Patient safety during hospitalization is a constant concern, given the possibility of infections, errors, or accidents. But hospitals can also be a hazardous work environment for nursing staff – one of the most perilous, in fact. Bureau of Labor Statistics data show that U.S. hospitals recorded more work-related injuries and illnesses causing employees to miss work days than the construction or manufacturing industries. Injury causes include slips, trips and falls, contact with objects such as needle sticks, and violence, but the majority of nursing injuries are caused by overexertion and bodily reaction from motions like lifting, bending, or reaching related to moving or transferring patients who have limited mobility.
The Department of Veterans Affairs (VA) has been at the forefront of an effort to protect nurses and reduce the incidence of those injuries. The Veterans Health Administration (VHA) implemented a Safe Patient Handling program in all VA medical centers a decade ago, and has since seen a dramatic reduction in nurses’ injuries.
Caregivers regularly reposition and transfer patients who have limited mobility as an integral part of their care, traditionally using manual techniques that emphasized using proper body mechanics but too often resulted in musculoskeletal injury.
“Before the 2000s, there was little happening in the VA or around the country to protect nurses from injury,” said Jill A. Earwood, MSN-HCQ, CSPHP, RN, VHA Office of Nursing Services liaison for Safe Patient Handling and Mobility and the Asheville VA safe patient handling and mobility coordinator/nursing quality manager. “In the 1990s, a nurse researcher, Audrey Nelson at the Tampa VA [Patient] Safety Center, saw a need to protect nurses from injuries. She led the way with Dr. Michael Hodgson, at that time the VA chief consultant for occupational health and safety, and ergonomist Mary Matz. They created pilot sites to demonstrate the role of technology with bedside nurses and how the solutions would hopefully be successful in reducing nursing injuries.”
The pilots were highly successful, said Earwood, and in 2008, a VHA “Executive Decision Memo” and funding of more than $200 million signaled the national roll-out of the Safe Patient Handling program in 153 VA medical centers. The program to reduce injuries focused on patient-handling because, with approximately 47 percent of injuries resulting from mobilizing patients, it is the most common work-related injury to nursing staff, which includes registered nurses, licensed practical nurses/licensed vocational nurses, and nursing assistants.
The program has made a significant difference. “Since the implementation of Safe Patient Handling in the VA, nursing injuries overall have decreased 40 percent, and specific injuries related to patient-handling have been reduced by 50 percent,” Earwood said.
The program is now identified as Safe Patient Handling and Mobility (SPHM), adding the word “mobility,” Earwood explained, “because we recognized that the technology we use to move our patients also contributes to their early mobilization.”
Caregivers regularly reposition and transfer patients who have limited mobility as an integral part of their care, traditionally using manual techniques that emphasized using proper body mechanics but too often resulted in musculoskeletal injury. “Nurses mobilize patients; we know that’s risky,” Earwood said. She pointed to research estimating that “in an inpatient setting, nurses will lift, push, pull, tug approximately 1.8 tons in an 8-hour shift if they use manual techniques alone,” adding that most nurses work 12-hour shifts.
“If nurses are injured and working, hurting and working, taking medications to alleviate pain, our patients are at risk and the quality of care suffers,” said Earwood. Additionally, “nurses sometimes have their careers ended and have to seek other ways to contribute to the mission rather than direct care. That’s why the VA focused on patient-handling injuries in particular.”
To reduce the risk of injury, the SPHM program utilizes a wide array of technology to mobilize patients. Overhead full-body lifts using slings mounted on ceiling tracks assist with transferring patients out of bed and into a chair, for example. Earwood said when the program was instituted, the goal was for all facilities to have full-body lifts in at least 75 percent of their direct-care areas within the first years of the program, and that has been successful.
Other technology includes powered standing-assist devices and non-powered stand aids. “We have air-assisted technology [that] helps us move patients from one surface to another or even from the ground up, because we know a lot of individuals sustain life-altering injuries from trying to lift someone up off the floor who is unable to get up,” said Earwood. “We also have many devices for hygiene, like shower chairs that are powered and powered lift devices for toilets; and we have specialty beds and specialty stretchers that are powered.” And, she added, they have technology to help patients when they arrive at the hospital and need assistance getting out of a vehicle, when the previous method was “all hands on deck, do the best we could.”
The use of technology also promotes the beneficial aspects of early mobilization for patients. One example Earwood cited is “a patient in an ICU that is on a ventilator for supportive breathing and we help that person ambulate using a floor-based lift, and subsequently they are able to come off that ventilator, whereas before they were dependent on the ventilator and weren’t able to be weaned off it.” While the SPHM program and the technology utilized protect nurses from injury, she said, “This doesn’t just benefit the nurse. It benefits the patient.”
The increased focus on the benefits of early patient mobilization has heightened the need for assessment tools. “We know as nurses,” said Earwood, “if we move people, they get better, so we mobilize our patients earlier and earlier. That can create risk for both patient and nurse; the patient can fall more easily, and the nurse is trying to catch the falling patient.”
While the SPHM program provides algorithms to help nurses choose equipment based on the patient’s mobility status, she continued, “What we haven’t had until recently was an objective tool that helps us assess a patient’s mobility status.”
To aid in assessing the mobility status of patients, Earwood said the VA Office of Nursing Services recently signed a national licensing agreement to utilize the industry-developed Bedside Mobility Assessment Tool, an instrument that “gives a nurse an objective way to do an assessment on a patient, and that assessment then indicates what equipment is needed to move the patient safely so the patient is protected from falling and the nurse is protected from being injured. We’re excited about this. This is new, and we’re hoping this is going to help us reduce not just our nurses’ injuries but also our patients’ injuries from falls.”
The VHA’s strong support for the SPHM program extends from the national level to the regional Veterans Integrated Service Networks (VISNs) to individual hospitals and units. A national program manager leads a network of facility coordinators to manage the programs at the local level, Earwood explained, with each facility having its own SPHM coordinator and program. Unit peer leaders are the “unit-level champions and the cornerstone of the culture change to prevent injuries,” said Earwood. “They step in to remind co-workers about using the technology and they help with training.”
Earwood said many facility coordinators from across the country also participate at the national level in technical advisory groups that work on finding solutions to specific challenging issues, such as maintaining a safe environment of care for nurses and patients in mental health or perioperative environments. These groups provide an opportunity to share information. “I can assure you that I have taken ideas from others and implemented them here in Asheville,” said Earwood. “We are a network of individuals who want to see one another succeed and have solutions that work.”
In an effort to share best practices with the private sector, a number of facility coordinators participate in a group called Universal Safe Patient Handling and Mobility, “working with private partners and even internationally to share ideas. There are private-sector facilities that have excellent programs; we want to learn from them, and they’re learning from us,” Earwood said. Collaboration also occurs at SPHM national conferences that include the VA and private sector. And some facility coordinators are partnering with schools of nursing and the American Association of Colleges of Nursing to assist them in connecting with vendors, for example, in an effort to augment the technology in their simulation labs.
Training for SPHM increasingly highlights utilization of simulation technology, according to Earwood. “We have simulation coordinators throughout the VA and it’s definitely becoming more of a focus area for all types of training,” she said, adding that simulating specific scenarios regarding new and emerging patient mobilization challenges was highlighted at a recent VA-hosted SPHM conference.
“Our schools of nursing, even though they have some of the most amazing simulation spaces, are still teaching our students body mechanics as the primary way to prevent injury from moving patients. So, our schools are behind, unfortunately. That’s probably one of biggest challenges we face.”
Despite the commitment to reduce injuries, they do still occur, in part because culture change and adoption of technology can take time, Earwood said. “We encourage [the] reporting of injuries, no matter what the cause, so injured nurses can receive treatment and we can process claims in a timely manner,” she said. “The VA is committed to those employees. There is a continuation-of-pay system and a liberal leave policy. We provide light-duty assignments to prevent re-injury during a time when they may not be well enough to take care of patients, following their physician’s recommendation. If a nurse cannot return to direct clinical care, every effort is made to assign them to a nonclinical role, but still able to contribute their expertise on patient care, because we don’t want to lose that nurse.”
In addition to the health implications of nurse injuries, the monetary cost can also be significant. “In theory, if we decrease the injuries, we decrease the cost,” said Earwood. “What we do know is that hospital workers’ compensation claims are between $9,000 and $12,000. The average cost of a low back injury in the U.S. is about $40,000. The average cost in the VA to replace a nurse injured so badly that he or she cannot return to direct care is between $40,000 and $80,000 depending on location. But the indirect costs outweigh the direct cost about 5-to-1, according to the U.S. Department of Labor, because there’s just so much involved in putting a nurse at the bedside. So, we believe as we reduce nursing injuries we certainly reduce costs and lost time.”
In expressing an even broader view, Earwood said, “In my role working with the Office of Nursing Services and nurse leaders in the VA, we are all fully aware that we have an emerging trend with a shortage of nurses in the coming decade, because a lot of ‘baby boomer’ nurses will be concluding their careers. So, it’s beneficial to the VA to do everything we can to keep nurses healthy and to support their vitality.”
Noting another trend, Earwood said while the overall and patient-handling injury rates for VA nurses continue to decrease, injuries from assault have increased approximately 31 percent over roughly eight years. “Even though the rate of injuries from assault is still lower than the rate of injuries from patient-handling, it is an increase, and we recognize that needs to be an area of focus,” she said.
Assaults can occur either by patients who act deliberately or by those who exhibit poor impulse control, such as a patient with dementia, Earwood explained, adding, “Each situation can pose a unique risk to the nurse.”
The VA’s Prevention and Management of Disruptive Behavior program provides education and training to address those risks. “But we’re finding that those programs are somewhat ineffective for that category of dementia,” she said, “so the VA has programs that are fairly new and being introduced in the facilities, that help give our nurses tools in how to approach those patients better.”
Earwood identified other challenges in their efforts to reduce nurses’ injuries. “Our schools of nursing, even though they have some of the most amazing simulation spaces, are still teaching our students body mechanics as the primary way to prevent injury from moving patients. So, our schools are behind, unfortunately. That’s probably one of biggest challenges we face,” she said.
Access to training can be difficult because nurses need to be able to come away from patient care to be trained, Earwood explained. “That’s been the age-old problem in nursing: How do we have time to take care of the patients and to also take the needed time for training? We accomplish it, but it’s always a challenge in organizing.”
Additionally, she pointed to the need to support facilities’ efforts to replace SPHM technology and equipment as it ages, and to promote design aspects that enhance SPHM components in facility renovation and construction.
Earwood emphasized that the VA is committed to providing a safe working environment through access to technology across all settings, through construction and design, and through training. She referred to a 2015 National Public Radio feature highlighting the VA’s SPHM program development as an example of innovation and leadership regarding reduction of nurses’ injuries.
“Those of us who are VA employees are committed to veterans. That’s why we work at the VA,” Earwood concluded, and with a predicted upcoming critical shortage of nursing staff, added, “The VA is committed to keeping nurses safe and healthy so that we’re able to support veterans into the future.”
This article was first published in the Veterans Affairs & Military Medicine 2018 Spring Edition publication.