How Can a Nursing Home Worker Avoid Injuries?

Summarized below are sections from OSHA's draft ergonomic guidelines for nursing homes --the first set of guidelines under the most recent plan for preventing injuries through better workplace ergonomics.

OSHA's Guidelines for Nursing Homes provides information to help employers identify ergonomic stressors (physical demands that have been associated with certain musculoskeletal disorders) in their workplaces and implement practical measures to control those stressors.

Despite the efforts of nursing home employers and employees in recent years, workers in nursing homes are more than twice as likely as other workers to be injured on the job. Many of these are serious injuries, with more than half require time away from work.

Hazards encountered by nursing home workers include exposure to bloodborne pathogens and other infectious agents, unsafe walking surfaces, hazardous chemicals and the risk of workplace violence from combative residents. Perhaps the greatest factor contributing to the high number of injuries in nursing homes, however, is the physically demanding nature of nursing home work. Manual lifting, transferring and repositioning of residents are tasks associated with an increased risk of pain and injury to caregivers, particularly to the back. These tasks can entail high physical demands due to the large amount of weight involved, awkward postures that may result from leaning over a bed or working in a confined area, shifting of weight or unexpected loading that may occur if a resident loses balance or strength while moving and many other factors.

Nursing home residents often require assistance to walk, bathe or perform other normal daily activities; in some cases residents are totally dependent upon caregivers for mobility. The ergonomic stressors that workers in nursing homes face include:

• 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 --Stressing the body or part of the body against a hard or sharp edge, such as using the hand as a hammer

Exposure to these stressors in the workplace can result in a variety of disorders in affected workers, including muscle strains and tears, ligament sprains, joint and tendon inflammation, pinched nerves, herniated spinal discs, and other conditions. These conditions, collectively referred to as musculoskeletal disorders (MSDs), may develop gradually over time or may result from instantaneous events such as a single heavy lift. Pain, loss of work, and disability may result. Although these conditions may be classified as either injuries or illnesses for Occupational Safety and Health Administration (OSHA) recordkeeping purposes.

The number and severity of injuries resulting from physical demands in nursing homes --and associated costs --can be dramatically reduced by introducing ergonomic programs. Ergonomics, the practice of designing equipment and work tasks to conform to the capability of the worker, provides a means for adjusting the work environment and work practices to prevent injuries before they occur.

Where to begin? OSHA recommends that manual lifting of residents be minimized in all cases and eliminated when possible. Minimizing and, where possible, eliminating resident lifting is the primary goal of the ergonomics process in the nursing home setting and of these guidelines. However, the approach to controlling the hazards associated with manual handling of residents should take into account other factors such as:

• Resident rehabilitation needs,
• The need to restore functional abilities,
• The need to restore functional abilities,
• Medical contraindications, Emergency situations, and Resident dignity and rights.
• Emergency situations, and
• Resident dignity and rights.

Training as a key element. To adequately identify and control ergonomic stressors and minimize the severity of workplace injuries, employees should receive training. Ergonomics training should enable employees at all levels of the organization--administrators, charge nurses, nursing assistants, maintenance workers, and equipment purchasers--to further the ergonomics program. People who work in nursing homes should be able to:

1. Recognize the signs and symptoms of MSDs so that they can report them early and respond to them appropriately;
2. Identify those jobs or tasks that have ergonomic stressors capable of causing MSDs; and
3. Know how to control ergonomic stressors.
4. Success of the ergonomics program depends to a great extent on the effectiveness of ergonomics training.

To be effective, training should be provided to all individuals in a nursing home who are at risk of incurring MSD injuries, as well as all employees who have responsibility for implementing ergonomics policies and procedures. Nursing home employers should consider training the following employees:

• Nursing assistants and other workers exposed to MSD stressors;
• Ergonomics program administrators;
• Charge nurses, supervisors and those involved in receiving employee reports of injuries or symptoms;
• Other healthcare providers who are on staff or otherwise work at the nursing home;
• Maintenance and purchasing personnel (persons involved in selecting and procuring equipment); and
• Management and human resources personnel.

Many sources of ergonomics training materials exist. OSHA intends to offer advice and training on the guidelines it develops through the Agency's website as well as through the 12 OSHA Education Centers nationwide. In addition, a free consultation service largely funded by OSHA provides assistance to small businesses in identifying available training resources, as well as with other ergonomics-related topics. The content of the training should be targeted to each specific employee group.

Addressing injuries when they happen Even after an effective ergonomics (injury prevention) program is implemented, work-related musculoskeletal injuries will still occur. Thus, an ergonomics program should include a process for addressing work-related injuries. Nursing home employers should develop an occupational health management process that ensures that workers receive prompt access to care for evaluation, treatment and follow-up of MSD injuries related to workplace ergonomic stressors.

Employers should assign a person to be responsible for occupational health management and this person should have the proper training, authority, resources and experience to carry it out effectively.

A system should be in place so an employee can report to the employer work-related signs or symptoms (e.g., pain, numbness) and injuries. Early reporting is essential to effective management of MSDs, allowing for timely and appropriate treatment and therefore should be encouraged. [Note: Employers should be aware of OSHA's recordkeeping rule (29 CFR 1904). Under this rule employers must record certain injuries including those related to workplace ergonomic stressors.]

In addition to establishing a good reporting system, employers should create a procedure that provides employees with prompt and appropriate assessment, treatment and follow-up of an MSD by an appropriately trained and licensed health care professional. The health care professional should be familiar with the nursing home facility and the employee's job duties and hazards, work history, and personal factors that may contribute to the problem. Often these health care professionals can help identify any work-related factors that may contribute to a reported injury.

The health care professional, in consultation with the employer and the employee, should prepare return-to-work procedures that ensure that assigned restricted duties do not further injure the employee. When making recommendations to return an employee to work, the health care professional should first determine that the employee's physical capabilities match the work requirements. The employer should make sure the job assigned to the employee is appropriate considering the work restrictions. The employer and employee should follow any work restrictions designated by the health care professional.

Documentation. Maintaining documentation of injury reports related to ergonomic stressors is critical to preventing their recurrence. In this process, the information in individual employees' health records should be kept confidential.

Information gained from work-related MSD reports can be used to make the workplace safer. An analysis of reports can identify areas of the nursing home that need focused worksite analysis and prevention. Reports can also help determine if injury trends are emerging that should be addressed.

Evaluation. The employer, with employee assistance, should periodically evaluate whether its system for identifying problems related to exposure to ergonomic stressors is functioning effectively. While trailing indicators such as injury rates provide useful information toward accomplishing this goal, the inquiry should not stop there. The employer should ensure that reports of problems are being filed, their contents evaluated and decisions made regarding their disposition.

An effective training program should have clear goals for developing employees' ergonomic awareness. When evaluating a training program, the employer should examine the content and frequency of training sessions. Does the training curriculum reflect the needs of the facility's ergonomics program? Does the frequency of training sessions allow for prompt training of new employees and follow-up training for veteran staff?

Also, the training is effective only if the material is understood and integrated into practice. Thus when conducting an evaluation, employers should observe trained employees to ensure that they are adhering to the work practices and ergonomic principles discussed in training sessions. Employers should ensure that employees follow the program through such actions as:

Reviewing the program and training to make sure that employees are fully informed of their responsibilities; Evaluating the workplace culture to ensure that poor performance is not rewarded; Ensuring that employees have the needed tools and equipment to accomplish their jobs safely; and Establishing policies that address employee compliance with program procedures.

• Reviewing the program and training to make sure that employees are fully informed of their responsibilities;
• Evaluating the workplace culture to ensure that poor performance is not rewarded;
• Ensuring that employees have the needed tools and equipment to accomplish their jobs safely; and
• Establishing policies that address employee compliance with program procedures

Finally, an ergonomics program that exists only on paper is unlikely to realize any health and safety benefits. Determining whether employees are accepting the program is often a difficult outcome to measure. Anonymous surveys of employees, as well as employee interviews, can be effective tools for gauging employee buy-in to the ergonomics program.