techniques to the medical ICU nursing
personnel. Friction-reducing devices (slider) use is
encouraged for turning the patients on a bed,
boosting patients up in bed, and during lateral
transfers. Mechanical patient lift devices are pro-
vided for bed-to-chair transfers. In the case of this
bariatric admission, further assistance was re-
quired with hands-on teaching in the unit.
Patient handling equipment provided
The following equipment was provided for the
patient; some was available on site, and others
had to be rented:
 Bariatric bed with rated weight to 1000 lb and
a 48 inch sleep surface
 Three double-width bariatric slide sheets (fric-
tion-reducing devices)
 Mechanical lift with scale and capacity to
manage up to 1000 lb
 Custom bariatric sling
 Wedge pillow, to maintain turning postures
 Pressure-reduction, low-air-loss mattress
 Stretcher chair
 Standing tilt table
 Overhead repositioning trapeze bar
 Step stool or bench for nursing personnel to
stand on
Patient handling tasks
Table 1 reviews the patient handling tasks, the
technique, equipment used, and the number of
people required. The desired outcomes from the
patient handling tasks included maintenance of
skin integrity to prevent further breakdown; facil-
itating circulation to the heart, lungs, and extrem-
ities; monitoring the patient’s weight; meeting
hygiene care needs; preventing infections; provid-
ing a safe patient handling environment, thus
236 MUIR et al

Table 1
Patient handling tasks
Number of Equipment
Patient handling task nursing staff required Algorithm Technique
Repositioning in bed 8 Two double-width #3 Slider insertion
sliders with head-to-toe unraveling
Overhead trapeze
bar
Changing bed linens 8 Completed during N/A
turns using sliders.
Also done when
up in lift
Weighing patient 6 Lift (Titan 1000 lb) N/A Sling insertion
with between two sliders
scale and sling technique
Transferring patient 8 Three double-width #2 Lateral transfer technique
to stretcher chair sliders
Transferring patient 8 Mechanical lift #2 Sling application
to alternate bed (rated to 1000 lb) using slider insertion
with sling method
Lifting patient
with mechanical lift
device and suspending
in air while
bed switching occurs
Transfer patient 8 Three double-width #2 Lateral transfer
to standing tilt table sliders with sliders
Chairing patient 1 Bed with N/A Using bed technology controls
in cardiac chair position cardiac chair
feature
Hygiene care 4 Long sheet #5 One nursing
to abdominal groin Area fan folded personnel stands on each
side of bed facing
patient’s feet; the sheet
is fan folded,
placed against the abdomen,
and used to lift
the abdomen during
hygiene care
Accessing patient 1 Platform to stand N/A Teaching nurses
(lines, tracheostomy, on to elevate to not over
and so forth) nurse to proper reach during care
height

preventing injuries to health care nursing person-
nel and to patients; maintaining or encouraging
patient strength in extremities; and providing
a dignified respectful environment during all
interactions.
A daily patient handling care plan schedule for
repositioning was designed and posted. During the
repositioning procedure, several other activities,
such as hygiene care, wound care, and pericare, also
were provided. This included deflation and reinfla-
tion of the Bardex tube, during each turn,
assessment and adjustment of the Foley catheter,
treatment of skin excoriations in creases, and treat-
ment of any wounds. Most tasks required 6 to 8
nursing personnel. Six nursing personnel were in
position to perform the maneuver using sliders;
the other two nurses provided the necessary treat-
ments. Every other day, the procedure also in-
cluded weighing the patient using a mechanical
lift. Changing of bed linens and insertion and re-
moval of the bariatric sling were required at this
time. On two occasions, the patient was lifted
 BARIATRIC PATIENT CARE: LESSONS LEARNED
with the mechanical lift to facilitate a well-
coordinated bed transfer (removal of one bed and
provision of another). When a lateral transfer was
performed, six people performed the maneuver
while one observed the patient and another ob-
served the patient lines (IV central lines, intubation
equipment, Foley bags, and Bardex).
Lessons learned
The technology of bariatric equipment has
improved greatly during the past 5 years with
new and emerging equipment designed that ac-
commodates these patients. Although equipment
may be rated for increased weight, it often is not
designed properly to accommodate the increased
size of patients (Table 2). The purchasing facility
should put more emphasis on patient assessment
and equipment fit, instead of weight capacity.
This applies to wheelchairs, commodes, stretchers,
walkers, and beds. Companies that manufacture
equipment need to solicit more feedback related
to equipment design needs from facilities’ front-
line health care nursing personnel.
Lift choices
A lift from another facility was borrowed, as
that in the HSC were weight rated to only 600 lb.
A floor lift was used but found difficult to maneu-
ver under the load during bed transfers. A ceiling
lift would have been easier to use under the cir-
cumstances as the space and exertion require-
ments would have been less.
Sling design
A sling should not bind or cut into a patient’s
thighs nor should it constrict the shoulders. It
should provide good support and not be uncom-
fortable. Currently, there is a limited choice in
bariatric sling sizes. Regular lift slings are provided
in a range of six sizes for patients weighing from 35
lb to 500 lb; however, it is common to find that only
one sling is provided for patients spanning 500 lb to
1000 lb. A patient’s individual body type, height,
and individual physical characteristics complicate
a sling’s fit further. A custom sling needed to be
ordered for this patient at his initial 750-lb weight,
although the ones provided with the lift could be
used when his weight decreased to 500 lb. In an
ideal situation, a facility should have a range of at
least four bariatric size slings to meet different body
types. Additionally, extra slings are needed to
enable the slings to be sent for frequent laundering.
237
Bed design
The bed manufacturers have improved selec-
tion and the ability to accommodate bariatric
patients by providing beds that can expand and
adjust to several sizes. When fitting a bed to
a patient, ensure that the bed is the right size. A
sleep surface that is too small limits the patient
handling maneuver; conversely, too wide a bed
surface causes the health care nursing personnel to
over-reach. Bariatric beds need to lower beyond
a regular bed capacity. A patient’s body thickness,
increased air mattress thickness, and the need to
have the head of the bed elevated puts a patient
out of reach of health care workers almost
constantly. The need to access a patient through
over-reaching resulted in a shoulder injury to one
of the nurses. Also, the authors have found
instances when a patient could not reach the floor
to stand, as the bed was too high. The bed must be
easy to set up and transport in a quick and easy
fashion, between units. A bed that can be reduced
to 39 inches will fit through most facility door-
ways and then be expanded to the necessary width
to accommodate patient size once in the room is
optimal. The facility experienced many difficulties
when transferring the patient’s bed between
the units. The patient could not be transported
in the bed because of a width of 48 inches. Thus,
the patient had to be removed and the bed
disassembled and reassembled manually at the
destination. Some newer bed designs have a power
transport feature, preventing worker exertion.
Additionally, equipment tuggers to move the
beds are another option.
Bed mattress
The facility bed comes with a regular foam
mattress. In this case, it was not effective in
preventing skin breakdown to the patient. A low
air-loss mattress was rented rated for 1000 lb. The
mattress available for rent was only 39 in wide, so
bolsters were placed on either side, to fill the
remaining space. The bolsters were problematic
when the patient was dangling, as they separated
from the mattress and needed extra reinforcement
with duct tape. Although the mattress did not fill
the entire bed space, it worked well to facilitate
skin integrity. The mattress did not inflate under
load and the patient needed to be removed from
the mattress to reinflate it. The variable pressure
oscillation on the mattress was a great feature. It
rotated pressure relief to varying parts of the
body using cyclical timed intervals.
238
Table 2
Problems and solutions associated with patient handling tasks
Problems
Recruiting enough nursing
personnel to assist with
repositioning, especially
scheduled turns.
Knowledge on techniques varied
between staff and shift changes.
Hands on and reinforcement of
techniques needed frequently.
Transfer of knowledge and skills
when patient transferred to
another ward limited.
Bed needed repairs.
Patient had to be transferred
into a rented bed. The bed
available for rent was too
small for the patients needs.
Sling fit inadequate and
compromised skin integrity
on thighs.
Weight rating on tilt table in
question.
Stretcher chair worked poorly
under load and was inadequate
in size to fit patient size.
(Although rated for 800 lb,
it was a poor fit for patient
at 550 lb.)
Difficulty maintaining patient
on side lying (to prevent
pressure sores and promote
circulation and so forth)
as he would crush positioning
pillows flat.
MUIR et al
Action taken
Unit manager and director
arranged with other
managers to send staff
to assist at designated times
(every 3 hours).
Light refreshments were provided
as a gesture of appreciation for
those that attended.
Trainers consulted 2–3 times per
day initially. This decreased
to once daily and then on
request only.
Trainers needed to be available
to problem solve for
unexpected events. Otherwise
trainer’s attendance was
scheduled.
A draft manual with techniques,
protocols and algorithms
was provided as a resource
and kept on front of the chart.
Critical care manager arranged
for critical care staff to attend
the unit on several occasions to
ensure transfer of knowledge.
Rush on bed repair ordered
Instruction booklet left at
bedside
Patient instructed in bed use
so he also could direct staff
Custom sling ordered
Call to company confirmed
that tilt table capacity
reduced from 600 to 500 lb.
Discontinued use of tilt table.
Only used as stretcher for
transport as patient had to
remain side lying.
Wedge cushions to maintain
patient side lying were designed.
Patient found them
uncomfortable
Future recommendations
Have a designated scheduled time, with
people identified to attend from other
units.
Provision of snacks as a goodwill
gesture of thanks.
Designated trainers in critical care units
need to be identified, trained, and
supported to problem solve and be
available more readily to their own
staff for when admissions occur.
Algorithms and safe work procedures
should be posted in room for easy
reference.
Experienced unit needs to communicate
and visit receiving ward to pass on
information (unit transition
planning)
Post instructions on bed use at bedside
to prevent further breakage
Several size bariatric slings should be
available.
Other means of maintaining and exer-
cising of legs needs to be explored.
Purchase higher rated tilt table.
Recommend purchase of larger chair
with hydraulic capacity and electrical
functions for operation. Communi-
cation to company redesign is
recommended.
Cushions need to be covered and
padded.
Repositioning mattress may be a useful
tool.
(continued on next page)
 BARIATRIC PATIENT CARE: LESSONS LEARNED 239

Table 2 (continued )
Problems
Mattress inadequate for
patient care.(Bed came with
regular mattress and patient
experienced significant skin
breakdown.)
Worker injury reported due to over- Platform provided at the bedside to
reaching. Bed height did not lower
adequately for safe worker
ergonomics.
Action taken
A low air loss mattress was rented.
The size available was a bit small.
Bolsters were provided to assist in
fitting the mattress to the bed.
enable shorter nursing personnel to
reach over patient.
Straps attached to sliders for lateral
transfers.
Future recommendations
Recommend purchase of our
own low air loss mattress, to
ensure availability and immediate
use,
and to reduce costs
Future bed purchase criteria requires
that bed have ability to lower to a
minimum of 15 in or less from the
floor.

Patient transport Worker education

Transporting a patient who weights 710 lb and
has a girth greater than 70 inches on a 39-inch
stretcher is a difficult task. A patient of this size
does not fit on a 39-inch stretcher comfortably
even if it is rated for 1000 lb. The stretcher-chair
was found too narrow for the patient at 32 in,
even when his weight was 550 lb. Also, bariatric
patients require the head of the bed to be elevated,
and the head elevation feature worked poorly
under load. One option is to have a patient to
remain side lying and if the girth hangs over the
stretcher, then abdominal binding may be
recommended.
Space planning
During this admission to the critical care unit,
the space required was beyond a normal cubical
size. Initially, this need was met by using a two-
patient bed space for the one bariatric patient;
once he was admitted to an isolation room, the
space was adequate to accommodate all the
equipment and nursing staff.
Diagnostic imaging
The CT scanner entrance was only 39 inches
wide with a table rated at 350 lb. Therefore, no
CT scan could be done. No facility could provide
imaging equipment, such as CT scanner or MRI,
that would accommodate the size of this patient
Other facility issues
Identification of pathways and department
capabilities to accommodate bariatric patients
also must be planned. Operating room tables,
elevators, and morgues may pose problems.
Training and written resource guidelines can
provide general information. The ability of nurs-
ing personnel to become proficient in caring for
these patients can be affected by the frequency and
time intervals between admissions. Providing re-
freshers and ready access to the resources for
support and training are required under these
circumstances.
Emotional supports
Nursing personnel often have an emotional
reaction to this type of patient admission, including
fear of injury, disgust, or anger that can have
a negative impact on patient care. As discovered in
the case history literature reviewed, this is not
uncommon. It is important that employers identify
and communicate, as part of training, the expecta-
tions for appropriate conduct of workers. The
critical care nursing personnel filed several injury
reports initially on receiving the patient. As the
nursing personnel were able to feel confident in
their techniques and became aware of the patient as
an individual, they became more sensitive to the
patient, and there were no further reports filed. The
ICU staff needed other patient care programs in
the facility to provide manpower and consultation.
The provision of these supports assisted the staff in
feeling supported.
Summary
Prevention of admissions to critical care units
might be mitigated by providing improved pri-
mary health care access. Currently, bariatric
patients avoid accessing medical treatment until
they are in a serious health crisis. Unfortunately,
there is a high mortality rate for these patients
240 MUIR
because of this delay in accessing treatment. This
may help explain why critical care units receive
a large proportion of the bariatric admissions.
This case study reviews the techniques, equip-
ment, and difficulties associated with a bariatric
admission to a critical care unit as it relates to the
patient handling perspective. The techniques dis-
cussed are limited to patient handling, not to
clinical nursing issues. The practices discussed are
limited to this unit and do not review the type of
equipment, techniques, struggles, and solutions
that are experienced on a regular or rehabilitation
unit.
As technology advances and the stream of
bariatric patient admissions increases, nurses need
to communicate their experiences to their peers so
that others can learn from each other’s experiences.
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