Last year I was invited by AORN to give a talk on nursing-related back injuries. I asked the audience of OR nurses how many of them had had a back injury on the job or knew a co-worker who had. More than 90 percent of the hands - in a standing-room-only ballroom seating 400 - went up.

Not a surprise when you consider the stress and duress of OR life. Static standing, neck flexion and trunk flexion. Holding patients' heavy distal extremities. Patient transferring and repositioning. Moving equipment. Manual holding of tools, equipment, heavy trays. Wearing heavy lead aprons. Crawling on the floor to get to the other side of the table.

But what is surprising, I've found, are the many myths surrounding how and why back injuries occur. Let's shatter a few.

Myth 1: Nurses get hurt because they lift improperly.
Nurses get hurt because the loads they lift exceed physical capacity. Decades of biomechanic research has identified thresholds of low-back compression associated with occupational injury. With the help of biomechanical modeling, scientists can predict the forces caused by lifting tasks.

The National Institute of Occupational Safety and Health has a well-respected and widely referenced lifting guideline based on biomechanic, metabolic and epidemiologic research. One way scientists have measured lifting capacity is the compressive force on a low back joint (L5/S1). Their research concludes that, for 90 percent of working adults (that's 95 percent of men, 75 percent of women), 6,400 Newtons of force on L5/S1 is the maximum acceptable limit; 3,400 Newtons on L5/S1 is the action limit at which jobs should be modified to help prevent the symptoms and injuries that present above that level.1

I looked at 10 studies published in peer-reviewed journals between 1986 and 2001 that examined the compressive force on L5/S1 during common patient handling tasks. Each reported everyday patient handling tasks that exceeded the NIOSH action limit; six reported common tasks that exceeded the maximum acceptable weight limit.2 In short: Patient lifting and repositioning tasks are dangerous. Intense and severe lifting used to be common in heavy manufacturing jobs, but has since been mostly engineered out of many industries - except healthcare.

There are two types of patient handling tasks in healthcare facilities: Those that can be performed by working humans, using proper technique, and those that should not be performed by humans without lifting equipment because the task exceeds human physiologic limitations. See "Spine Compression as a Function of Transfer Technique" and "Spine Compression as a Function of Transfer Task" for striking results from one study.

Myth 2: Education programs on lifting techniques and body mechanics are proven to prevent back injuries in healthcare.
A review of intervention strategies disputes that. A systematic appraisal of 880 papers from 1960 to 2001 found "strong evidence that interventions predominantly based on technique training have no impact on working practices or injury rates."3 Body mechanics training programs were borrowed from industry and brought into healthcare decades ago. They don't apply to living, fragile, complex patients the way they might apply to inanimate loads. Further, experts can't even agree on the proper mechanics for lifting compact and transportable boxes.

These training programs send the wrong message: You got hurt because you didn't do things right. In fact, the patient handling task is inherently dangerous and beyond the physical capacities of the majority of people. Lift and transfer techniques have a place in healthcare for tasks that are safe to perform, but not elsewhere.

Myth 3: Equipment isn't needed when a second set of hands is available.
Even with two people, common lifting and repositioning tasks can exceed safe lifting thresholds (see "Two Better Than One?"). Several of the aforementioned studies looked at two-person lifts, a surprising number of which left both employees with compressive forces far above safe limits. Sometimes with two employees, the center of gravity is farther out, causing even more awkward postures. Therefore, the resultant forces and torque on joints are greater. There were fewer exposures than when one person performed the same task alone, but not few enough to indicate the movements are safe. Getting help does not solve the problem.

Myth 4: Lifting devices eliminate the risks associated with manual lifting.
While lifting devices significantly reduce ergonomic stress on the back, there's still plenty of repositioning, leaning and bending involved in getting a sling on a patient, for example. But these activities are in the safe range, according to recent biomechanical research, so most workers can perform them without putting themselves at high risk of serious injury.4

Myth 5: Lifting devices' benefits are unproven and too expensive to consider.
Actually, there's plenty of evidence to the contrary:

• Glens Falls Hospital in upstate New York invested $350,000 in equipment when it implemented a minimal-lift program. The results were staggering. Over one year, the hospital had a 28 percent reduction in workers' compensation claims, 24 percent reduction in the cost per claim, 45 percent decrease in related comp costs and direct savings of $125,000. Further, the number of OSHA-recordable patient handling injuries was halved (43 in 2001; 23 in 2003).5
• One five-year prospective study looked at five types of equipment introduced as part of an ergonomics program. Before the equipment, the hospital had 20 injuries in 18 months. After? Twenty-six injuries in 60 months.6
• A Kaiser Permanente facility in Oregon bought 14 portable mechanical lifts, conducted usage training and instituted a policy that banned patient lifting or lowering without mechanical support. Injury rates were cut by 29 percent in two years.7
• A British Columbia hospital's extended care unit installed 65 ceiling lifts and initiated a no-manual-lift policy that included equipment training. Three years later, there was a 58 percent reduction in musculoskeletal disorders caused by patient transferd as compared to rates three years pre-intervention.8

When calculating the costs of back injuries, consider all the direct and indirect costs as well: lost work time, overtime, skilled replacement labor, retaining nurses, overwork on surviving employees, lowered morale and so forth. Patient safety and working conditions have been linked by many researchers.

Myth 6: If you buy lifting equipment, staff will simply use it.
Buying equipment is not a guarantee it will be used, at least not right away. Not all equipment is intuitive, but all equipment requires training, reinforcement, regular maintenance, patient assessment and ongoing evaluation as part of a comprehensive ergonomics program.9 Healthcare workers in general - and nurses, specifically - are oriented toward focusing on patient needs first and foremost, and certainly always before their own needs.

Implementing programs that require new equipment and practices will demand a culture change. As a result, surgical units must consider training, assistance and reinforcement as healthcare workers gain the confidence needed to use the equipment. A comprehensive ergonomics program is required to follow through on the tower of evidence that supports a new approach to patient lifting.

Myth 7: There isn't enough scientific evidence to do things differently.
The evidence is pouring out of the doors of the academy and landing like hailstones on the roofs of facilities. There is simply a huge gap between scientific evidence and practice. There are no laws, standards or regulations to mandate the precise amount of lifting that is safe to perform. Yes, ladies and gentlemen: One of the most egregious and expensive hazards in the healthcare industry is largely unregulated. OSHA has cited some hospitals and nursing homes for extremely high lifting-related injury rates under the "general duty" clause. But such citations are uncommon. Nonetheless, many hospitals have made positive changes and are enjoying the results. Yours can, too.

Changing our approach
In a recent American Nurses Association survey, nurses reported their top three concerns as stress and overwork, disabling back injuries and contracting HIV/HBV from a needlestick. Less than 20 percent of nurses say they feel safe on the job.10

Genuine prevention efforts must be evidence-based, comprehensive and holistic. The risk factors for injury are not just biomechanical; the increasing psychological stress of healthcare work is also associated with mental and physical health problems. Nursing will always require physical activity; the goal is eliminating tasks that are beyond human ability and freeing up nurses to do what they do best: provide skilled services and care for patients. Some solutions:

• forming a comprehensive ergonomics program that includes written policies, equipment interventions, medical management and training to reduce employee suffering and facility costs;
• bringing together employees who are affected at all levels in the facility to incorporate their experience, ideas and insight into how to make a program work for your facility's needs; and
• using engineering controls, such as specialized lifting and transfer equipment, that can reduce or eliminate peak exposures.

Increase employee satisfaction? Save thousands on workers' compensation costs? Retain more nurses? Support patient safety initiatives? Take the back-breaking work out of healthcare? Sounds like just what the doctor ordered.