OSHA’s draft of ergo guidelines for nursing homes praised and criticized

Industry professionals respond with praise and criticism

In the wake of its ill-fated ergonomics rule, the U.S. Occupational Health & Safety Administration (OSHA) decided, instead, to draft a series of ergonomic guidelines for specific industries. Significantly, the first of these drafts to be published deals with health care workers — those in nursing homes. In addressing this working population, OSHA identified several key ergonomics stressors common to these professionals that put them at high risk:

Force: the amount of physical effort required to perform a task (such as heavy lifting) or to maintain control of equipment or tools;

Repetition: performing the same motion or series of motions continually or frequently;

Awkward postures: assuming positions that place stress on the body, such as reaching above shoulder height, kneeling, squatting, leaning over a bed, or twisting the torso while lifting;

Vibration: rapid oscillation of the body or part of the body, often caused by use of powered hand tools or equipment;

Contact stress: pressing the body or part of the body against a hard or sharp edge, such as using the hand as a hammer.

The draft guidelines go on to address key management and training issues and offer diagrammed examples of ergonomic-friendly practices.

Better than a rule

The guidelines were presented for comment from the industry, culminating in a meeting of stakeholders in November 2002. While reaction to the guidelines themselves has been mixed, there was no question that they were preferable to an ergonomic rule. "Rule making is dead, I believe," says Deborah V. DiBenedetto, MBA, RN, COHN-S/CM, ABDA, president of the Atlanta-based American Association of Occupational Health Nurses (AAOHN). Part of the reason, she notes, is that the current administration looks favorably upon business. "I am all in favor of guidelines, and if they are easy enough to implement that they provide a business case for a return on investment, this gives you a winning combination."

Kurt Hegmann, MD, MPH, an associate professor at the University of Utah, Salt Lake City, and chair of the ACOEM (American College of Occupational and Environmental Medicine) ergonomics committee, agrees. "As opposed to a rule, a guideline is not mandatory, but rather is supposed in theory to represent best practices," he notes. "A straight-jacket approach has been shown to fail in ergonomics so in the view of many people, rules are not appropriate. However, some people feel that if you don’t have mandatory protections against potential job exposure, some workplaces will do nothing."

Hegmann argues, however, that the workplaces that are likely to do nothing in the absence of mandatory regulations are small employers, "And even if there were a regulation they would likely to do nothing anyway. So it’s reasonable to try guidelines and see what happens."

DiBenedetto, for one, is gratified that the first OSHA ergonomic guidelines deal with health care. "This is only appropriate," she says. "More than 50% of all health care worker injuries are musculoskeletal, and it makes sense to target an at-risk population. This is an appropriate first jump out of the box for OSHA."

What’s right, what’s wrong

Both DiBenedetto and Hegmann found positive aspects to the document (web site: www.osha-slc.gov/ergonomics/guidelines/nursinghome/index.html). "It’s a good working document, but it has to be more turnkey and operational for the user," says DiBenedetto. "My main recommendation is that they have a sample program where you can almost fill in the blanks. Also, we should engage in a more multidisciplined approach, including human resources, for example, because they deal with workers’ comp."

AAOHN offers a detailed response on its web site, www.aaohn.org. Among some of its other suggestions are:

  • Add an executive summary and simplify content.
  • Tailor the guidelines to multisized facilities, to address resource issues and challenges common to smaller nursing homes.
  • Include more information about how to implement an ergonomics program.
  • Provide additional detail on how to garner management commitment.
  • Elaborate on the training section to include more information about a regular training schedule, as well as how to train all nursing home staff — not just those who will be developing the program — about ergonomics procedures.

Hegmann notes that the primary evidence for the need of an ergonomics program in a nursing home setting is in respect to back pain from patient transfers. "The guidelines primarily deal with that, but in my opinion they should only do that," he says. "In other areas, we have little evidence, so to be helpful it would be better to stick to only back pain from transfers."

However, he adds, the guideline is not as helpful as it could be because "there is more specific information available [on back pain from transfers] from the research community, which probably should have been taken into account."

Thus, he says, the result is more of a menu of options rather than a hierarchical approach to altering manual patient transfers. "The latter would possibly have occurred had more information been used in the process of developing this guideline," he suggests. Nevertheless, he observes, "The guidelines do appear to discuss most of the available technologies to be used to reduce the amount of force for transfers, it is relatively easy to read and, unlike most documents of this type, it uses pictures, so people can actually see the devices."

Ergonomics works

One of the key assertions made in the draft guidelines is that "facilities that have implemented ergonomics-based injury prevention programs using effective engineering and work practice controls have achieved considerable success in reducing work-related injuries and workers’ compensation costs." The authors go on to suggest that additional benefits of effective ergonomics programs can include reduced staff turnover (thus, lower costs for training and administration); reduced absenteeism; increased productivity; improved morale; reduced resident injury; and increased resident comfort.

OSHA provides several examples of effective ergonomics programs in nursing homes and some of the key aspects of their programs:

• Wyandot County Nursing Home in Upper Sandusky, OH, reported that staff had suffered back injuries, including a single injury that resulted in workers’ compensation costs of $240,000. The facility acquired 18 ceiling lifts, as well as portable total lifts, sit-to-stand lifts, a lift walker, and 58 electrically adjustable beds at a cost of approximately $150,000. Since Wyandot implemented a policy of performing all assisted resident transfers with mechanical lifts or gait belts, back injuries from resident lifting have been eliminated. Increased efficiency has allowed staff members to spend more time with residents, and caregivers’ attitudes and energy levels have reportedly improved. In addition, residents no longer complain of shoulder pain and bruises that had previously been associated with manual resident handling.

• At Citizens Memorial Health Care Facility in Bolivar, MO, concern about the number of injuries related to lifting and their economic impact led to the establishment of an ergonomics component in the existing safety and health program. The facility emphasized education and the use of assistive devices. In each of the four years after the program was established, the number of OSHA-recordable lifting-related injuries declined by at least 45% over previous levels, and the number of associated lost workdays declined by at least 55%. These reductions contributed to a direct savings of approximately $150,000 in workers’ compensation costs over a five-year period.

• The Sisters of Charity Health System in Lewiston, ME, established an ergonomics program, which included staff involvement through a number of committees and an ergonomics task force, the purchase of 15 mechanical lifts, specialized ergonomics training, and provisions for medical management when injuries occurred.

Two years later, workers’ compensation costs related to MSDs (musculoskeletal disorders) had declined by approximately 35%. The ergonomics program was also reported to have contributed to reduced turnover and absenteeism, increased efficiency and effectiveness, and improved morale among employees.

[For more information, contact:

• Deborah V. DiBenedetto, MBA, RN, COHN-S/CM, ABDA, president, American Association of Occupational Health Nurses, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. E-mail: president@aahn.org.

• Kurt Hegmann, MD, MPH, associate professor, Department of Family and Preventive Medicine, Public Health Programs, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108. Telephone: (801) 587-3333. E-mail: khegmann@dfpm.utah.edu.]