guidelines for nursing homes: ergonomics for the prevention of musculoskeletal disorders

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  • GuidelinesforNursingHomesOSHA 3182-3R 2009

    Ergonomicsfor the Prevention ofMusculoskeletal Disorders

  • Guidelines for Nursing HomesErgonomics for the Preventionof Musculoskeletal Disorders

    U.S. Department of LaborElaine L. Chao, Secretary

    Occupational Safety and Health AdministrationJohn L. Henshaw, Assistant Secretary

    OSHA 3182-3R 2009

    Guidelines for Nursing Homes 1

  • 2 Guidelines for Nursing Homes

  • Table of Contents

    5 Executive Summary

    7 SECTION I:Introduction

    9 SECTION II:A Process for Protecting Workers

    9 Provide Management Support9 Involve Employees

    10 Identify Problems10 Implement Solutions10 Address Reports of Injuries11 Provide Training11 Evaluate Ergonomics Efforts12 SECTION III:

    Identifying Problems and Implementing Solutions for Resident

    Lifting and Repositioning

    12 Identifying Problems for Resident Lifting and Repositioningn Figure 1. Transfer to and from: Bed to Chair, Chair to Toilet,

    Chair to Chair, or Car to Chair

    n Figure 2. Lateral Transfer to and from: Bed to Stretcher, Trolley

    n Figure 3. Transfer to and from: Chair to Stretcher

    n Figure 4. Reposition in Bed: Side-to-Side, Up in Bed

    n Figure 5. Reposition in Chair: Wheelchair and Dependency Chair

    n Figure 6. Transfer a Patient Up From the Floor

    17 Implementing Solutions for Resident Lifting and Repositioningn Transfer from Sitting to Standing Position

    n Resident Lifting

    n Repositioning in Chair

    n Ambulation

    n Lateral Transfer; Repositioning

    n Lateral Transfer in Sitting Position

    n Transfer from Sitting to Standing Position

    n Weighing

    n Transfer from Sitting to Standing Position; Ambulation

    n Repositioning

    n Bathtub, Shower, and Toileting Activities

    Guidelines for Nursing Homes 3

  • 27 SECTION IV:Identifying Problems and Implementing Solutions for

    Activities Other than Resident Lifting and Repositioning

    n Storage and Transfer of Food, Supplies, and Medications

    n Mobile Medical Equipment

    n Working with Liquids in Housekeeping

    n Working with Liquids in Kitchens

    n Hand Tools

    n Linen Carts

    n Handling Bags

    n Reaching into Sink

    n Loading or Unloading Laundry

    n Cleaning Rooms (Wet Method)

    n Cleaning Rooms (Electrical)

    31 SECTION V:Training

    31 Nursing Assistants and Other Workers at Risk of Injury31 Training for Charge Nurses and Supervisors31 Training for Designated Program Managers33 SECTION VI:

    Additional Sources of Information

    35 References36 Appendix: A Nursing Home Case Study

    Table of Contents

    4 Guidelines for Nursing Homes

  • These guidelines providerecommendations for nursing homeemployers to help reduce the numberand severity of work-related muscu-loskeletal disorders (MSDs) in theirfacilities. MSDs include conditionssuch as low back pain, sciatica,rotator cuff injuries, epicondylitis,and carpal tunnel syndrome. Therecommendations in these guidelinesare based on a review of existingpractices and programs, State OSHAprograms, as well as availablescientific information, and reflectcomments received from representativesof trade and professional associations,labor organizations, the medicalcommunity, individual firms,and other interested parties. OSHAthanks the many organizationsand individuals involved for theirthoughtful comments, suggestions,and assistance.

    More remains to be learned aboutthe relationship between workplaceactivities and the development ofMSDs. However, OSHA believesthat the experiences of many nursinghomes provide a basis for takingaction to better protect workers.As the understanding of these injuriesdevelops and information andtechnology improve, the recommenda-tions made in this document maybe modified.

    Executive Summary

    Although these guidelines aredesigned specifically for nursinghomes, OSHA hopes that employerswith similar work environments, suchas assisted living centers, homes forthe disabled, homes for the aged,and hospitals will also find thisinformation useful.

    OSHA also recognizes that smallemployers, in particular, may nothave the need for as comprehensive aprogram as would result fromimplementation of every action andstrategy described in these guidelines.Additionally, OSHA realizes thatmany small employers may needassistance in implementing anappropriate ergonomics program.That is why we emphasize theavailability of the free OSHAconsultation service for smalleremployers. The consultation service isindependent of OSHAs enforcementactivity and will be making specialefforts to provide help to the nursinghome industry.

    These guidelines are advisory innature and informational in content.They are not a new standard orregulation and do not create any newOSHA duties. Under the OSH Act,the extent of an employers obligationto address ergonomic hazards isgoverned by the general duty clause,29 U.S.C. 654(a)(1).

    Guidelines for Nursing Homes 5

  • An employers failure to implementthe guidelines is not a violation, orevidence of a violation, and may notbe used as evidence of a violation, ofthe general duty clause. Furthermore,the fact that OSHA has developedthis document is not evidence andmay not be used as evidence of anemployers obligations under thegeneral duty clause; the fact that ameasure is recommended in thisdocument but not adopted by anemployer is not evidence, and maynot be used as evidence, of aviolation of the general duty clause.In addition, the recommendationscontained herein should be adaptedto the needs and resources of eachindividual place of employment.Thus, implementation of the guide-lines may differ from site to sitedepending on the circumstancesat each particular site.

    While specific measures maydiffer from site to site, OSHArecommends that: Manual lifting of residents beminimized in all cases andeliminated when feasible.

    Employers implement an effectiveergonomics process that: provides management support; involves employees; identifies problems; implements solutions; addresses reports of injuries; provides training; and evaluates ergonomics efforts.These guidelines elaborate on

    these recommendations, and includeadditional information employerscan use to identify problems andtrain employees. Of particular valueare examples of solutions employerscan use to help reduce MSDs in theirworkplace. Recommended solutionsfor resident lifting and repositioningare found in Section III, whilerecommended solutions for otherergonomic concerns are in SectionIV. The appendix includes a casestudy describing the process onenursing home used to reduce MSDs.

    Executive Summary

    6 Guidelines for Nursing Homes

  • Nursing homes that haveimplemented injury prevention effortsfocusing on resident lifting andrepositioning methods have achievedconsiderable success in reducingwork-related injuries and associatedworkers compensation costs. Pro-viding a safer and more comfortablework environment has also resulted inadditional benefits for some facilities,including reduced staff turnover andassociated training and administrativecosts, reduced absenteeism, increasedproductivity, improved employeemorale, and increased residentcomfort. These guidelines providerecommendations for employers tohelp them reduce the number andseverity of work-related musculoskele-tal disorders in their facilities usingmethods that have been found to besuccessful in the nursing homeenvironment.

    Providing care to nursing homeresidents is physically demandingwork. Nursing home residents oftenrequire assistance to walk, bathe, orperform other normal daily activities.In some cases residents are totallydependent upon caregivers formobility. Manual lifting and othertasks involving the repositioning ofresidents are associated with anincreased risk of pain and injury tocaregivers, particularly to the back (2,3). These tasks can entail high physicaldemands due to the large amount



    of weight involved, awkward posturesthat may result from leaning over abed or working in a confined area,shifting of weight that may occur if aresident loses balance or strengthwhile moving, and many otherfactors. The risk factors that workersin nursing homes face include: Force - the amount of physical

    effort required to perform a task(such as heavy lifting) or to main-tain control of equipment or tools;

    Repetition - performing the samemotion or series of motions contin-ually or frequently; and

    Awkward postures - assumingpositions that place stress on thebody, such as reaching aboveshoulder height, kneeling,squatting, leaning over a bed, ortwisting the torso while lifting (3).

    Wyandot County Nursing Home in UpperSandusky, Ohio, has implemented a policyof performing all assisted residenttransfers with mechanical lifts, and haspurchased electrically adjustable beds.According to Wyandot, no back injuriesfrom resident lifting have occurred in overfive years. The nursing home also reportedthat workers compensation costs havedeclined from an average of almost$140,000 per year to less than $4,000 peryear, reduced absenteeism and overtimehave resulted in annual savings ofapproximately $55,000, and a reduction incosts associated with staff turnover hassaved an additional $125,000 (1). (seeReference List)

    Guidelines for Nursing Homes 7

  • Excessive exposure to these riskfactors can result in a variety ofdisorders in affected workers (3, 5).These conditions are collectivelyreferred to as musculoskeletaldisorders, or MSDs. MSDs includeconditions such as low back pain,sciatica, rotator cuff injuries,epicondylitis, and carpal tunnelsyndrome (6). Early indications ofMSDs can include persistent pain,restriction of joint movement, or softtissue swelling (3, 7).



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