Presentation by Bernice Owen, University of Wisconsin School of Nursing
MR. FRAGALA: Our next speaker, Dr. Bernice Owen, has really been a pioneer in health care ergonomics. For many years, she's published studies, highlighting the magnitude of the problem in health care. She's also published studies on the effectiveness of some of her ergonomic solutions and has been active in evaluating lifting aid devices. She's at the University of Wisconsin, School of Nursing, and has been there for a number of years. Dr. Owen will talk about the long term care industry and also about some of the engineering controls. So would you join me in welcoming Dr. Bernice Owen.
DR. OWEN: Thank you, Guy. Like Eric and the rest of the team, I'm very glad to be here and have the opportunity to share some of the work that a team of us have been doing. It was really in the mid-80's when some intervention studies began to be done. We've had probably 39 years of descriptive work in the health care setting identifying what the problems are. Most of the studies come back that the major problems relate to the actual handling of patients and residents. That's where the bulk of the back injuries and shoulder injuries occur.
And so, we didn't need any more descriptive studies, although we still have more descriptive coming and more coming. We need a lot of intervention studies. In the mid-80's, then, NIOSH did some work in looking at a number of states with the worker comp reports. That was where they really pulled together the data then that some work needs to be done on intervention in nursing homes, long term care facilities.
And Dr. Garg, who is an industrial engineer from the Milwaukee campus and myself from the nursing school, with a background in occupational health and safety, and also a nurse who has worked in nursing homes, we, as a team, then were funded by NIOSH to do what was supposed to be a two-year study that ended in being about a five year study, because it took us much longer to do the things we needed to do, and the design had to change.
The design that was suggested in the contract was one that is used in industry where you look at the problem, and then you go to the book and you find the answer. And then you implement the answer, and then you see if it worked. And when we went to the book, the whole answer wasn't there. There are pieces of answers, and we had to put the rest of those pieces together. So why don't I take the first slide. I'm going to quickly share two studies with you. One relates to long term care, and another relates to hospitals. By the way, with the same results. Okay.
At the time when NIOSH did the pulling together of the worker comp data, they found that nursing personnel ranked high with back injuries; (when I say nursing personnel, it was everybody, nurses, nursing assistants, personnel care workers that were involved in patient and resident care). They ranked number five for compensated back injuries in the United States, number five. Now, that means that this primarily female occupation and profession was up there with these very occupations that were very strenuous, manual material laborers, shipbuilders, miscellaneous laborers, garbage collectors, the people who lift all day long. We were up there.
And, consequently, then the contract that came out from NIOSH, the purpose was to reduce back stress for nursing personnel by changing the physical demands of the job. So we were to look at the job and figure out how could that be changed.
Now, I know that you can't see this slide, and I don't want you to see it. But I want you to note that there are a number of squares there. The top square is the goal of trying to determine what are the stressful tasks. And then to the left is another goal of trying to look at ergonomics, doing an ergonomic evaluation. That part of the study, by the way, was about a six month part of the study where we were in the clinical setting very long and very hard hours.
Then we would go to the right, and that is goal number three. Now, if we're going to reduce the physical demands of the job, we're going to have to have assistive devices. So for that goal, where are the assistive devices and what might be best for the problems that we have in this setting? And then down again to the middle of the slide is another part of goal number three. After we find what it is we need in assistive devices, we'll do a pilot to determine if this is going to work. Now, that wasn't really part of the original design, because we were supposed to know the answers.
Then the next square is the goal to do a laboratory study. Because the human subjects committee does not permit you to test out a lot of the unknown. We needed a laboratory study, and that was another whole year which was not accounted for in the original design. And then you go down to the bottom square, and that was to apply what was successful from the laboratory study back with the residents in the nursing home.
Now, the nursing home that we selected for the study was a large county home in southern Wisconsin. And in this nursing home, you primarily had residents who no longer could be taken care of in other nursing homes. They were beyond the capacity of the staff, so they were very, very difficult residents. Many of them had Alzheimer's, and many of them had a number of physical afflictions. So we felt that if we could make some progress in reducing the physical stress in this nursing home, then the results should be a bit more generalizable to those homes where there were less difficult, less taxing residents.
So what did we find? I'm going to tell you what they are. We went to the workers and said, "What are your stressful tasks?" If our job was to reduce the stressfulness, we had to find out what are the tasks that are stressful. The literature already says, patient handling task. Now, can I focus this or do you have to focus that, or is it focused? When you have tri-focals it's really hard to see from the side. You have to look straight on.
What we found, then, from the nursing assistants, and the nursing assistants are primarily the ones who do the lifting and handling of residents in the nursing home. What we found from them and what ranked the highest in stress for all parts of the body (the neck, the shoulder, the low back and the whole body) were transferring tasks; transferring from toilet to chair was ranked first. And then from chair to toilet, and transferring from chair to bed, bed to chair, and then the bathing process and the weighing process. And then it went down from there, lifting residents up in bed, etc.
Now, we knew, and we learned this morning, you don't bite off too much. And we thought, well, why don't we start with the transferring techniques. As you see, the top ones are transferring. Now actually, the weighing one also ended to up to be transferring, because they were being transferred onto a weight chair. So those were the tasks we studied.
Goal number two, then, was to go into the clinical setting and really observe, describe these tasks: how frequently are they done, the frequency of three important variables of flexion over 45 degrees, rotation of the torso, and asymmetric lifting. And then, we had bio-mechanical data derived from a bio-mechanical model. NIOSH wanted us to use compressive force to L-5, S-1 as the most important variable of the study. And then there were also environmental variables. And what did we find?
These slides, I'm using for a purpose of helping you to understand the patient handling. They may be offensive to some people. I want you to look at the transfer technique. I had a woman come up and say to me one time I should not use these slides, because her mother was in a nursing home, and she did not want her mother handled in this way. And I do not show you these slides for that purpose. I want to show you what we saw and then what we did about it. And this lifting and handling is not malicious in any way whatsoever. It is not.
Now, this type of manual transfer was done about 96 percent of the time in the six months of observation. We saw a mechanical lift being used several times, and we saw a gait belt used several times. Otherwise, everything was manual, meaning, without any assistive devices. So what the nursing assistants would do, would be to bend down and grasp the resident under the arms in the axilla area and then vertically lift the resident up; they would either push the chair out of the way or else back up and then pivot around or carry the resident to the bed, and then put the resident on the bed.
Many, many of these residents were not able to bear their own weight or they couldn't follow directions well enough and be predictable enough to bear weight. And you notice that this resident is sitting in a geriatric chair which means that the resident sits down further than in a wheel chair and back further. So the nursing assistant needs to reach down further and back further in grasping the resident, pulling her up to the edge of the chair and then vertically lifting, carrying and putting the resident down on the bed.
Again, now the task is taking place in confined work space. Remember that the first two highly ranked tasks were transferring on and off the toilet. Now, the bathrooms between the rooms were very small. These two nursing assistants are in the bathroom. They're taking this resident out of the wheel chair and going to be placing him on the toilet, there is hardly enough room for everything that's going on in there. Many times they'd push the wheel chair and then pivot around real fast and put the resident down on the toilet.
Now, you do notice that this resident is doing something you'll never want a resident to do or you want to be perceptive that the resident is doing this so you don't have an unexpected happen. And this is typical for a resident to grab and really hang on tight and, of course, she's got the grab bar. Sometimes they grab the armrest of the wheel chair the Geri chair. And if you can, look at the expression of the resident, and I would behoove you to try out on each other at some time this under the exlia transfer. It hurts. It does hurt.
And in addition, the brachial plexus is right in the exlia area. And when you put pressure on that, especially our older frail residents, it is no wonder that sometimes when a transfer is done, the resident will say, "I can't feed myself now, because I can't feel this hand." And it may be so. They may not feel their hand for quite a while as the nerves supplying feeling to the tips of the fingers comes off of that big brachial plexus.
Again, just some more. They're going to be taking the incontinent pad off. So they have lifted this resident up in the bathroom again, and they're holding her while one will reach down and pull her nighty up and take the incontinent pad off and then they will swing her around to the toilet. So there's a lot of lifting and holding. Sometimes the nursing assistants lift by themselves. It's obvious this resident does not bear weight. And think of the physical stress that must be endured by that nursing assistant who's not just pulling the resident out of a wheel chair, but a Geri chair, and doing this alone.
And once in a while, lifts were done this way. In fact, this young many, throughout the observation period, lifted this way, and it did not seem to matter how heavy the resident was.
This resident just decided she wasn't going to walk anymore while being walked to the bathroom by 2 nursing assistants. And so, they're going to take her into the bathroom, but they're going to be carrying her whole weight.
This is called a fireman's carry, and this is one that I learned, and the book will tell you, you only do this in an emergency. If there's a tornado or something and you've got to clear everybody out fast, you might use the fireman's lift technique. There's a bath blanket or sheet underneath the resident, and there are two nursing assistants.
This is a comatose resident, by the way. And they're carrying her way over to the Geri chair. I'm not exactly sure why the chair is so far away.
In addition to the lifting and handling of residents, there is a lot of bending and reaching which gets into a lot of the shoulder stress. There are also some environmental variables. They had placed new tile down on the floor of the bathrooms. It was only an eighth of an inch higher than the room floor but created enough of an impediment so the mechanical lift swayed and tipped. There were also safety bars around the toilets in the bathrooms, so the nursing assistants had to take the resident from the wheel chair or Geri chair around the safety bars and onto the toilet seat.
Okay. So that gives you a clue. I've only shown you some of the things, but it gives you a clue of what we saw. Now, what are we going to do about this in relation to those tasks that we are studying? Well, we had to located the assistive devices and then do a pilot. What devices did we find? Well, the gait belt is used in many, many long term care facilities and in hospitals. It's a narrow canvas type of belt. Usually one belt fits all, because it is a long belt and has a big loop buckle type closure. But it does give you something to grasp if you've got it on right and tight enough. It gives you something to grasp so that you don't have to tug the resident underneath the arms. So we knew we needed to study the gait belt and the effect that the gait belt would have on the nursing assistant.
In the observation period we studied the pattern that went on in the morning for feeding, toileting and bathing and wondered if there was a way that we could eliminate some of the tasks? We found the pattern was that the residents were washed, dressed, and toileted when they got up, and then pushed down to the cafeteria to eat. And then if it was bath day, they were brought back, toileted again and then taken down to the bath area. If we could transfer onto the shower chair, and that shower chair would fit over the toilet, then they didn't have to transfer on and off the toilet. So we could eliminate some tasks. Eliminating tasks certainly does reduce the force.
Then we wanted a belt that one could use that had actual handles on it. And we worked with a company to change the loops in the front of this belt. Because time is important, we couldn't have the nursing assistants looping and securing several buckles. We needed fast released buckles, and that was called the transfer belt.
This is the most common lift used in hospitals and nursing homes (Hoyer). The handle which is off to one side, is pumped to activate the hydraulic mechanism for lifting; the sling must stay under the patient. At the time of this study there weren't the prolific number of lifts that there are now. We wanted to test this model of lift because the caregiver could rotate a handle located between her chest and shoulder level and not have to bend to the side. The sling had to stay under the patient with lift also.
This third lift was also a manual/nonbattery-operated lift. The caregiver rotated a wheel located at chest/shoulder level for the lifting process. However, once transferred, the sling did not have to stay under the patient.
So those were the devices we then tested in the lab study. We studied these assistive devices in relation to those seven most stressful tasks e.g., those transfer ones, on and off the toilet, et cetera.
In the laboratory the subjective data we collected was the perceived exertion and physical stress; a tool similar to the board one that was used this morning from zero up to 10 was used and then comfort and security data were collected from the "patients".
(We were using senior nursing students.) We could not use patients or residents of course. So they were our subjects and also our patients. They rated their comfort and security feelings in relation to the use of different devices. We used the bio-mechanical model and, again, our major variable was compressive force.
The methods that we used in studying each of the 7 patients handling tasks (e.g., transfer from wheel chair to toilet) were under the axilla method (that was the method that presently was being used about 96 percent of the time), Gait belts, the walking transfer belt with the quick release buckles that was wide and had some handles on it with one subject making the transfer, this same walking belt but with two subjects making the transfer, (And then we used another kind of a sling, which I'm not going to talk about today), and then the three lifts.
Now, what did we find? Only the circled part is really what I need you to see in this slide - the compressive force to L-5, S-1. Now, the under the axilla lifting method with two people making the transfer, was 4751 newtons of force. Now, that's the average. Only 3400 are allowable by NIOSH. So the under the axilla lift is way over the limit for compressive force to L5/S1. The gait belt was okay. The walking belt with two people, 2,000 newtons. The walking belt with one person, 2,000 or 1,900, and then, that other sling was okay. So this was the most important variable for NIOSH. The under-the-axilla lift should be eliminated in nursing care!
Perceived stress ratings for transfer from toilet to wheel chair; this is subjective data. The scale used here was no stress = zero and nine = extreme stress. For the under the axilla lift, the perceived stress was 7.2; remember nine is the utmost stress. The gate belt, 5.9; so bio-mechanically for compressive force to L-5/S-1, compressive force to the gait belt was okay, but for perceived stress, it was not okay. The Walking isn't without any stress. The mechanical lift which has an easy sling to put on was 1.8, pretty low. So that was some of the subjective data.
Now, what did our clients (nursing students) think? For a feeling of comfort, the scale was zero to seven; zero being very comfortable and seven, extremely uncomfortable. Comfort, 6.7, almost seven for uncomfortable feeling for the under the axilla lift. And I tell you, it is uncomfortable, and they didn't feel secure with this lift either!
Now, a big thing that's not in our favor is the time element; for the under the exlia lift, it took eight seconds. They didn't have anything to fasten. But now remember, the two people were already in the room. We did not count the time of going to find someone to help.
The "patients" are not comfortable. The gait belt was stressful to the care giver and not comfortable for the "patients." The walking belts were very comfortable, a good feeling of security, and it took 37 seconds to put it on.
The Hoyer lift was quite uncomfortable. If you ever have an opportunity, if you haven't already had the opportunity, get into a Hoyer lift. There are a lot of them around. They tip and are not comfortable. There are many more lifts available today that do not tip and the slings are easier to put on; they are much more comfortable.
The least amount of time needed was for the lift that was most comfortable. It took two and half minutes to put the sling on and to get the resident ("the patient" in this situation) up off the toilet and back into the wheel chair. That includes putting that sling on.
The next part of the study was to take into the nursing home the devices and program we found effective in the laboratory setting. We know we're going to take the lift with the easy to apply sling. We know we're going to take the wide belt with the handles, and we know we're going to bring the shower chair so we can eliminate some tasks. We're going to bring those things that were effective into the nursing home now with the real residents.
We're going to do a teaching program for all three shifts of duty. We've already got management support, and I can't overemphasize that. Management was concerned about the injuries and did want this study to go on. A good patient assessment was essential so that you know what device should be used with which resident. A good communication system was needed so that the nursing assistants knew what they were supposed to do. Adequate devices are important because no one is going to run to other units to try to find equipment.
Major findings from this nursing home study were: "Pre-intervention, there were 82 injuries per 200,000 work hours. Post-intervention, there were 47 injuries per 200,000 work hours." We did not eliminate the injuries, but we decreased them. The rating of perceived exertion was light. And the compressive force to L5/S1 was reduced to acceptable limits.
Now, I just want to touch on a hospital study. Guy tells me I've one minute to do this. Again, we went to the nursing assistants. What are your stressful pasts? Again, they're the same. In and out of bed, on and off the toilet. Here we also had lifting patients off the floor which was not mentioned in the nursing home study. And we also had the horizontal transfers, on and off gurneys and carts which we did not have in the nursing home. At the time of this study we had more mechanical lifts to choose from; this lift has a sling that just goes under the arm. It's great for toileting. Everything is there to work with easily.
This patient here weighed almost 300 pounds, and she would not permit the nursing assistants or nurses to touch her after she had experienced going down to PT and getting out of bed with this lift.
This is called the slipp. It's just silicone lubricant in between two pieces of Gortex-like materials; it reduces the friction. It goes under the draw sheet and you pull the draw sheet and the patient slides easily onto stretcher; it reduces friction. So that was for on and off carts. Most of the mechanical lifts now will indeed go to the floor and you can lift residents, patients up off the floor. And this is that belt that has handles and the quick release buckles.
Toileting in bed also came up as a stressful task and believe it or not, we found a device. The part of the device under the pelvis gets directly pumped up so the pelvis is raised and a special bed pan put underneath. The head of the bed is up just a little bit. Toileting in this manner was very comfortable and very effective. In fact, we couldn't get the patients to have a spill. It was very precise. It fit in there just perfect.
Now we have real patient reaction to the program. These responses are from patients who were unable to bear weight. We're comparing two rural hospitals, a control and an experimental. In looking at the bed to wheel chair task in experimental site, you can see that the patients are very comfortable. They averaged .8 for comfort and 1.0 for feeling of security. (The scale is zero to seven; zero being very comfortable and 7 being extremely uncomfortable, and the same with security.)
And you can look down all the patient handling tasks studied and you see an asterisk which means there is a significant difference between the experimental and control sites with comfort and security responses. Findings for injuries in the experimental hospital, eighteen months pre-intervention, there were 20 injuries, 64 lost work days and 15 restricted days.
In 18 months post-intervention, there were 12 injuries, 3 lost work days and 12 restricted days. So there are still some injuries but we decreased and decreased the severity of those injuries.
So that tells you a little bit about some possible interventions with the use of assistive devices and the whole ergonomic program. It is not just bringing in assistive devices. The staff have to be trained in them. They have to have time to use them. They have to be available. Good patient assessment must be done. It's a total program.
MS. COHEN: Thank you, Bernice. And you all will have a chance to ask Dr. Owen and Eric and our next presenter some questions in just a few minutes.
