Applied Ergonomics
for LTC
University of Oregon, Labor Education and Research
Center (LERC) and Oregon Occupational Safety and Health
Administration (OR-OSHA)
This material has been made possible by a grant from the Oregon Occupational Safety
and Health Division, Department of Consumer and Business Services
Acknowledgements
Materials for this presentation material made possible
by
Oregon OSHA
Veterans Health Affairs
SAIF Corporation
HumanFit
Bay Area Hospital, Coos Bay, OR
Oregon Nurses Association (ONA)
University of Oregon, Labor Education and Research Center
Back Injury Resource Nurses (BIRN)
National Institute of Occupational Safety and Health
(NIOSH)
Introduction
Today’s workshop will cover
• Ergonomic concepts
• Risk factors for musculoskeletal
injury
• Elements of an ergonomics
program
• SRH Case studies
Learning Objectives
By the completion of this class you should be able
to:
• List 4 risk factors for musculoskeletal injury
• Describe 4 action steps that can reduce your risk
of injury during resident handling activities
• Identify effective solutions to prevent injuries in
for number of common resident handling
activities
What is Ergonomics?
Worker
Task/job
Environment
The goal of ergonomics is to design the
job to fit the worker
NOT make the worker fit the job
What kinds of Injuries are
Musculoskeletal Disorders (MSDs)?
Acute injuries
• Happen immediately due to overload
• Can become chronic
• Re-injury possible
• Strains, sprains, disc herniations
Chronic injuries
•Pain or symptoms lasting more
than a month
Cumulative trauma
•Happen over time
•Difficult to cure
Cumulative Trauma/Injury
microtrauma
(small tears)
irritation
to tissue
results in:
 flexibility
 strength
Function
*INJURY*
Keeps repeating
as long as
activity continues
tears
combine
produces
scar tissue
adhesions
form
The Cumulative Effect
Fatigue
Continued
exposure to
risk factors
Discomfort
Nurses/CNAs
report here
Pain
Injury
Time
Disability
Terms for Disorders
•
•
•
•
•
Work-related Musculoskeletal Disorder (WRMSD)
Cumulative Trauma Disorder
Repetitive Strain Injury
Overexertion or Overuse Injury
Types of disorders
–
–
–
–
–
–
Strains and sprains
Rotator cuff injuries
Disc herniations
Carpal Tunnel Syndrome
Bursitis, tendonitis
Sciatica
Why is Manual Resident Handling
so Hazardous?
• Physical demands of the
work
– Job exceeds physical
demands of individuals
• Poor equipment and facility
design
• Poor work practices
• Individual characteristics
– Age, past injuries, physical
condition, leisurely activities
What are the Risk Factors for
Musculoskeletal Disorders?
• Excessive force
• Awkward postures
• Prolonged postures
• Repetition
Excessive Forces
Common activities contributing
to excessive force:
• Lifting and carrying
• Pushing and pulling
• Reaching to pick up loads
• Prolonged holding
• Pinching or squeezing
Awkward Postures
Common risky postures:
• Working overhead
• Kneeling all day
• Reaching to pick up loads
• Twisting while lifting
• Bending over to floor/ground
• Working with wrist bent
Prolonged Postures
•Standing or sitting for long
periods of time
•Holding arms in fixed
positions for extended
periods
Repetitive Motions
Common problem to look for:
• Same posture or motions again and again
• can be very frequent over short period of time
time
injury
• can be less frequent but repeated over time
time
injury
Common Problems Leading
to MSDS
: • Poorly Designed Equipment
• Does not have a good grip
• Too heavy
• Hard to use
• Uncomfortable
• Bad condition
• Wrong tool/equipment for the job
Common Problems Leading
to MSDs
• Poor work organization
• In adequate scheduling
• Lack of planning
• Poor communication among staff and other
resident stakeholders
• Poor work practices
When is an Activity Likely to
Become an Injury?
• Activity performed frequently
• You do the activity a long time
• Work intensity is high
• There are a combination of risk factors
How do you find solutions?
Job
Tasks
Solution
Hazards
•
•
•
•
Form SRH team
Ergonomic Risk Analysis
Needs Assessment
Formulate solutions
Solution
Solution
Solution
Proper
body
mechanics
Fitness &
wellness
Engineering controls/
Equipment improvement
Risk of
Work practice
controls
musculoskeletal injury
Personal
protective
equipment
Administrative
controls
Choose Effective Solutions
Engineering
•Tools/equipment
•Workplace design
Most
Effective
Administrative
•Job rotation
•Number of workers
Work practices
•Changing bed height
Behavioral
•Body mechanics
•Stretching/Fitness
•PPE
Least
Effective
Preventing MSDS
First Choice: Engineering Controls
• Eliminate or reduce primary risk factors
• Use resident handling equipment, such as,
ceiling and portable floor lifts, air assist transfer
devices, and mechanical sit to stand lifts
• Must match equipment use with
• Resident dependency (physical and cognitive abilities)
• Type of lift, transfer or movement
• Number of staff available
Preventing MSDS
Second Choice: Administrative Controls
• Reduce employee exposure to primary risk
factors
• Ergonomics training
• Policy & procedures that define good work
practices
• Staffing and overtime practices
• Job rotation
Preventing MSDS
Second Choice: Work Practice Controls
• Reduce employee exposure to primary risk
factors by using best work methods:
•
•
•
•
•
•
Plan work organization
Use good housekeeping practices
Use adjustments on equipment
Get help when needed
Eliminate unnecessary movements
Don’t use broken equipment
Remember – it’s the employee’s responsibility to use
good work practices and follow the organizations’ safe
resident handling policy and procedures
Preventing MSDs
Second Choice: Work Practice Controls
• Neutral spine posture - 3 Curves
make your spine strong and minimize
physical stress
Cervical
• It is important to KEEP THESE CURVES
when moving, bending and lifting
Thoracic
• Neutral spine is the reason body
builders can lift so much weight without
injury
Lumbar
Using good body mechanics is important, even when using
equipment, but alone body mechanics will NOT prevent MSDs
Conduct Ergonomic Risk
Assessment
• Recognizing hazards is the first
step toward injury prevention
• Job analysis performed by people
with ergonomics training
– Ergonomics team
– Safety committee members
– Line personnel
What Can You Do to
Reduce Your Risk of MSDs?
The following materials from the Safe Resident Handling in Health
Care Guide, and made possible by a grant from Oregon OSHA,
Department of Consumer and Business Services, 2004.
Used with permission from Oregon Nurses Association, UO LERC and Bay Area Hospital,
Coos Bay, OR
Risk Assessment steps
1. Assess the resident
2. Assess & prepare the environment
3. Get necessary equipment & help
4. Perform the Resident care task, lift or
movement safely
Plan and Prepare – It only takes a minute but
can save a career
1. Assess the Resident
Goal:
To assess if resident status (physical and cognitive
abilities) has changed and to determine the safest
method to transfer or move the resident.
Compare assessment with resident handling
orders or instructions in the Resident's Care Plan
and ensure that staff are alerted to changes in
resident status.
1. Assess the Resident
This brief observation includes assessment of the
resident’s:
• Ability to provide assistance
• Physical status – ability to bear weight, upper
extremity strength, coordination and balance
• Ability to cooperate and follow instructions
• Medical status – changes in diagnosis or
symptoms, pain, fatigue, medications
When in doubt, assume the resident cannot assist with
the transfer/ repositioning
2. Assess & Prepare the
Environment
• Ensure that the path for transfer or movement is
clear and remove obstacles and clutter that
constrain use of good posture and access to the
Resident, e.g.,
– bed tables, and chairs
– trip hazards, e.g., cords from medical equipment
– slip hazards , e.g., spilled beverages or other fluids on
the floor
2. Assess & Prepare the
Environment
• Consider safe handling of medical devices, such
as catheters, intravenous tubing, oxygen tubing,
and monitoring devices
• Ensure good lighting.
• Adjust equipment, such as beds to correct
working height to promote good postures
• Keep supplies close to body to avoid long reaches
3. Get Necessary Equipment
& Help
• Get the correct equipment and supplies for the
task as determined in the Resident Care Plan and
after the Resident Assessment in Step 1
• Get additional help as required
• Ensure that
– Equipment is in good working order
– Devices such as gait belts and slings are in good
condition and the correct size
– The resident is wearing non-slip footwear if they are to
be weight bearing
4. Perform Resident Care Task,
Lift or Movement Safely
• Explain the task to the resident – agree on how
much help he or she can give during the task
• Position equipment correctly, e.g., height
between a stretcher and bed is equal
• Apply brakes on equipment and furniture used
• Lower bed rails when necessary
You should receive training on correct use of
equipment, resident assessment and safe work
practices before handling Residents
4. Perform Resident Care Task,
Lift or Movement Safely
• Coordinate the task as a team (nurses and
Resident)
• Have the Resident assist as much as possible
• Use good body posture – keep work close to
the body and at optimal height
• Know your physical limits and do not exceed
them
Follow your organizations safe Resident handling
policy and procedures
What else can you do?
• Report ergonomic problems to your supervisor
• Apply back injury prevention principles to your off
-the-job activities
• Report any physical problems early – leads to a
quicker recovery
Case Studies
Safe Resident Handling Program:
Applied Ergonomics for Nurses and
Health Care Workers
Case Studies
•
•
•
•
•
Case
Case
Case
Case
Case
study
study
study
study
study
1:
2:
3:
4:
5:
• Case study 6:
Repositioning resident in bed
Transfer from chair to bed
Transfer from bed to stretcher
Transfer from wheelchair to bed
Making a bed & repositioning
resident in bed
Resident ambulation and fall
recovery
Ergonomic Analysis Form
Potential Risk
Factors and Body
Regions
Repetitive Forward
bend of torso >60
coupled with twisting
and side bending back
Root Causes
Observed (Reason)
Lifting bags from floor.
Dirty linen bags
Weighing about
20 lbs each
Possible Solutions
Consider carts for
garbage and soiled
laundry with spring load
bases that reduce reach
and force required to
load and unload bags.
Case Studies
• Remember – what you are about to practice is
not a substitute for specific training on safe use
of resident handling equipment
• Not all resident handling equipment available is
shown in the video
• Always follow the Resident handling policy at
your facility
Case Study 1
Repositioning Resident in Bed
What Did You See?
• Identify primary risk factors for MSDs
• Identify hazards that may cause slips, trips,
falls or other acute or traumatic injuries
• Determine the cause or the primary risk
factors and hazards observed
• Determine a safer way to perform the task
Case Study 1
Repositioning Resident in Bed
Task
Risk Factors & Hazards
Cause
Injection of Back bent & twisted coupled Bed too low
medication with static posture
Rail up
Bed table obstructs
Trip Hazard
access
Phone on bed –
cord on floor
Dispose of Back bent
Bed table obstructs
needle
access
Neck bent backwards
Long reach (arm overhead)
Case Study 1
Repositioning Resident in Bed
Task
Reposition
resident
Risk Factors & Hazards
Cause
Back bent & twisted
Bed too low
Neck bent backwards
Rail up
Forceful exertion– back
and shoulder
Resident weight
Resident did not
assist
Case Study 1
Repositioning Resident in Bed:
The Safer Way
1. Assess the Resident
– Has upper extremity strength, can sit
unaided, is non-weight bearing, cooperative
(consider medical status etc.)
2. Assess the Environment
– Move bed table and phone, raise bed, lower
rail when administering injection
– Raise bed and lower bed rails before moving
resident
Case Study 1
Repositioning Resident in Bed:
The Safer Way
3. Get Necessary Equipment & Help
– Friction reducing device (slippery sheet)
& two nurses or CNAs
4. Perform the Task Safely
– Coordinate the move
– Use good posture
– Have resident assist
Case Study 2
Transfer from Chair to Bed
What Did You See?
• Identify primary risk factors for MSDs
• Identify hazards that may cause slips, trips,
falls or other acute or traumatic injuries
• Determine the cause or the primary risk
factors and hazards observed
• Determine a safer way to perform the task
Case Study 2
Transfer from Chair to Bed
Task
Assisting
resident from
chair to bed
Risk Factors & Hazards
Cause
Forceful exertion –
Resident weight
back
Resident not capable
Back bent & twisted
of bearing full weight
Resident not assessed
Chair too low
Case Study 2
Transfer from Chair to Bed
Task
Assisting
resident onto
bed
Repositioning
in bed
Risk Factors & Hazards
Cause
Forceful and sudden
Resident not capable
of full weight bearing
exertion – back
Back bent & twisted
Neck bent backwards
Forceful exertion –
back
Back bent & twisted
Neck bent backwards
Resident not
assessed
Resident not capable
of full weight bearing
Bed too low
Case Study 2
Transfer from Chair to Bed:
The Safer Way
1. Assess the Resident
– Partial weight bearing, cooperative, has
upper extremity strength and can sit
unaided
2. Assess the Environment
– Move bed table, lower head of bed; lower
bed rail using good posture
Case Study 2
Transfer from Chair to Bed:
The Safer Way
3. Get Necessary Equipment & Help
– Powered Sit-to-Stand device
– Only one caregiver needed
4. Perform the Task Safely
– Apply equipment brakes when raising or
lowering resident
– Raise bed before lifting resident’s legs
– Use good posture
– Have Resident assist
Case Study 3
Transfer from Bed to Stretcher
What Did You See?
• Identify primary risk factors for MSDs
• Identify hazards that may cause slips, trips,
falls or other acute or traumatic injuries
• Determine the cause or the primary risk
factors and hazards observed
• Determine a safer way to perform the task
Case Study 3
Transfer from Bed to Stretcher
Task
Positioning
stretcher in
room
Preparing
transfer
Risk Factors & Hazards
Back bent and twisted
Sharp corners or
protruding edges on
furniture (risk of soft
tissue contusion)
Back bent
Long reach (arm
overhead)
Cause
Poor posture or
bodymechanics
Moving furniture in
constricted space
Passing IV bag and
tubing over bed
Case Study 3
Transfer from Bed to Stretcher
Task
Risk Factors & Hazards
Performing Extreme forceful exertion –
transfer
back and shoulders
Back bent
Neck bent backwards
Cause
Resident weight/
shape
Resident unable to
assist
Stretcher higher than
Extreme bending of knee
bed height
(on bed) coupled with force
Extended reach to grasp
drawsheet
Width of stretcher
and bed
Forceful grip (poor hand
hold)
Use of drawsheet to
move resident
Case Study 3
Transfer from Bed to Stretcher
Task
Moving
stretcher
Risk Factors & Hazards
Cause
Forceful exertion - back Pushing and
and shoulder
pulling stretcher on
carpeted surface
Back bent and twisted
Lack of holder on
Neck bent backwards
stretcher for O2 tank
and twisted
Lack of steering
Arms extended away
control on stretcher
from body
Stretcher too low
Case Study 3
Transfer from Bed to Stretcher:
The Safer Way
1. Assess the Resident
– This is a Bariatric resident who cannot
assist with the transfer
2. Assess the Environment
– Move furniture from of work area before
bringing stretcher into room
Case Study 3
Transfer from Bed to Stretcher:
The Safer Way
3. Get Necessary Equipment & Help
– Air assisted friction-reducing device & three
caregivers
– Pass IV bag around resident
– Stretcher has holder for IV and Oxygen
tank
– Larger wheels and steering assist
mechanism
Case Study 3
Transfer from Bed to Stretcher:
The Safer Way
4. Perform the Task Safely
– Coordinate the preparation and transfer
– Work heights equal and equipment/bed
brakes applied
– Use good posture
– Adjust stretcher height for movement to
allow good posture
– 2nd person required to guide front of
stretcher only
Case Study 4
Transfer from Wheel Chair to Bed
What Did You See?
• Identify primary risk factors for MSDs
• Identify hazards that may cause slips, trips, falls
or other acute or traumatic injuries
• Determine the cause or the primary risk factors
and hazards observed
• Determine a safer way to perform the task
Case Study 4
Transfer from Wheel Chair to Bed
Task
Preparing to
assist the
resident
Assisting
resident
from
wheelchair
to bed
Risk Factors & Hazards
Cause
Forceful exertion Holding resident’s leg
back
while adjusting foot rest
Back bent
Neck bent backwards
Adjusting leg supports/
foot rests
Forceful exertion –
back
resident not capable of
full weight bearing
Back bent & twisted
Resident weight
Resident not assessed
Case Study 4
Transfer from Wheel Chair to Bed
Task
Assisting
resident
onto bed
Risk Factors & Hazards
Cause
Forceful and sudden
Resident not capable
exertion – back
of full weight bearing
Back bent & twisted
Resident not assessed
Neck bent backwards
Wheel chair away
from bed
Case Study 4
Transfer from Wheel Chair to Bed
Task
Repositioning
in bed
Risk Factors & Hazards
Cause
Forceful exertion
Bed too low
-back
Bed rail up
Back bent & twisted
Neck bent backwards
Head of bed partially
raised
Resident does not
assist
Case Study 4
Transfer from Wheel Chair to Bed:
The Safer Way
1. Assess the Resident
– Partial weight bearing, cooperative, has
upper extremity strength and can sit
unaided
2. Assess the Environment
– Move bed table, raise bed, raise head of
bed, lower bed rail using good posture
Case Study 4
Transfer from Wheel Chair to Bed:
The Safer Way
3. Get Necessary Equipment & Help
– Gait belt; crutches and trapeze bar
– Only one caregiver needed
Case Study 4
Transfer from Wheel Chair to Be
The Safer Way
4. Perform the Task Safely
– Use good posture to apply gait belt and to
adjust wheel chair foot supports
– Have resident assist to hold leg while adjusting
foot support
– Do NOT lift but guide resident to a standing
– Have resident transfer self to bed with standby assist
– Have resident reposition self on bed
Case Study 5
Making Bed & Repositioning
Resident in Bed
What Did You See?
• Identify primary risk factors for MSDs
• Identify hazards that may cause slips, trips,
falls or other acute or traumatic injuries
• Determine the cause or the primary risk
factors and hazards observed
• Determine a safer way to perform the task
Case Study 5
Making a Bed and Repositioning
Resident in Bed
Task
Making bed
Risk Factors & Hazards
Forceful exertion – back and
shoulders (CNA turning &
holding resident)
Back bent & twisted in static
posture (CNA turning &
holding resident)
Repetitive bending & twisting
of back (CNA making bed)
Neck bent backwards (both
CNAs)
Cause
Resident weight
Resident unable
to assist
Bed too low
Bed Rails up
Case Study 5
Making a Bed and Repositioning
Resident in Bed
Task
Making the
bed
Repositioning
resident in
bed
Risk Factors & Hazards
Forceful grip - Poor hand
hold (nurse turning &
holding resident)
Slip Hazard
Forceful exertion – back
and shoulder
Back bent & twisted
Neck bent backwards &
twisted
Cause
Using drawsheet
Spill on floor
Resident weight
Resident unable
to assist
Bed too low
Rail up
Case Study 5
Making a Bed and Repositioning
Resident in Bed:
The Safer Way
1. Assess the Resident
– This is a semi-conscious resident who is
unable to assist
2. Assess the Environment
– Clean up spill, have bed linens ready,
raise bed and lower rails
Case Study 5
Making a Bed and Repositioning
Resident in Bed:
The Safer Way
3. Get Necessary Equipment & Help
– Ceiling hoist and 2 nurses or caregivers
4. Perform the Task Safely
– Coordinate lift and movement
– Each nurse makes a side of the bed
– Move bed and/or use ceiling lift to
reposition resident safely
Case Study 6
Resident Ambulation & Fall
Recovery
What Did You See?
• Identify primary risk factors for MSDs
• Identify hazards that may cause slips, trips,
falls or other acute or traumatic injuries
• Determine the cause or the primary risk
factors and hazards observed
• Determine a safer way to perform the task
Case Study 6
Resident Ambulation and Fall
Recovery
Task
Risk Factors & Hazards
Ambulating Trip hazards
resident
Sharp corners or
protruding edges on
furniture (risk of soft
tissue contusion)
Poor and unstable
coupling (handhold)
Cause
Equipment in walkway
No safe way to support
resident – holding wrist
may cause soft tissue
trauma to resident
during fall
Case Study 6
Resident Ambulation and Fall
Recovery
Task
Attempting
to control
the resident
fall
Risk Factors & Hazards
Forceful exertion – back
and shoulders
Back bent & twisted
Cause
Resident weight
coupled with sudden
motion
Neck bent backwards
Location of resident
at floor level
Forceful twisting of left
forearm when attempting
to ‘hold’ resident during
fall
Poor coupling –no
location to securely
support resident and
control the fall safely
Case Study 6
Resident Ambulation and Fall
Recovery
Task
Lifting
Resident
from floor
Risk Factors & Hazards
Forceful exertion –
back and shoulder
Back bent
Neck bent backwards
Forceful grip - Poor
coupling hand hold
Cause
Resident weight
Resident unable to assist
Location of Resident
- lift from floor level
No safe way to hold
resident’s arms and legs.
Risk of soft tissue
trauma to resident
Case Study 6
Resident Ambulation and Fall Recovery:
The Safer Way
1. Assess the Resident
– Can weight bear with standby assist and
is cooperative
– The resident cannot stand without
assistance after fall
2. Assess the Environment
– Move IV pole and wheelchair in walkway
Case Study 6
Resident Ambulation and Fall Recovery:
The Safer Way
3. Get Necessary Equipment & Help
– Use gait belt for ambulation
– Only one nurse or caregiver needed
– Portable powered floor lift and two nurses or
caregivers to safely lift resident from floor
using equipment
Case Study 6
Resident Ambulation and Fall
Recovery:
The Safer Way
4. Perform the Task Safely
–
–
–
–
Improve coupling or handhold by using gait belt
with handles (less grip force required)
Control fall correctly using gait belt as aid (but
not to ‘lift’ Resident)
Maintain good posture while controlling the fall
and supporting resident in floor lift sling
Use of portable powered floor lift reduces injury
risk for caregiver and resident
Applying your knowledge:
Conducting a risk assessment
Resources
• National Center for Resident Safety
– http://www.va.gov/ncps/
• Resident Safety Center of Inquiry
– http://www.visn8.med.va.gov/Residentsafetycenter/
• National Institute of Occupational Safety and Health
– http://www.cdc.gov/niosh/topics/healthcare/
• OSHA (federal)
– www.osha.gov
– http://www.osha.gov/SLTC/etools/nursinghome/index
.html
• Oregon OSHA: www.cbs.state.or.us/osha/
• SAIF Corporation: www.saif.com/
Wrap up & Evaluation