Effects of training in modifying working methods during common patient-handling activities

Abstract

It is commonly recommended that those who must perform strenuous physical exertions be given training in proper techniques, and that musculoskeletal risks are thereby minimized. In the present study, the effects of training were examined at a behavioral level, and it was assumed that any long-term reduction in injuries must be preceded by measurable changes in how exertions are performed. Because of high injury incidence rates among nurses, common patient-handling tasks were the basis of the study. Participants performed several such tasks and sub-groups received training that consisted of either a commercial video or combined lecture and practice sessions. Compared to a control group, several perceptual, postural, and biomechanical measures were significantly altered following training. Specifically, training was associated with the adoption of a more upright lifting posture, and this change was retained in follow-up measures obtained after 4–6 weeks. While substantial inter-subject variability was present, the results suggest that training can modify behaviors in an intended direction. This observation provides support for the use of training as potential control measure, however more information is needed regarding retention and the relationship between trained behaviors and long-term injury risk.

Relevance to industry

Numerous training techniques have been recommended as ergonomic controls, yet there is mixed evidence regarding their efficacy. This study evaluates the potential of training to modify behaviors, and thus potentially reduce injury risk, in a setting of patient handling.

Introduction

Nurses are among the occupational groups with the highest incidence rates of musculoskeletal injuries (Stubbs et al., 1983; Klein et al., 1984; Videman et al., 1984; Harber et al., 1985; Troup and Rauhala, 1987; Venning et al., 1987; Cato et al., 1989; Garg et al., 1991; Winkelmolen et al., 1994). A recent review found that nurses had the highest incidence rates among private industries within the US, and that these were four times higher than the average (NIOSH, 1997). Large proportions of nurses have also reported suffering from back pain due to work-related activities, developing back pain at work during a recent period, taking medication for back pain, and missing work because of their symptoms (Dehlin et al., 1976; Harber et al., 1985; Cato et al., 1989).

Several studies have identified patient handling as a risk factor associated with the development of low-back pain (LBP). One survey (Stubbs et al., 1983) found 16% of all LBP cases and 13% of new cases associated with patient-handling tasks, and another (Jensen, 1985) found a nearly four-fold increase in LBP prevalence among nurses who performed frequent patient handling. Among the variety of specific patient-handling tasks, those involving moving patients within bed and to/from the bed are most often reported as contributing to LBP (Harber et al., 1985; Cato et al., 1989). These same types of tasks have also been perceived by nurses as the most stressful (Owen and Garg, 1989). It has been suggested that the risk involved with patient handling tasks stems from patients being relatively large masses, potentially uncooperative, unpredictable, or resistive of movement, with varying levels of dependency, and who must be handled in a working environment that may have inadequate space, interference from equipment, and non-adjustable beds (Hellsing et al., 1993; Corlett et al., 1994).

As a potential ergonomic intervention, assistive devices have been suggested to reduce injury risk, yet they are infrequently used, possibly owing to excessive time demands, lack of availability, and a perception that these devices are neither less stressful nor more comfortable for patients (Garg and Owen, 1992). In contrast, training has been widely used as an intervention among nurses. Despite extensive work, the effectiveness of training in reducing injuries is debatable, with some studies showing clear reductions and others no obvious effects. Contrary results, such as an increase in back injuries following implementation of a training program, have been attributed to a number of potential confounding influences including changes in attitudes among workers and management (Goldenhar and Schulte, 1994).

A number of cross-sectional studies have examined the effects of training on subjective perceptions and postures employed. While most of these have found training to be beneficial (e.g. Troup and Rauhala, 1987; Videman et al., 1989; Hellsing et al., 1993), they have typically used qualitative or subjective measures of effectiveness (e.g. lifting ‘skill’). Among several longitudinal studies of training effectiveness, the majority of results suggest that training does not lead to reductions in the rates of injuries (e.g. Daltroy et al., 1997; Lagerström and Hagberg, 1997).

A definitive evaluation of the effectiveness of training, specifically applied to the nursing profession, does not appear warranted at present. In addition to the wide range of results noted, there is disparity in the specific training approaches employed by various authors, and even a lack of agreement about what method should be employed or what techniques should be trained. It is difficult to separate training effectiveness (or lack thereof) from a lack of implementation or even a use of inadequate procedures. As an example applied to lifting, can training be faulted when there is no consensus on the relative risk imposed by stoop versus squat lifting (Dieën et al., 1999)? The intuitive appeal of training, combined with a general perception of effectiveness, will likely ensure that it continues to receive wide attention.

For a given task, injury risk is contingent on several intermediate influences. While injuries result from specific musculoskeletal stresses and strains, these in turn are dependent on working behaviors such as postures and motions. Working behaviors are similarly dependent on environmental conditions, worker characteristics, and possibly training. Rather than addressing injury directly, the present work is focused on working behaviors, and it is assumed that if training is to be effective it must first modify these behaviors. In a controlled experimental study, training was examined when applied to common patient-handling tasks among nurses. Two different training approaches were examined, with an objective to determine whether training leads to short-term decreases of known injury risk factors through quantifiable changes in behaviors.