Reducing the impact of nursing assistant back injuries in the nursing home The following article was written by Barbara Anderson, R.N., who works in infection control and quality assurance at St. Joseph‘s Medical Center, Brainerd, MN, and Cherlyn Morrison, R.N., patient care administrator, Cuyuna Range Nurs- ing Home, Crosby, MN. The authors wish to acknowledge the assistance of John Schaubach, Paul Prefontaine, Mary Lowe, and Becky Guida of Cuyuna Range District Hospital t9 Home in developing and implementing this program.

Staffing shortages, changes in reim- bursement systems, and ever-evolving government regulations have heavily affected the long-term care industry. Added to this scenario is the always- present problem of employee back injury. The literature leaves no doubt that nursing staff at all levels and in most settings have a high back injury ratio compared with other occupa- tions. Further analysis indicates that, in the health care system, nursing home nursing assistants have the greatest incidence of disabling back problems (ref. 1). Our facility (Cuyuna Range Nursing Home, Crosby, MN) was not unique in this respect. Management-staff consensus, often so elusive, exists on this point.

Back symptoms related to lifting and turning residents are common. Our nursing assistants routinely spend seven hours of their eight-hour shift on their feet. They are expected to lift up to 100 pounds, often in less than ideal environments, always with less than predictable loads. Researchers suggest that factors such as age, family history, loss of flexi- bility, lack of training related to body mechanics, and inadequate staffing patterns may also contribute to this industrywide problem (ref. 2) .

Nursing staff in our 130-bed rural public nursing home were all affected in some way. Caring for a debilitated, primarily geriatric popu- lation takes its toll. For the injured worker, the impact is direct and painful. For co-workers, the impact, although less direct, is real - already strained staffing pools are stressed further, resulting in lowered morale.

At the management level, high workers’ compensation premiums are an additional threat to an already precariously balanced budget. There is also concern that, left to escalate, the staff back injury problem could result in an altered community per- ception of our ability to provide high-quality resident care.

In mid-1986, the position of employee health coordinator was developed at Cuyuna Range to facili- tate a more comprehensive and aggressive approach to employee health concerns. Although there had been attempts to address the back injury issue previously, no one had been assigned that specific aspect of the organization’s risk management activity. The position description was written for a registered nurse with expertise in occupational health. To gain maximum benefit from this investment in an additional staff member, the employee health coordi- nator, working three days per week, was also designated infection control nurse for the nursing home and attached 42-bed hospital.

With the employee health coordi- nator on board, the safety committee began working on identifying the problem. Review of our workers’ compensation data, as well as discus- sion with staff, managers, physicians, and chiropractors, quickly revealed the following multifaceted dilemma:

H Excess resident care incidents, result- ing in nursing assistant back symptoms H Inconsistent return-to-work plans H Limited opportunity for meaning- ful input from physicians and chiro- practors

We decided to address the three aspects of the problem indepen- dently. In several cases, however, a response to one issue had a positive effect on another.

Reducing the incidence of back injuries

The response to this aspect of the problem came from several sources. In an attempt to reduce risk through preplacement screening, a physical demand analysis for the nursing

assistant position was developed (fig. 1). It is shared with applicants early in the first interview to facili- tate self-selection during the hiring process when applicable. A limited applicant pool and the legal mandate to do more complete health screen- ing preplacement versus prehiring made that approach alone insuffi- cient, however.

Monthly assessment tours by members of the safety committee and occasional assessment by risk management consultants were instituted to focus on identifymg ergonomic and environmental risks. Placing the employee health coordi- nator and a physical therapist on the safety committee also provided useful and complimentary perspectives.

The main thrust of our effort was the back injury prevention program. The program has three components: education, back support vests, and preshift warm-up regimen.

Education

The education component includes a comprehensive orientation session, facilitated by a registered physical therapist, focusing on appropriate body mechanics. It is mandatory for all new employees and demands sig- nificant employee participation and demonstration. In addition, there is at least one annual session for cur- rent nursing staff.

In this session, the patient care administrator and the employee health coordinator assist the physical therapist. Again, attendance is man- datory and participant involvement is encouraged. The physical therapist also provides back care classes for employees who experience work- related back symptoms to prevent reinjury.

Back support vests

Back support vests must be worn by all nursing assistants at all times. The vest is considered part of the uniform and employees cannot start their shift without one. Although there is some debate among experts about the actual physiological benefit of the

20 Perspectives in Healthcare Risk Management Fall 1989

vests, there is less debate about their ability to serve as a concrete reminder to use proper body mechanics.

The vests were pretested on a sam- ple of our at-risk population with favorable results. A follow-up survey found that 87 percent of our staff “always or often” used the fastened vest to lift. In the first two years of use, no nursing assistant came pre- pared to work without a vest.

Preshift warm-up

The preshift warm-up phase of the prevention program was the most challenging to implement. Nursing assistants balked at the idea of licensed staff supervising the stretch- ing sessions. In an effort to foster cooperation from within the ranks, the nursing assistants were given a copy of the suggested regimen and asked to participate in a demonstra- tion session.

health coordinator also provided the staff with a rationale for the warm- up from an anatomical and physio- logical perspective. At that point, the nursing assistants were “on their honor” to complete the regimen prior to each shift. A two-year follow-up survey revealed that only 35 percent of the nursing assistants “always or often” did the five-minute routine; however, 56 percent believed the regimen was a helpful way to reduce the risk of back injury. Sixty- three percent agreed that participa- tion in an off-duty program to pro- mote strength, flexibility, and general health would reduce their back injury risk at work. This aspect of the program is being reviewed.

All nursing staff are included in the various training sessions. This enhances the registered and licensed practical nurses’ ability to serve as resources in the absence of the employee health coordinator, physical therapist, or patient care administrator.

Improving return-to-work plans

The physical therapist and employee

Despite our best efforts, we have been unable to eliminate incidents resulting in nursing assistant back

injuries. However, our workers’ com- pensation rates have stabilized and we partially attribute that to our paying closer attention to the return- to-work plan. A uniform procedure was developed whereby all incidents resulting in back symptoms are immediately reported to the employee health coordinator. She follows up by promptly contacting the injured worker and the involved health care provider. The goal for these contacts is to initiate a supportive and active role for the organization in the employee’s recovery. The employee health coordinator also reviews the incident report to ensure a thorough and complete postincident investiga- tion and follow-up plan.

The aim for every injured worker is return to work, in some capacity, as soon as possible. That expectation is communicated to all employees during the orientation session, at other related in-service programs, and during the first contact with the injured employee postincident. The employee health coordinator makes sure the physician or chiropractor has a “return to work” form when seeing the injured employee (fig. 2). The form is to be completed regard- less of the worker’s status. It is up to the employer to determine what restrictions can be accommodated. The health care provider is not left with only two choices-that is, return to work or not return to work. He or she merely indicates the restric- tions that exist. In cases where the provider is unfamiliar with the nurs- ing assistant’s role, a physical demand analysis is attached to the form.

As soon as the nursing assistant has restrictions that can be accom- modated, a modified job offer is made. In cases where the restrictions are minimal, the modified job may not differ significantly from routine, and replacement staff may not be necessary. In cases where the restric- tions are severe, an employee may be assigned to answering the telephone or delivering messages amid frequent rest periods. In those situations, it is necessary to replace staff. In some cases the employee uses three hours of modified job time to attend the

back care class provided in the physi- cal therapy department.

Close attention is paid to the “expected duration of restriction” noted by the provider on the “return to work” form. A follow-up physi- cian or chiropractor appointment is made prior to that date so that the employee will not remain in the modified job longer than necessary. In situations where the restrictions are unchanged over an extended period, consultation with another health care provider or new treat- ment approaches are encouraged.

The employee health coordinator accompanies the returning worker to the work area initially to share the new job description with the super- visor and respond to concerns of fel- low employees. Care is taken to not reveal confidential personal health information. The supervisor and the injured nursing assistant both receive a copy of the modified job description.

Injured employees are not rewarded for back problems. They are treated uniformly and with respect for the restrictions identified by the health care provider. It is not productive for the employer to judge the severity of the problem or to intimate that the symptoms do not exist, because once those battle lines are drawn, employees will expend energy to prove their disability rather than work to regain ability. Creating a “win-win” scenario in workers’ compensation cases is our goal.

Facilitating communication among provider, employee, and employer

Minnesota employees injured on the job can choose their own health care provider without significant employer input (ref. 3 ) . That situa- tion makes it imperative that there be a system to facilitate meaningful communication among provider, employee, and employer. Initial and intermittent contact with the employee health coordinator, as well as use of the “return to work” form, have substantially improved commu- nication among the three critical par- ties in any workers’ compensation

21 Perspectives in Healthcare Risk Management Fall 1989

Figure 1. Employee Health Service Physical Demand Analysis

Job Title Department/Unit Full time - Part time - Days ___ Evenings - Nights - Rotation

~

NOTE: In terms of an 8-hour workday, “Occasionally” equals 1% to 33%; “Frequently” 34% to 66%; “Continuously” 67% to 100%.

1.

2.

3.

4.

5.

6.

In a/an __ hour workday, employee must: (Circle full capacity for each activity) a. Sit No. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (hours) b. Stand No. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (hours) c. Walk No. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (hours)

Occasionally Employee’s job requires: Never Frequently Continuously a. b.

d. e. f. g. h.

C.

1.

Bend/Stoop ~

Squat Crawl Climb height - Reach above shoulder level Crouch Kneel Balance Push/Pull

Employee’s job requires he/she carry: a. Up to 10 lbs. b. 11-24 lbs. C. 25-34 lbs. d. 35-50 lbs. e. 51-74 lbs. f. 75-100 lbs.

Never Occasionally

Occasionally

Frequently Continuously

Continuously Employee’s job requires he /she lift: a. Up to 10 lbs. b. 11-24 lbs. C. 25-34 lbs. d. 35-50 lbs. e. 51-74 lbs. f. 75-100 lbs.

Employee’s job requires:

Never Frequently

Occasionally Frequently Continuously Never a. b.

d. e.

f.

C.

Verbal communication Written communication Hearing ordinary conversation Hearing high-pitched or low-pitched sounds Estimated max. number of noise decibels and list continuous time Seeing with near acuity -far acuity -accommodation -full field of vision -distinguishing colors -depth perception

Never Job requires coordination for repetitive action: a. in operating foot controls rt/lt/both b. in simple grasping rt/lt/both c. in firm grasping rt/lt/both d. in fine manipulating rt/lt/both

Occasionally Frequently Continuously

22 Perspectives in Healthcare Risk Management Fall 1989

Figure 1. Continued

7. Job requires environmental exposure to: a. Working on unprotected heights b. Being around moving machinery c. Exposure to marked changes in temperature

d. Driving automotive equipment e. Exposure to dust, fumes, odors, mists, toxic

gases, poor ventilation, antineoplastic agents, & adhesives

f. Working outside g. Exposure to water h. Exposure to biological, mechanical, electrical,

& chemical hazards (detergents, acids, alkalis, explosives, radiation, and heavy metals)

and humidity

Never Occasionally Frequently Continuously

Additional information on job:

Supervisorldepartment head signature Date I HAVE READ AND UNDERSTOOD THE ABOVE JOB ANALYSIS.

Date Employee signature Adapted with permission from a form provided by the Minnesota Dept. of Labor & Industry.

Figure 2. “Return to work” form

To: Employee Please Note: From: This form must be completed by your physician and returned

to the employer before you can return to employment.

Employee Name Position

has experienced health problems. In order to allow the employee to work, the Hospital & Home requires authorization indicating the employee is able to assume the duties of hidher position. Please complete the needed information below. A physical demand analysis has been done for the position. 0 See attached physical demand analysis.

Diagnosis: UNRESTRICTED 0 This employee is authorized to return to regular work without restrictions on:

RESTRICTED 0 This employee is unable to work without restriction. Effective

Date

the following Date May work ~ hours per day.

May work ~ days per week. May lift up to ~ pounds. May not (circle): Bend Stoop Kneel Push Pull Other

restrictions apply:

Expected duration of restriction: Additional comments:

Physician’s signature Date Adapted with permission from a form provided by St. Cloud Hospital, St. Cloud, MN.

23 Perspectives in Healthcare Risk Management Fall 1989

case. The providers who most fre- quently care for our injured nursing assistants are all aware of the organi- zation’s goal related to prompt follow-up and early return to work. Most appreciate using their expertise to diagnose and treat patients rather than serve as mediators in workers’ compensation struggles. Taking phy- sicians and chiropractors out of the return-to-work decision-making role and using their professional abilities to identify specific restrictions and abilities has had a positive impact on the employee-employer-provider relationship.

Summary

A risk-reduction program such as this needs to be evaluated over several years to accurately assess its lasting impact on workers’ compen- sation insurance premiums and injury incidence. Nearly three years into our efforts, however, we believe that early evidence makes a strong statement for its continuation here and potential application elsewhere.

Staff members report a new will- ingness to have their body mechanics skills evaluated by the physical ther- apist and licensed nursing staff. The elected governing board continues to financially support this risk-reduction program because of the stabilization of injury frequency and related expenses. There have been numerous positive comments from residents’ families and regulatory agencies related to the most visible aspects of the program - the vests and transfer belts worn by the nursing assistants. Administrators and staff believe the time and attention invested promotes an attitude of teamwork and further substantiates the organization’s com- mitment to employee safety and excellence in resident care.

In 1985, 145 days were lost and 141 days modified because of work-related back symptoms. In 1987, 26 days were lost and 61 modified. In 1986, our workers’ compensation insurer handled 11 new back injury cases; in 1988, we reported 4 new cases.

The workers’ compensation insur- ance premium is based on our

experience over three years. Evidence at this point suggests that, at a mini- mum, we can expect continued stabilization of these rates.

It will be important to watch the numbers over the next two or three years to further establish the impact of this risk management approach. We do believe that the addition of an occupational health position to the nursing home staff is appropriate and cost-effective. The nursing home nursing assistant back injury challenge must be met; creating the position of employee health coordi- nator may be one way to meet that challenge.

References

1. Jensen, R. C. Disabling back inju- ries among nursing personnel: Research needs and justification. Research in Nursing and Health.

2. Neuberger, J. S., and Hartley, S. S. Occupational safety and health issues affect registered nurses. Occupational Health and Safety. 1988 Sept. 57(10):25-27, 75-76. 3. Droste, T. States battle high cost of workers’ comp claims. Hospitals. 1989 June 20. 63(12):80.

Minnesota Department of Labor and Industry, Workers’ Compensa- tion Division. Staff interview, June 30, 1989, St. Paul. 4. St. Cloud Hospital, Employee Health Dept., St. Cloud, MN. 5. United Hospitals, Physical Ther- apy Dept., St. Paul, MN.

1987. NO. 10. Pgs. 29-38.

Additional resources

Bowen, L. Backs to Health remedies financial, worker strains. Provider. 1985 Jan. ll(1):36.

James, B. Accident prevention- Establish safety program. Dimen- sions in Health Service. 1983 May. 60( 5):21.

Levy, S. Occupational Health: Recog- nizing and Preventing Work-Related Diseases, 2nd ed. Boston: Little, Brown & Co., 1988.

Reif, L. Access to employee medical record. Occupational Health Nurs- ing. 1983. No. 5. Pgs. 38-40.

Rozovsky, L. E. and F. A. Employee health records: A two-edged sword. Canadian Journal of Public Health. 1982. Vol. 73. Pgs. 24-25.

Sautter, M. G. Employment in Min- nesota: A Guide to Employment Practices and Regulations. St. Paul: Maron Publishing Co., 1983.

Smith, S. M., Campbell, J. M., and Luksic, H. C. Secrets of success in long-term care. Nursing Manage- ment. 1989 July. 20(7):90-92.

24 Perspectives in Healthcare Risk Management Fall 1989