Nursing OnPoint

Snapshot: This article reviews some of the most common injuries nurses sustain in the workplace, how to avoid those injuries, and what to do in case you are injured.

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Injuries Overview Preventing Back Injuries: Basic Principles Safely Lifting & Transferring Patients Preventing Other Injuries
 

Injuries Overview

• Nurses practice in physically demanding environments. Unfortunately, nurses are at high risk for injury compared with other occupations.
  • The U.S. Bureau of Labor Statistics reports that nurses are about 2.5 times more likely overall to suffer injuries of all kinds than the ‘average’ worker. Healthcare workers as a whole are more likely to experience musculoskeletal injuries than workers in even the manufacturing or mining sectors.
• Musculoskeletal injuries are the most common. Back injuries, and in particular injuries to the lower back, are the most prevalent type of musculoskeletal injury that nurses sustain. Thankfully, such injuries are usually preventable (see “Safely Lifting & Transferring Patients”).
• Injuries don’t have to be “big” to matter. Small, repeated, injuries or strains – called cumulative injuries – can cause long-term damage too.
  • Examples of such injuries include continually reaching across beds to perform patient care, lifting loads that are too heavy (even if no individual lift is incapacitating), or even sitting and typing at a computer incorrectly over time while charting.
• The key to managing injuries is prevention. Most injuries are avoidable, and result from a combination of improper technique, poor staffing, or absent or inadequate equipment.
  • Some nurses also seem to operate under a misguided ‘tough it out’ mentality. This attitude not only undermines teamwork, but also fails to appreciate that a nurse who hasn’t first taken care of him or herself is a nurse who can’t take care of others.
• Nurses who are injured should not keep it to themselves. The right way to respond to an injury is to promptly report it to your manager or supervisor so that you can get the help that you need.
• Nurses are not alone in their risk for injury. Many studies show that other healthcare workers, especially nursing aides and attendants, are at equal or even greater risk for injury. Injury prevention must therefore be a focus for the entire healthcare team.

Preventing Back Injuries: Basic Principles

• Let your legs ‘do the work.’ To avoid back injuries, above all don’t bend your back when lifting. Instead, bend at the knees, using your legs for force. In other words, let your legs ‘do the work,’ not your back. Your goal should be to maintain your back in a neutral position that preserves its natural curvature.
• Work as a team, and don’t exceed your limits. Avoiding back injuries is all about working together, and getting help. No matter how well positioned you are, if you don’t have adequate support from others to safely lift a load, or transfer a patient, you will be at risk for injury. Don’t ‘be a hero’ and try to lift more than you are able. Be honest about your strength, for your own safety and for the sake of your patients. When you are working as a team, communicate effectively; count down and coordinate your lifts.
• Get help from the patient. While it may not always be physically or medically possible for a patient to assist you with a lift or transfer, if it is then ask the patient to do so. This will help lessen the ‘dead weight’ of a total assist, and is safer for both you (or for you and your team), and the patient. It also helps a patient to gradually build strength, which can improve outcomes and shorten recovery times.
• Adjust bed height and bed rails. When caring for a patient, you should ensure the bed is high enough to prevent you from leaning over too far, and unnecessarily straining your back. The bed should be at about hip level, and bed rails should be down so that you don’t strain your shoulders reaching over the patient.
• Don’t try to stop a fall. If a patient falls, don’t try to stop the fall, or to lift them unassisted off the floor after a fall. Instead, try to guide or lower the patient to the floor while maintaining proper posture yourself (e.g. back not bent). Under no circumstances should you attempt to abruptly stop the fall; doing so could easily lead you to injure yourself, and by breaking the fall to quickly, could also injure the patient.
• Stay fit, take breaks, and manage stress. It’s common sense, but easily forgotten. Those who don’t stay in good physical shape, take periodic breaks, and learn to handle stress are much more likely to be injured. Being worn down, physically and mentally, especially when working in a fast-paced clinical environment, is a recipe for injuring yourself – and potentially your patients too.

Safely Lifting & Transferring Patients

• Assess first. Before you begin a lift or transfer, ask yourself: How heavy is the patient? What is their strength/capacity to assist you? How much help from other nurses or other staff will you require?
  • You should also consider whether all obstructions – e.g. on the floor, or on the bed or chair – have been cleared out of the way in advance of the move. Ask yourself: Is there any medical equipment or anything else in the room that could impede you, or that could cause you or the patient to trip or fall? If so, move it out of the way.
• Use the right equipment. Whenever possible use equipment or lift devices to eliminate manual work that may place you at risk for injury.
  • Always use mechanical lift equipment, such as a Hoyer Lift, which is designed to support the entire weight of an individual, for all total body transfers.
    • Note: Morbidly obese patients (e.g. those weighing in excess of 400 lbs or 500 lbs) may require special lift equipment, depending upon the design and capacity of the equipment
  • When transferring patients, use transfer boards or sliding equipment, and always get help from someone else.
    • To reduce friction and drag, low tech solutions can be effective. For example, you can place large plastic trashcan liners under a draw sheet during lateral transfers. Some hospitals and other facilities have similar sheets made out of smooth plastic or “parachute” material that makes sliding similarly easy.
  • When moving a patient into or out of a bed or chair, use a stand-assist lift to help ease the burden. Stand-assist lifts are for moving patients to and from beds, chairs, toilets, or into and out of the shower.
    • To use this equipment properly, the patient must have some upper-body strength. If a patient lacks upper-body strength, consider using total body lift equipment, such as a Hoyer Lift.
  • Note: Lift equipment may be expensive (often many thousands of dollars) but injuries to nurses are usually more expensive still, both in terms of lost work and productivity, and associated healthcare and rehabilitation costs. Costs for rehabilitation post-injury often exceed $20,000 per incident.


• Use proper body mechanics when lifting or moving patients. Letting “your legs do the work” should be your foundation; here are some other important techniques:
  • Use a wide, balanced stance with one foot slightly ahead of the other, and always face the patient. Then, lower the bed or chair so the patient can place his or her feet on the floor.
  • Position the patient closer to the edge of the bed or chair and ask him or her to lean forward as they stand (if they are able, and if medically appropriate) while keeping the patient close to your body.
    • Note: If your patient has a weak side or weak leg, you can block it with your legs or knees. An alternative is to use a transfer belt with handles and straddle your legs around the weak side or weak leg of the patient.
  • Pivot your entire body so that it is in the same direction as the move, and use smooth, fluid movements as much as possible. Never twist when turning or lifting.
    • If the patient is getting into a wheelchair, place it on the patient’s strong side (e.g. for CVA or hemiparalysis patients) so that he or she can assist with the transfer as much as possible
    • Note: If the patient isn’t able to ambulate well, and simply needs to use the bathroom, consider placing the bedside commode to the side of the bed so that he or she can get out of bed, and with assistance (if the patient is physically able), pivot onto the commode.


• Use proper techniques for slides and lateral transfers. These transfers usually require less brute strength compared with lifts, but can nonetheless place you at serious risk for injury. Here are some tips:
  • Always work with others for a slides and lateral transfers.
    • While it is possible to safely lift a patient using the right equipment on your own, this is usually not possible for slides and lateral transfers, which require that at least one person stand on either side of the patient.
  • When moving a patient in bed, if need be kneel on the patient’s bed to avoid bending your lower back, or straining by reaching across the patient.
    • Reaching may not place as much weight on your back, but can lead to sprains and muscle tears.
  • If you are moving a patient up in bed, always lower the head of the bed first. This will greatly reduce the physical work that you and your partner must do.
    • Note: When using a drawsheet, roll up the edges of the sheet, and ask the patient to ‘give yourself a hug’ (i.e. draw in the arms) before raising them in bed (as patients often slide down in bed). Roll up the edges to provide an adequate grip, and as always, work with your partner by communicating well and counting well to coordinate the move.

Preventing Other Injuries

• Needle-stick injuries. To avoid needle-stick injuries, above all remember and respect the risks you’re assuming, and the equipment you’re using. (Just because you use needles on a regular basis as a nurse doesn’t give you license to be casual about them).
  • Before you begin, make sure you’re wearing gloves, and prepare your patient for what you’re about to do.
    • A patient who is surprised or unprepared for a needle can move or fidget, leading to injuries for them or for you.
  • When you’re finished with a needle, never manually recap it, as doing so is difficult to coordinate and could lead you to stick yourself.
    • Instead, using the same hand that you used to manipulate the needle, engage the needle’s automated safety/closure device, if it has one. Always dispose of all used needles in designated sharps containers.
  
  
  
  • The chance of transmission of blood borne disease from a needlestick injury varies depending upon the type of injury, the condition of the patient, and the type of pathogen.
    • Injuries in involving hollow-bore needles with deep penetration and visible blood on the needle are the most likely to transmit blood-borne pathogens. Terminally ill or immune-compromised patients are also more likely to transmit pathogens.
    • Statistically, Hepatitis B poses the greatest risk, with approximately 35 to 60% of exposed individuals eventually showing seroconverson, and about 20 to 30% showing clinical Hepatitis B infection.
    • If you haven’t been immunized for Hepatitis B, you should strongly consider it.
    • Non-immunized nurses who may have been exposed to Hepatitis B can receive the Hepatitis B immune globulin, or HBIG, for post-exposure prophylaxis. HBIG should be given within 14 days of exposure to Hepatitis B.
  • Hepatitis C, and to a lesser extent HIV transmission, are also of concern.
    • The chance of Hepatitis C transmission varies from about 0.5% to 1.5%, and the overall risk of HIV transmission is about 0.3%.
    • There is no immunization or post-exposure prophylaxis available for Hepatitis C, although early detection of Hepatitis C can make long-term treatment and management easier.
    • There is no immunization for HIV. However, post-exposure prophylaxis (PEP) can be done in the case of HIV exposure, ideally within 2 hours of coming into contact with potentially contaminated blood. After approximately 72 hours, research demonstrates that PEP is unlikely to be effective.
  
  
  
  • Repetitive strain injuries. Repetitive strain injuries result from small, repeated physical actions that are repeated in anatomically incorrect or uncomfortable ways. Nurses are especially at risk for these injuries when charting and typing. To avoid repetitive strain injuries when doing this work, follow a few simple but powerful rules:
    • Sit in a chair that supports your lumbar spine (lower back).
    • When sitting and writing or typing, keep your shoulders relaxed, and your feet flat on the floor and facing forward.
    • Your hips should be under your shoulders; if not, you are sitting too far back in your chair, or too close to the edge of your chair.
    • Keep your arms close to your sides, with your elbows bent at about 90 degrees. Your forearms should be parallel to the floor.
    • Keep your computer screen at eye, and approximately 18 – 24 inches from your face.