<< Back to Back Facts

Purpose: To learn about the different kinds of equipment, devices and work practices that help protect workers from back injuries.

Task 1:

Review factsheets #1, 2, 3, and 4 to help you answer this question.

1. Working alone, make a list of the equipment ("engineering controls") that you use NOW in your nursing home.

2. Working in your small group, talk about what kind of equipment would make your job easier. Make a list of two or three items. Look at factsheet #4 for help.

Task 2:

Review factsheets #5, 6, and 7. Answer these questions based on YOUR JOB.

1. Which work practice controls (such as resident assessment and training) are used RIGHT NOW on your job?

2. How do you find out what the transfer needs are for each resident?

3. In your small group, come up with a better way to get information about resident transfer needs.

Task 3:

Your group is the safety and health committee at your nursing home. You get the document on the next page from your employer- Look at factsheets #1 and #6 to help you answer these questions.

1. How will you respond to the memo?

2. Can back belts prevent back injuries?

3. What do you think is the solution?

Document 1:

Best Rest Nursing Home
1001 Valley Wind Road
Harrisburg, Pennsylvania 17111

September 5, 1995

Hr. John Justice
President, Local 711
1400 Oak Street
Harrisburg, Pa. 16111

Dear Mr. Justice:
The Best Rest nursing home corporation will be implementing a back support program on a nation-wide basis. The back support is a personal protective device which helps nursing assistants to follow correct lifting procedures. This device, called the Pro-Flex back support, is currently being used in major Fortune 1000 companies. After many months of testing and evaluation of various products, our company has chosen this positive approach in the enhancement of our safety program for all nursing home workers.

Policy Guidelines

1. All nursing assistants, nurses, laundry and dietary personnel will be required to wear the back belt as part of their uniform.

2. All employees will receive in-service training on the use of the back support.

3. Failure or refusal to wear the back support may be subject to disciplinary action, up to and including discharge for just cause for failure to follow company safety policies and procedures.

This program demonstrates a major commitment in both time and expense on the part of Best Rest Nursing Homes, Inc., to reduce the rate of workers' compensation costs on a national basis. Please contact me if you have any questions.


Bill Ruinback 
Human Resources Director 
Best Rest Nursing Home, Inc.

Fact Sheet 1

In control

A control is any equipment or method that does the lifting for you or makes lifting easier and safer to do. In a nursing home, a control is:
  • Equipment that does the lifting for you.
  • A transfer board or transfer belt that makes lifting easier to do.
  • A work practice that makes sure you always have a nursing assistant to help you when you need one.
Not all Controls are the same.

Controls work better the closer they are to the hazard other than the worker. You will see three kinds of controls in your nursing home:

1. Controls that remove the hazard at the source.

2. Controls that remove the hazard along the way.

3. Controls like personal protective equipment that you wear.

Your Best Bet

The best controls are machines, equipment and devices that do the lifting for you. Why?

Because they remove the lifting hazard at the source. Machines don't get back injuries. A machine can lift and transfer residents for you so you have less chance of getting hurt.

Example: Battery-run lifting devices that can safely transfer a resident from the geri chair to the bed.

Machines and devices that do the lifting and transferring for you are called engineering controls. These are the best bet because they solve many problems and let you do what you do best: care for the residents.

Second Best

The second best type of controls are changes in how the lifting is done in your nursing home. These are only second best because you still have to do all the lifting and transferring. The difference is that you have more help.

  • Transferring residents with a helper at all times. You shouldn't have to transfer alone.
  • Color-coded labels in every room that tell you the special lifting needs of that resident.
  • Education programs on how to lift and transfer patients safely.
These controls are called work practice controls because they change how you do your job. They're second best because they don't remove the real hazard: lifting. You get help along the way. These controls stop working when communication breaks down or when there aren't enough hands to help out.

The Last Resort

The last kind of control is one that is put on you, the worker. This control is called personal protective equipment (PPE)- often protective clothing such a gowns and gloves. There are problems with this kind of control.
  • Personal protective equipment does not remove the hazard in the workplace.
  • PPE is often uncomfortable and restrictive.
  • PPE often does not fit properly. Remember, one size does not fit all!
  • PPE is often not taken care of-cleaned and maintained.
  • The burden is put on you to prevent injuries. If you get hurt, it becomes your fault.
According to OSHA, it's your employer's responsibility to keep the workplace safe.

Some nursing home operators think the back belts (belts that a worker wears) are personal protective equipment and that they protect you from back injuries. They are wrong. Back belts are medical devices and should only be prescribed by a health-care provider. There is no proof that back belts prevent back injuries.23 They don't stop you from lifting and transferring heavy residents.

Remember: There are three kinds of controls.

1. The best: Machines and devices that do the lifting for you.

2. Second best: Changes in work practices that give you more help and more information.

3. The last resort: Personal protective equipment doesn't fix the real problems in your workplace, and may not even protect you at all.

Often more than one kind of control is needed to make the job as safe as possible. Both the "best" (equipment and devices) and "second best" (work practice) controls are necessary to prevent injuries. The last resort" type of controls are only to be used:

1. When they are proven to work.

2. When there is no equipment or solution of any kind that can do the same or better job.

3. As a short-term solution while the permanent solution is on its way.

Fact Sheet 2

Not all lifting devices are created equal

You are an expert about the job you do. The experience of nursing assistants all over the country tells us what to look for when shopping for new equipment. Since you use the equipment, you should be involved when new lifting equipment is being bought for your facility. If you use lifting devices at your facility, then you've heard these complaints:
  • "It takes much longer to use. I can't take the time."
  • "It won't fit in the bathroom. That's where I need it the most."
  • "I feel like it's going to tip over and hurt a resident."
  • "My shoulder aches all day from turning that broken crank."
  • "I can never find the sling for the lift when I need it. Why bother?"
You must receive training on any new equipment before you can be expected to use it.

How does the equipment in your facility rate? Many lifting device companies are making safer and better products. Your facility's joint labor/management safety and health committee can use the equipment checklists found in this activity and other tools to evaluate equipment and get the information you need.

Fact Sheet 3

Out of sight

Even good lifting devices are useless if they aren't around when you need them. Ask yourself these questions:
  • Is the lift available when you need it?
  • Are there enough lifts on your floor?
  • Do you have to go to another floor to get it?
  • Is the lift easy to find? Is it stored in the same place when not in use?
  • Did you get "hands-on" training to use the lift?
  • Is the lift in working order?
  • Are you using broken lifting devices where you work?
  • Is the lift maintained on a regular basis?
  • Are slings available when you need them?
Few studies have been done about these new devices. Do they prevent injuries? Are they easy to use? Do they feel safe and comfortable for the resident? Your opinions are important.

Fact Sheet 4

Tools of the trade

There is a lot of equipment available to help nursing home workers avoid injury on the job. Some of it is good, some is not so good. See Appendix C for the names and addresses of equipment manufacturers.

Chairs With Wheels: The Good, The Bad and The Scary

Shower chairs can help reduce the number of transfers you do every day. How does your shower chair rate? These are the features that matter:
  • High enough to fit over the toilet (saves many stressful transfers such as bed to wheelchair, wheelchair to toilet, toilet to shower chair, and back).
  • Adjustable arm rests (less strain to transfer resident).
  • Steady construction (won't tip over).
  • Brakes on at least two wheels (foot-operated brakes mean less strain).
  • Commode (bucket) for toileting (makes transfer to toilet unnecessary).
  • Comfortable commode seat for the resident (increases amount of time resident can stay on chair).
  • Footrest releases (avoids hazards from tripping, scraping and extra leaning to transfer resident).
  • Removable armrests (easier transfer; residents don't have to be lifted over the armrest height).
  • Removable or swing-out footrests (space is needed to help the resident turn [pivot] during transfers).
Walk The Walk

Walking belts can help protect you and the residents you care for.

Posey belts are walking belts with handles. Nursing assistants should receive training on how to use the Posey belt. You will learn a rocking and pulling motion that makes the transfer easier to do. This motion uses the weight of the resident to help with the transfer. You don't have to use as much force to lift. The good points of Posey belts include:
  • Wide, sturdy, with buckles and Velcro for a good and quick fit.
  • Padded handles on each side make it easier to grip.
  • No forceful grasping or gripping is needed. Less pressure from fingers and knuckles against the resident.
  • When used correctly, walking belts reduce the force on the discs in your lower back.24
However, placing this belt on the resident can be somewhat time consuming.

Gait belts are simple canvas walking belts used to support residents who can walk with assistance. They also help the nursing assistant protect him or herself from slipping and falling residents. However, they have several bad points:
  • They can slide up on a resident, causing scrapes and skin tears and pushing onto the rib cage. This is a big problem with pear-shaped residents.
  • They are not safe to use with heavy patients.
  • They can be stressful to the nursing assistant's hands and wrists.
  • They are uncomfortable for residents because the wearer can feel the knuckles of the nursing assistant.
Moving On

Inflatable transfer devices (Air Pal) blow up like pillows and can be very helpful when transferring a resident between beds of different sizes. Some problems include:
  • The resident can slide off the Air Pal if he or she is not placed directly in the center of the device.
  • The resident can slide off the Air Pal if the straps are not used or are used incorrectly.
  • It takes a long time to use it.
  • It is noisy and may be frightening for some residents.
  • An electrical outlet must be nearby in order to operate it.
  • The canister providing the air pressure is bulky and heavy.
Beasy boards are transfer boards set up like a slide. There is less friction and more comfort than wooden transfer boards. Here are some concerns:
  • Chairs of unequal height make the board unstable.
  • The board is very hard and uncomfortable under the resident's head.
  • Very large people may experience skin friction with this device.
  • The board is heavy.
Glider transfer devices are plastic transfer boards. A movable piece goes under the residents' buttocks. This reduces the friction usually caused by transfers. It may be hard to get the device under the resident correctly and then out from under the resident after the transfer.

Pivot discs are devices that residents stand on when getting out of bed. The nursing assistant can turn the resident on the disc to transfer him or her into a chair. The pivot disc is a good idea, but it doesn't work very well for many nursing home residents. Many residents cant remember to stay on the pivot disc or don't have the cognitive skills to follow instructions.

Patient handling slings (Medesign) can help move residents from one location to another. The sling can be quick and handy to use. But a sling can:
  • Dig into the resident.
  • Slip off because it isn't attached to the resident.
  • Only be used with residents who can bear weight.
Pelvic lift devices (Kimbro) inflate like a pillow and lift the pelvis of the resident so they can be toileted without getting out of bed. Good points include:
  • The Kimbro pelvic lift can be used for both urinating and defecating; toilet transferring is eliminated.
  • Comfort level is high for the resident.

  • Bad points include:

  • The foot inflator is hard to use.
  • The residents' upper body has to be raised. Some lifting might be involved.
Crank It Up

Bed cranks are hand cranks located at the bottom of the bed. Most beds are kept in the "low" position. To make the bed higher or lower you have to squat and stoop. Many old bed cranks are broken or hard to turn. Bed cranks need to be in good working order. Using force in a stooped position is bad news for back health.

Bed brakes must be in good working condition. Brakes that are not working can be a strain to use and be dangerous for both nursing assistants and residents.

Nursing assistants must receive training before any lifting and transfer devices are used on residents. Without proper training, this equipment is neither effective nor safe.

Fact Sheet 5

Work practice controls that work

Resident Assessment Matters

Has this ever happened to you?
  • You are transferring a new resident. You didn't know that he is combative and is afraid of the lifting device.
  • You are transferring an unfamiliar resident, who barely speaks, from the bed to a geri chair. You don't know if she can bear any of her weight.
Finding out what the resident needs is called resident assessment (a resident assessment checklist can be found at the end of this chapter). You need to know how each patient should be transferred. Transfer needs don't stay the same. The mental and physical states of residents can change quickly. Resident assessment should be updated on a regular basis - biweekly, for example.

You should be included in the assessment since you provide most of the direct care to residents. You need to see this information before you can work with the resident.

Your workplace should have a system that tells you the lifting needs of the residents. Communication is a vital part of making our workplaces safer.

It's not good enough if your supervisor has this information and you have to ask every time. It's not good enough if the lifting needs are only listed in the "Activities of Daily Living" (ADL) log. It's too time-consuming for you to be looking for folders and answers. Often this information isn't part of the ADL anyway.

A system must be in place that makes it easy to get this information, like color-coded stickers attached to easy-to-see places like the door or bed. Resident privacy is important. These codes are one solution. They can tell you:
  • Which lift to use
  • What the resident can do on his or her own
  • What kind of help the resident needs
  • If the resident is combative.
It Takes Two

Work practice controls include having the help you need in order to perform transfers safely. Some transfers need two people.

Unfortunately, there aren't any state or federal laws that make sure nursing homes have enough staff to match the needs of residents who need more care. That's why there isn't a second person on hand when you need it most.

Lift and Learn

Learning how to lift properly is very important and should be known by everyone. Good lift training classes should talk about bending your knees, keeping your back straight, keeping the load close to your body and using your legs.

We know that lifting people is very different firm lifting boxes. Even with the best equipment on hand, lifting technique is both important and necessary.

Not all lifting training programs are the same. The best programs are hands-on, and are taught by someone who understands the hazards of nursing home work as well as you do.

You can use the checklist found at the end of this activity to tell you how your program rates.

Fact Sheet 6

Beyond the belt way

In some nursing homes, nursing assistants are required to wear back belts. But do back belts work?

What are Back Belts Good For?

Back belts are a medical device, not protective equipment. They are prescribed by doctors for certain medical problems. There is no proof that back belts prevent injuries.25 Belts do not remove the hazard of heavy lifting, pushing, pulling, bending, or twisting. Back belts don't make us stronger. They may even cause other lends of problems:
  • Long-term use of back belts may lead to less muscle strength. Since the belt holds you up, your muscles lose their tone. Weak muscles can mean a higher chance of getting hurt.
  • Back belts may give a false sense of strength and confidence. Workers may lift harder and heavier loads thinking they're safe. They're not.
  • Back belts put the burden of fixing the workplace on the worker. The best protection is removing the hazard at the source. Back belts cant replace good lifting devices and work practice controls. They don't fix the job and they don't make lifting safe.
Fact Sheet 7

Non-solutions: Hidden in the closet

That's where a lot of old and broken lifting devices are - in a corner or closet. Or they're on the second floor and you work on the fourth floor. Some lifting devices are used even though they don't work right. This puts both resident safety and your safety at risk.

Out of The Closet and Into The Trash

That's where unsafe equipment should go. Maintenance and repair are as important as getting the equipment in the first place.


Lifting Devices

Does your lifting device pass the test? Yes No
1. Can it be safely operated alone? __ __
2. Is it in working condition? __ __
3. Is it stable (not easily tipped over)? __ __
4. Can it be cranked, maneuvered, or operated without strain? __ __
5. Can the lift pick up a resident who has fallen to the floor? __ __
6. Can you place the resident in the sling without lifting or pulling them? __ __
7. Can you remove the sling without lifting the resident? __ __
8. Is the resident's head erect when he or she is suspended in the sling? __ __
9. Can the device fit through a narrow bathroom doorway? __ __
10. Can the device fit around a bulky wheelchair? __ __
11. Can the resident be toileted directly from the hoist? __ __
12. Does the device reach high enough to lift a resident off a Clinitron (or other high) bed? __ __
13. Is the resident safe from falls caused by slipping through the straps of the sling? __ __
14. Does the sling design avoid pushing the residents legs apart (concern for residents with hip replacements)? __ __
15. Can the battery be replaced without squatting or stooping? __ __
16. Does the lift have an emergency shutoff button? __ __


Does your equipment have these features? Yes No
Shower Chairs
1. Removable armrests __ __
2. Removable footrests (or that swing to one side) __ __
3. High enough to fit over the toilet __ __
4. Easy-to-repair wheel casters __ __
5. Foot-operated brakes __ __
Wheel Chairs
6. Adjustable armrests __ __
7. Adjustable footrests __ __
8. Bed cranks that can be reached without squatting __ __
9. Bed cranks kept in good working order __ __
10. Brakes in good working order __ __
Walking Belts
11. Comfortable handles __ __
12. Buckles that are easy and quick to fasten __ __
13. Were you trained to use the rocking/pulling motion to avoid lifting? __ __
Walking Belts
14. Are transfer devices in use at your facility? __ __
15. Were you trained to use transfer devices safely? __ __

Resident Assessment

Yes No
1. How much does the resident weigh?
2. Does the resident understand instructions? __ __
3. Can the resident bear weight? __ __
4. Is the resident able to sit? __ __
5. Can the resident help physically? __ __
6. Can the resident walk with assistance? __ __
7. Do you need more than one person to transfer safely? __ __
8. Does the resident have any special problems, like contracture or amputation? __ __
9. Is the resident combative? __ __
10. Is the resident's behavior predictable? __ __
11. What is the condition of the resident's skin?

12. What kind of lifting device is needed?

13. How many nursing assistants are needed to transfer this resident?

14. Are all residents evaluated for transfer needs? __ __
15. Are the recommendations of the nursing assistants included in this assessment? __ __
16. Is this information made available to all caregivers in a way that everyone can understand? __ __

17. How is this information made available?

Lifting Training Program

1. Did every worker from all shifts attend the training? __ __
2. Was the trainer familiar with nursing home work? __ __
3. Did the trainer have experience lifting and transferring residents? __ __
4. Was the training hands-on? __ __
5. Did some part of the training take place at the bedside? __ __
6. Did everyone have a chance to practice in front of the trainer? __ __
7. Were you encouraged to ask questions? __ __
8. Did you practice on people of different shapes and sizes? __ __
9. Did you learn how to handle combative residents? __ __
10. Did you practice on people who cannot bear weight? __ __
11. Did you learn how to handle residents with special needs such as contractures or amputations? __ __
12. Did you practice lifting people up from the floor? __ __
13. Did you get answers to your question? __ __
14. Do you get a refresher training program every year? __ __
15. Do you feel comfortable doing resident transfers as a result of the training program? __ __


Making your job safe: Solutions that work

1. Controls make jobs safer by preventing injuries. The best kind of controls are those that remove the hazard at the source. These are also called engineering controls. The second best kind of controls are work practice controls which control how your work is organized and how you get the information you need. The last resort is protective equipment which puts the burden of safely on you, the worker.

2. Good equipment is an important part of back injury prevention.
  • Well-designed lifting devices.
  • Shower chairs that fit over toilets.
  • Wheelchairs with moveable armrests and footrests.
  • Walking belts with padded handles.
  • Devices that work and are regularly maintained.
  • Training for proper use.
3. Not all lifting devices, belts, chairs or transfer devices are created equal. Get involved in choosing equipment in your facility. You need to be trained on how to use the new equipment before you can be expected to use it.

4. Resident assessment can help you select the correct lifting devices and to work safely. This information must be updated regularly. The health status of a resident can change quickly. Communication is the key. Make sure resident needs are communicated to all workers who provide direct care.

5. Some transfers can only be done safely with two workers. There are no state or federal laws that require staffing levels to match the needs of residence who require more care.

6. Get the right stuff in your training. Training programs should be hands on, answer all of your questions, and be taught by someone who is very familiar with the hazards of nursing home work.

7. Back belts are medical devices that should be worn only for certain medical problems. There's no proof that back belts prevent back injuries. They don't make lifting safe and they don't fix unsafe jobs.