Ergonomics: Guidelines for Nursing Homes
Stakeholder Meeting on Ergonomics Guidelines for Nursing Homes
Occupational Safety and Health Administration
United States Department of Labor
Hyatt Dulles Hotel, Herndon, Virginia
November 18, 2002
1. MEETING FORMAT
OSHA representatives presented a summary of the current draft document "Ergonomics for the Prevention of Musculoskeletal Disorders: Guidelines for Nursing Homes," along with a summary of written comments previously provided to the Agency. These presentations were followed by verbal feedback and discussion from stakeholder meeting participants, in response to three primary topics: Management Practices, Worksite Analysis, and Control Methods.
The following text is a summary of the key points made by stakeholders during the stakeholder feedback and discussion period. All participant comments are grouped together by topic, without reference to the identity of the speakers.
2. MANAGEMENT PRACTICES
Use an ergonomics program approach
Some of the stakeholders suggested that a programmatic approach to ergonomics is needed for any high-risk work environment. A systematic approach is needed to deal with problems that arise in the context of a specific workplace. They recommended that OSHA clearly discuss the elements of an ergonomics program, like it did in the meatpacking guidelines. The overall approach to ergonomics should be similar for many industries. In light of this history of effective ergonomic programs and corporate-wide settlements, the question was raised whether OSHA is now backtracking by writing new guidelines without a strong program approach. A stakeholder noted that there are many similar issues regarding risk factors and types of repetitive motion injuries across the different industries; therefore, it should be possible to adapt existing guidelines in use by other industries.
Resident lifting and repositioning at nursing homes has distinct features compared to other industries
Another view expressed by the stakeholders is that moving live people, as in residents in nursing homes, is a very unique activity, even though many of the MSD risk factors for workers are similar. A link needs to be made between the clinical and protective elements, because both the workers' and the residents' interests need to be considered. It was observed that a careful examination of the clinical aspect in nursing homes may suggest that in some cases the move to using equipment for resident lifting and repositioning is a decision made too soon, without full consideration of the clinical point of view.
Some stakeholders suggested that, although the guidelines are intended to produce effective workplace requirements for the benefit of workers, there is concern to also promote the health, well being, and quality of life for nursing home residents. It is important to look at the problem from the resident standpoint, as well as from the worker and management standpoints.
They also identified that another element of the clinical aspect is the need to emphasize the independence of residents in relation to equipment used. The guidelines should clearly say that equipment is not to be used to perform lifting or moving that residents can do for themselves -- and which they may, in fact, need to do for themselves. It is important to promote the independence of residents with relation to equipment used.
The concern that some residents may become upset because they feel that workers do not want to lift them and that the use of machines for lifting can feel impersonal to some people was also identified.
Coordinate with other government entities
Some stakeholders raised the issue of compatibility of OSHA's guideline with other state and federal regulations governing nursing home operations. For example, state public health departments also conduct inspections at nursing home facilities. Is there any knowledge of whether State requirements will complement or conflict with OSHA guidelines? Will the two groups work together and have similar expectations?
Other stakeholders noted that each State has its own inspection system, so it will be hard to communicate with all, despite OSHA's best efforts. This is one of the reasons to create guidelines and not regulations. Some stakeholders expressed hope that nursing home providers will choose to make these changes on their own, without OSHA promulgating specific requirements.
A suggestion was made to try to create one set of guidelines that everyone in the industry can use. Make the effort to align the guidelines with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other standards. Use the Center for Medicare and Medicaid Services' guidelines and other guidelines that have already been established whenever available. Nursing home staff are already deluged with paperwork. Other monitoring agencies -- especially the State agencies -- require much more documentation than OSHA does.
Several attendees suggested that it may be a positive strategy for the guidelines to acknowledge the resource constraints of providers. However, nursing homes still need to be encouraged to voluntarily implement the guidelines. It will be important to get the Center for Medicare and Medicaid Services involved as a supporter of the guidelines, as nursing homes will need monies to invest in equipment.
Implement best practices
A few stakeholders remarked that the language contained in the current document is intimidating. To make it more attractive, the document should feature case studies from nursing homes that use the new guidelines. Include pay scales and other detailed information from homes that have implemented the new equipment procedures. Remember that many smaller homes do not have the means to purchase such expensive equipment.
Several stakeholders noted that the Department of Veterans Affairs has a step-by-step document that addresses resident lifting and which outlines a broad approach for implementing such new programs. Although the VA program may be too detailed for smaller facilities, it can be useful as a model for setting up teams to establish a programmatic approach. The VA guidelines provide a template that can be adapted.
Some stakeholders suggested that voluntary guidelines should be attractive to both employers and employees. Employers need to hear from their peers how the effective use of mechanical lifts relates to resident care, reduced injuries, financial savings, and reduced turnover. The approach needs to be holistic and must show that it can be productive from an operating sense.
Several stakeholders asked whether the OSHA guidelines will be expanded to address long-term assisted living care facilities and intermediate care homes for the mentally retarded. Although genuine differences exist, there are often needs for similar lifting equipment at other long-term care facilities. Some suggested, however, that it would not be appropriate to apply these guidelines to home care situations, where costs would be prohibitive. If considering expansion, input from stakeholders in the long-term care field should be requested, collected, and assimilated into the published document.
Formatting of the guidelines document
Some attendees remarked that the guidelines should be presented in a format that people would both want to use and find easy to use. Create an attractive, user-friendly document that gives people access to resources. Move beyond the limitations of a written document and include links to related information on the Internet, such as case studies, tools, and research. People have more access to guidelines and other information now -- via web pages -- than they did a dozen years ago. Providing links to examples of implementation success at various places can help people research the issues and make decisions for their own workplaces. However, other stakeholders remarked that many nursing homes do not have access to the Internet.
A number of stakeholders commented that the draft guidelines are somewhat disjointed -- a series of fact sheets. Rather than having fact sheets, insert something early in the document that ties it all together and makes it easier for employers and employees to understand. The programmatic approach is important, plus the use of clear examples to pull it all together. State what the guidelines are and why it is important to implement them. Give examples of how they have worked, and encourage people to choose whether these guidelines can work for them.
Some stakeholders suggested that, if the term "light duty" is used, it should be defined. Some workers would say that there is no such thing as "light duty" at a nursing home, and anyone who needs a light duty job should not be employed there.
A stakeholder suggested that web links to manufacturers can be a helpful resource related to lifting devices. The guidelines document should include a list of web links to manufacturers of all mechanical lifts.
Some attendees stated that employers may have limits on their ability to purchase equipment, because of constraints placed on providers by the government through Federal reimbursement programs. For non-profit providers, there are not usually enough financial resources resources for major capital improvements. Likewise, small nursing homes and long-term care facilities may not be able to reach the desired ratios of equipment to residents; therefore the guidelines need to be scalable to the nature and size of the facility. In light of the workforce shortage, employers want to take steps to protect their current workforce. However, they are often limited in how rapidly they can implement changes because of the cost.
Employer buy-in will be increased if the scalability issue is recognized -- acknowledging that some facilities can implement changes sooner than others. Most stakeholders said that the document should not be threatening, but should present a positive and inviting tone, as is appropriate for encouraging the use of a voluntary document.
Some stakeholders suggested that voluntary guidelines are the best approach, so hopefully the various stakeholders can work together to find common ground, to highlight the best practices, to find an attractive way to package the guidelines, and to make the guidelines both usable and adaptable by employers, and employees. These stakeholders said that the guidelines should be based on sound science, and there should be a way to encourage employers and employees to implement them, even without regulations.
Previous programs had successful employee involvement
Several attendees noted that, in other industries with existing ergonomic programs in place, employee involvement has been a key element of successfully addressing ergonomic issues.
Some stakeholders remarked that employee involvement in training, decisionmaking, and use of equipment should include the maintenance, laundry and dietary staff, as well as the staff that care for residents. Licensed health care professionals and other staff need to be involved in the assessment of ergonomic needs related to the moving of people. Trained employees are the best source for recommendations about the most appropriate ways to move people on a daily basis. Automation may be efficient but may not always be the best choice for residents, whose needs for assistance often change from one day to the next. Both management and employees need to have a broad understanding of ergonomic problems, including as well as work-related factors that are associated with development of MSDs.
Difficulties in getting employees to use resident lifting and repositioning equipment
Several attendees indicated that if employees are working along with management to make decisions related to using new equipment, they will feel more involved and take more personal ownership of the program. However, it is often difficult to get employees to use mechanical lifting devices in all recommended situations. For example, having just a few lifting devices is not sufficient in many large multi-floor facilities, because employees cannot always wait until the equipment is available. Instead, they are apt to perform the task manually, which may result in injuries. Sometimes there are lifts available in the building, but if the lifts do not fit under the beds, employees will not use them. Also, if it takes too long to get the lifts into position for use, staff may not use them routinely.
Positive results for both residents and workers
Several attendees pointed out that some facilities have had notable success with getting employee involvement in the use of equipment. They maintain that full use of equipment for lifting residents can both create a safe working environment and provide a higher quality of care. For example, modern electric beds can move from low to high position within 20 seconds, which is fast enough for staff to wait for the bed to lift the resident.
Some stakeholders stated that creative use of equipment may help residents improve their own lifting and moving capacity. Some residents have progressed from a non-ambulatory to ambulatory status as a result of using ambulating lifts. Staff enjoy using the equipment and report fewer injuries and greater job satisfaction, thus resulting in fewer workers compensation claims, fewer sick days, and lower job turnover rates. A stakeholder familiar with a nursing home with a no-lift policy reported a turnover below 10 percent and worker compensation costs under $4,000 per year.
Some stakeholders noted that it is safer for the resident when workers use mechanical lifts rather than depending on manual lifting. Education is needed for workers, residents, and families to understand these issues. Mechanical lifts may seem impersonal to family members, but they are safer.
Strategies for gaining effective employee involvement
A number of attendees stated that some methods have proven effective in getting employees to understand and comply with ergonomic procedures, such as participation on heath and safety committees, facility inspections, and continuing education programs.
A stakeholder expressed concern about the requirements of the National Labor Relations Act (NLRA) as they relate to the use of safety committees.
Some stakeholders remarked that nursing assistants who are new on the job do not always use equipment because they do not know where it is kept. Training for new employees should include telling them where to find needed equipment as well as how to use it.
Ratio of available lifts
Some attendees noted that some homes want CNAs to use the new lifting devices, but cannot get them to do it because there are not enough devices available when the need arises. When short staffed, people do not have the time to wait for availability of a mechanical lift. Likewise, if proper use of the equipment requires two people and only one is there, staff will return to manual lifting. For effective use of mechanical lifts, an adequate number of lifts and available staff is required.
Several attendees suggested that guidance is needed to help a facility determine the optimum ratio of lifts per resident. Successful nursing homes have developed appropriate ratios for specific equipment per the number of residents needing a certain kind of assistance. The Beverly Settlement Agreement also provides a useful model.
Several stakeholders pointed out that when employers force workers to use equipment by imposing punitive measures, workers will be less likely to report injuries caused by not using the devices.
A number of attendees remarked that buy-in from employees is essential. Some employees are resistant to learning to use equipment and will make excuses for not using. However, once they learn to use the equipment properly and have adequate access to it, workers often become strong advocates of mechanical lifts.
Reluctance to report injuries
Some stakeholders said the fear of discrimination against those who report injuries may be an issue in some workplaces. If workers are afraid to report problems because they think that they may be replaced, they may quietly continue working until they develop more serious MSD problems.
Importance of early identification
Several attendees argued that early identification of ergonomic problems is critical. It is important to include reporting, treatment, and removal of the employee from the high-risk activity when MSD problems arise. Some attendees said that it is often difficult to determine if an injury is work-related for workers' compensation purposes. Therefore, workers must often keep working while a case is being determined, thus exacerbating the injury. If the OSHA guidelines increase the number of MSD reports, it may create further problems.
Musculoskeletal Disorders (MSDs)
Lifting causes injuries
Some attendees stated that lifting as a cause of back injury is well documented. Back injuries and other repetitive motion injuries are major contributors to workers' compensation claims in nursing homes. It is not appropriate to blame employees' personal activities for injuries that are clearly related to work activities.
Equipment unable to solve all problems
Some stakeholders remarked that the use of mechanical lifting equipment does not solve all ergonomic problems. Equipment should be used to help with non-routine situations, not the routine ones. Body mechanics are still important.
3. WORKSITE ANALYSIS
Guidance needed by employers
Some stakeholders suggested that the draft guidelines are not sufficiently detailed to help employers perform effective worksite analysis. They recommended detailed step-by-step guidance. Types of guidance needed include how to use available data such as OSHA logs, how to use worker surveys to help analyze risks, and how to assess the architectural layout of nursing homes.
Definition of ergonomics
Several attendees suggested that the guidelines be expanded to better explain the needs of nursing homes and to better define ergonomics. Accurate record keeping is important, and a non-discriminatory approach is needed. For example, a recent analysis at one large company showed that the management rated only 1 percent of worker injuries as MSDs, while the union rated 22 percent of worker injuries as MSDs. This type of discrepancy shows the need for a consistent approach to ergonomics issues.
Tasks other than resident lifting and repositioning
Some stakeholders stated that the guidelines should address laundry, housekeeping, dietary and maintenance staff. Others stated a preference for focusing on only resident lifting and repositioning for now, until the scientific evidence on other tasks is stronger.
Some stakeholders said that if the document is titled "guidelines for nursing homes," it must be a guideline for the entire home. If only resident lifting and repositioning are addressed, other important parts of the home where employees encounter MSD issues would be left out, including rehabilitation, housekeeping, maintenance, and other departments.
It was suggested that the assessment tool from the Beverly Settlement or other existing assessment tools be used for worksite analysis.
Another suggestion was to replace the VA system with the Center for Medicare and Medicaid Services system (CMS), which is used in nursing homes that receive medicare payments. Whatever system is used needs to be consistent with the CMS. The system used must enable staff to make daily decisions based on individual need.
Some attendees suggested the Agency create tools that will assist in the evaluation of a facility. There was some interest in defining specifically what is meant by "heavy" lifting at a nursing home, providing more information on obese residents, and having a table in the document to provide a guide for lifting. Others preferred that the document avoid specifying limitations on lifting, as this will vary from person to person. They said it is better to show staff how to assess an individual lifting job rather than to devise safe lifting guidelines to cover all situations.
A number of stakeholders stated that checklists are helpful to give general directions to staff, but a checklist still requires training for effective use.
Employee involvement in worksite analysis
Some attendees suggested that occupational therapists need to be involved in the analysis process, but physicians may not need to be directly involved.
Another suggestion was that, when doing surveys and analysis, workers on night shifts, evening shifts and weekends, as well as those who must work mandatory overtime should be included. It is important to follow-up on analysis conducted. Otherwise, employees can feel left out of the process. Use surveys to keep workers involved in the process.
Some stakeholders suggested that worksite analysis must account for the various classes of employers involved. The differences between a skilled nursing facility and a rest home or assisted care living facility must be considered. Smaller facilities may not have the same level of refined job or role descriptions, as that found in larger facilities.
4. CONTROL METHODS
Some stakeholders recommended that another specific control guideline could be added relating to the issue of "low beds" or "beds on the floor." This is a relatively new problem created by the removal of side rails on beds and the resulting lowering of bed height to protect residents from fall injuries. These low beds can be hard for workers to reach. Unless electric beds are used to enable workers to raise the bed to a comfortable working level when they are attending to the resident, back injuries may increase.
Another stakeholder suggested that the guideline call attention to the importance of preventive maintenance on equipment wheels and other parts. For example, a resident may fall and sustain injury when a wheelchair wheel breaks, and a worker may likewise be injured when trying to catch the resident and prevent the fall.
Another recommendation made by a stakeholder was to encourage the inclusion of new lifting equipment, such as ceiling lifts and electric beds, whenever new facilities are constructed.
Some stakeholders suggested that employers should pay attention to administrative controls, such as staff work load and staff hours, which also have an effect on work-related injuries.
Several attendees remarked that personal protective equipment is generally not considered effective for preventing MSDs. For example, NIOSH does not advise the use of back support belts. There should be a clear statement in the guidelines that back belts are not advised.
Peak lifting times
Some stakeholders suggested that workplace analysis and controls need to identify peak lifting times of the day so staffing levels are appropriate. Lift manufacturing are also interested in workplace analysis and controls, as they need to determine what the lifting requirements of staff are and whether the time of day makes a difference in those needs.
Other concerns for analysis and controls
Other issues that were identified by stakeholders include level floors, storage, equipment maintenance, time and motion, space, and maneuverability. If staff do not use the equipment, the reason needs to be determined. Staff should also be asked for information on accidents that almost happened but did not, in order to identify problem areas.
Factors influencing equipment ratios
Several attendees pointed out that there are other issues that influence the use of equipment in addition to equipment ratios. Each situation should be considered separately. For example, if all slings are in the laundry, the lift cannot be used. The purchase of additional slings, in this case, could lead to better use of lifts.
Value of worker evaluation of equipment
A number of attendees noted that getting genuine worker input related to the usability of a piece of equipment is important. The workers' evaluation should be considered before an item is purchased.
Some stakeholders suggested that there needs to be an emphasis on management involvement in the control process - both clinical management and administration management. The input of clinical staff is vital to control process decisions such as communication between shifts and training new CNAs.
Use of inexpensive equipment
It was observed by a stakeholder that few of the illustrations in the draft guidelines addressed less expensive lifting devices, such as slip-sheets.
It was noted by a stakeholder that some important information is missing in the illustration for control method #18, which refers to the use of a pivot disk. Common practice rarely uses a pivot disk when a resident cannot reach a standing position alone. Figure 18 describes the disk's use for pivoting, but not for standing. The flow chart in the CMS system gives a more useful description.
5. OTHER COMMENTS AND SUGGESTIONS
Retention of workforce
An attendee said the aging of the workforce is a critical issue. With the average age of nurses at 47, the industry must address the reality of the physical limitations of employees. Improving ergonomics can have a marked impact on both the retention and recruitment of workers. Some attendees felt that scientific evidence of the relation of ergonomics to worker injuries is of little consequence to the issue of worker retention. Others felt that ergonomics is clearly important for the retention of workers.
Some attendees noted that reliable vendors provide customized services. Some believed that, although vendors can often be truly helpful, it is wise to remember that not all vendors will give the same level of service to all providers. The larger providers are apt to receive the most attention.
Some stakeholders suggested OSHA balance the guidelines against the maintenance of confidentiality. It was observed that most personal care services are provided behind closed doors for the purpose of resident privacy, so it is harder to measure compliance in this context. Another participant responded that 0 percent of care is given behind closed doors.
A number of stakeholders remarked that ergonomics is a piece of a broader process. Neither buying the equipment nor having guidelines for mechanical lifting will solve all the problems. For example, residents must be turned every two hours, and it is not always practical to use a lifting device this often with all residents. In addition, training provided by co-workers will tend to prolong current practices and make it harder to implement new practices.
Some attendees indicated that the use of mechanical lifting equipment is not universally accepted as appropriate. Many nursing home professionals believe that a manual lift by two people is appropriate. Research that supports the case for mechanical lifting has not all been published or disseminated throughout the industry.
Resistance to implementation
Several stakeholders observed that, although administrators can always find excuses not to implement, those who have done so have learned that residents as well as workers want to see something happen to minimize injuries to workers. Oftentimes, there is money available to invest in lifting equipment, but people are resistant to using it. Hopefully, the OSHA guidelines will call attention to the problems and encourage action by administrators.
Some stakeholders argued that the proposed guidelines do have legal consequences. Saying that these guidelines are voluntary does not necessarily mean that they are not required. There could be legal complications if someone is not practicing a recognized best practice or guideline when an injury occurs. Efforts to secure scientific support to support the guidelines should be continued. The document should make a stronger disclaimer and try to avoid broad statements until science can provide the needed support.
A group of stakeholders suggested the disclaimer should be expanded to include a clear statement that adherence to the guidelines may reduce injuries and may improve services. This statement should be followed by an encouragement to try the guidelines to determine whether they do improve the comfort of employees, reduce injuries, and improve services to residents. Reference to "inadequate science" should not be included.