670162
research-article2016
WHSXXX10.1177/2165079916670162Workplace health & safetyWorkplace health & safety
vol. XX  ■  no. X
Initial Results of an Evidence-Based Safe Patient
Handling and Mobility Program to Decrease
Hospital Worker Injuries
Linda Przybysz, DNP, RN, COHN-S1 and Pamela F. Levin, PhD, APHN-BC2
Abstract: The rate for musculoskeletal injuries among
health care workers is one of the highest for all industrial
sectors in the United States; these injuries often occur during
manual handling (i.e., lifting, moving, transferring, and
repositioning) of patients. The following article describes
the process used to complete a comprehensive assessment,
as well as the planning, implementation, and initial
evaluation of a quality improvement program to reduce
work-related musculoskeletal disorders (WMSD) among
health care workers employed by a rural Midwest hospital.
Key elements for WMSD injury reduction were identified
and compared across literature sources, national standards,
and current state and federal legislative requirements for
hospitals. The program used a multi-factor design that
included evidence-based interventions (i.e., those supported
by emerging evidence) to create a comprehensive Safe
Patient Handling and Mobility (SPHM) program intended
to address the unique needs of the organization. Initial
program results are reviewed as well as significant
considerations and challenges for SPHM programs.
Keywords: safe patient handling and mobility,
musculoskeletal disorders, health care workers, program
planning, evidence-based interventions
M
usculoskeletal injury rates for workers in the health
care industry rank among the highest of all U.S.
industries (Centers for Disease Control and Prevention
[CDC], The National Institute for Occupational Safety and
Health, 2013). These injuries often occur as a result of
overexertion, with manual handling of patients during lifting,
moving, transferring, and repositioning creating the greatest risk
for sustaining this type of injury (CDC, 2014). The Bureau of
Labor Statistics (2011) ranks overexertion as the leading cause
DOI: 10.1177/2165079916670162. From 1Kimberly-Clark Corporation, and 2Rush University. Address correspondence to: Linda Przybysz, W2731 Brookhaven Dr, Appleton, WI 54915, USA;
email: linda.przybysz@comcast.net.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2016 The Author(s)
Workplace Health & Safety
Successful Progr am
of injuries among health care workers across the United States.
The 2011 injury rate from overexertion for U.S. hospital
employees was 6.8 per 100 full-time employees, almost twice
the injury rate for workers employed in private industry, and
also exceeding the injury rate for hazardous industries such as
construction and manufacturing (Occupational Safety and
Health Administration [OSHA], 2013). Contributing risk factors
for health care workers include an aging workforce of registered
nurses with an average age of 44 years, an ongoing nursing
shortage, and the ever increasing rate of obesity among U.S.
workers (CDC, 2014).
Hospitals are experiencing substantial changes in the delivery
and reimbursement of health care services and are continuously
seeking cost-effective strategies that will set them apart from
their competitors, while bringing added value to their
organizations. The program described here was initiated in a
small, rural community hospital in the Midwest as a step toward
decreasing the number of musculoskeletal injuries sustained by
health care workers. The following article describes in detail the
process of identifying the problem and then planning,
implementing, and initiating a formative evaluation of a quality
improvement program to reduce work-related musculoskeletal
disorders (WMSD) for this organization.
Problem Identification
To aid in problem identification and gain an ecological
perspective of the organization’s health, multiple data sources
were examined, including health insurance annual summary
reports, work injury data, and health risk assessment aggregate
reports. The organization had recently implemented a corporate
employee wellness program, and employee health data were
collected through voluntary participation in on-site screenings
and self-reported data. Initial data sources reviewed confirmed
that musculoskeletal conditions and injuries were a leading
health concern for employees in this organization.
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Workplace Health & Safety
To further define the problem, a comprehensive assessment
was then conducted, which examined both qualitative and
quantitative data sources, and organizational factors that could
influence worker behaviors that hinder and promote workplace
safety. Data sources included employee and stakeholder
interviews, employee demographic and injury surveillance data,
workers’ compensation claims and cost reports, workplace
policy and procedure manuals, national data from the Bureau of
Labor Statistics (2011), and a literature review. The results of this
in-depth assessment included (a) inadequate and fragmented
utilization of patient handling equipment and processes, (b) a
lack of detailed and timely injury reporting and monitoring, and
(c) missing or ambiguous policies and procedures relevant to
employee safety and patient handling.
Although the organization had some equipment to decrease
the need for manual patient lifting by employees, the
equipment was often not used. Interviewed workers attributed
this lack of equipment utilization to perceived lack of time,
inconvenience, or limited available assistance from coworkers. A
complete inventory of patient handling equipment and
technology was not available, nor were any relevant ergonomic
assessment data. Patient handling and mobility assessments
were not completed, nor were decision algorithms or clinical
decision pathways used to determine when and what type of
handling and mobility equipment were appropriate for each
individual patient. A formal policy or procedure aimed at
providing limitations and guidance when lifting or mobilizing
patients was also not available.
In addition, this organization (a) lacked a formal policy
regarding the reporting and handling of employee injuries, (b)
did not include any provisions for employee safety in the patient
safety program, and (c) did not address employee injuries via
either the employee health or safety departments. A part-time
nurse working in the Human Resources Department provided
case management services for workers’ compensation claims, but
was not tasked with any post-injury trending or analysis. The
OSHA Total Case Incident Rates (TCIR) and Days Away,
Restricted, or Transferred (DART) scores for work injuries were
not calculated or monitored. The OSHA summary reports for
2010 to 2014 were accessed and reviewed: TCIR and DART
scores were calculated and compared across years as were
OSHA TCIR rates for U.S. hospitals (see Table 1). Although the
TCIR for this hospital was below the median, the DART score, an
indicator of severity, exceeded the national median for U.S.
hospitals. Days Away, Restricted, or Transferred scores are the
most useful indicator when examining injury data because DART
scores are based solely on those injuries severe enough to
require days away from work or restriction of regular job duties
and should be lower than the TCIR. A comparison of annual
injury and cost data was completed for years 2010 to 2014, and
results indicated that musculoskeletal injuries accounted for 40%
or more of employee injuries each year since 2010, with 25% or
more annually being related to overexertion (see Table 2).
Annual injury costs for WMSD accounted for 40% or more of
total costs for each year from 2010 to 2014 (see Table 3). A
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Mon 2016
Table 1.  Comparison of OSHA TCIR and DART Scores for
Project Hospital
TCIR (U.S. hospitals- DART (U.S. hospitals-
Year median 5.9) median 1.9)
2010 4.03 2.64
2011 5.07 3.77
2012 3.42 2.85
2013 4.56 3.16
2014 4.55 2.88
Source. OSHA (2013).
Note. OSHA = Occupational Safety and Health Administration;
TCIR = Total Case Incident Rate; DART = Days Away, Restricted, or
Transferred.
random sampling (n = 82) of open WMSD injury cases for 2014
were examined for contributing factors; results of this review
confirmed that work practices (e.g., lifting or repositioning
patients) were a contributing factor in 65% of the cases.
The next step in the assessment process was to identify best
practices in preventing overexertion injuries and compare the
practices to those of the organization. As most overexertion
injuries are related to patient lifting and moving, implementation
of a comprehensive Safe Patient Handling and Mobility (SPHM)
program to reduce these injuries was well supported by the
literature (American Nurses Association, 2011; Cohen et al., 2010;
Miner, Laramie, Davis, & Tran, 2013; OSHA, 2013). Key program
elements were identified (VISN8 Patient Safety Center of Inquiry,
2013) and compared across literature sources, national standards,
and current state and federal legislative requirements for
hospitals. These next steps include a formal SPHM program with
an organization-wide policy restricting the manual handling of
patients; a comprehensive risk analysis; inclusion of engineering
design, technology, and equipment; initial and ongoing staff
training; use of patient assessment tools and decision algorithms
to guide clinicians; and building a culture of safety that includes
monitoring of key performance indicators for both employees
and patients that are leadership driven (American Nurses
Association, 2013; Illinois General Assembly, 2010; OSHA, 2013;
VISN8 Patient Safety Center of Inquiry, 2013). A comparison of
key program elements to hospital data revealed various
standards and requirements were not currently met by the
hospital. For example, a formal SPHM program had not been
implemented by the hospital, a safe patient handling policy was
lacking, risk analysis and control processes were not in place,
and SPHM training was provided only at time of hire to select
employees and not on an annual or ongoing basis. Safe patient
handling and mobility training for newly hired employees was
conducted on the employee’s unit supervised by preceptors who
had not received formal annual SPHM training. The organization
vol. XX  ■  no. X Workplace Health & Safety

Table 2.  Comparison of Study Hospital Employee Injuries 2010-2014

Percentage of injuries per year

Injury type 2010 2011 2012 2013 2014
Overexertion 27 25 27 27 28
Slips, trips, falls 21 24 19 13 25
Contact injury 20 18 20 16 17
Exposure 16 15 18 33 14
Violence 15 14 13 9 9
Other <1 4 3 2 7

Table 3.  Cost Analysis of Worker Injury Claims 2010-2014

Percentage of injury costs per year

Injury type 2010 2011 2012 2013 2014
Overexertion 42 82 51 63 50
Slips, trips, falls 28 9 13 15 36
Contact injury 7 5 2 9 3
Exposure 3 2 3 4 3
Violence 20 3 4 9 6
Other 10 4 27 1 3

also lacked a SPHM committee to address employee safety issues
and a program coordinator to facilitate compliance.
Planning
The program was designed based on evidence from the
literature on effective interventions to reduce patient handling
injury rates, and meet legislative requirements and current
standards. The Agency for Healthcare Research and Quality
publication, Patient Safety and Quality: An Evidence-Based
Handbook for Nurses (2008), examined interventions for safe
patient handling that were either evidence-based or supported
with emerging evidence. Incorporating patient handling
equipment and devices, minimal or no-lift policies, ongoing
training, and lift teams are examples of evidence-based
interventions. Interventions supported by emerging evidence
include peer leader education, patient assessment tools,
algorithms, and after-action reviews following an injury or when
near-miss events have occurred. A study by Powell-Cope and
colleagues (2014) reported that evidence supporting a multiple
component approach should include comprehensive training and
the use of equipment. Training aspects found to be significant
included peer leader training, demonstrated competency in the
selection and use of SPHM technology and equipment, and
incorporation of evidence-based training into new hire
orientation. Findings also included organizational factors (i.e.,
lack of leadership support and equipment availability and supply)
that were associated with patient handling injuries (Powell-Cope
et al., 2014). The American Nurses Association (2013)
incorporated training, equipment, and other evidence-based
interventions into the publication, Safe Patient Handling and
Mobility: Interprofessional National Standards. The literature
suggests that multi-factor interventions (e.g., administrative,
engineering, and behavioral controls) are more effective in
reducing injury rates and costs (Stevens, Rees, Lamb, & Dalsing,
2013) than single factor interventions. Inclusion of such
interventions as injury analysis, use of decision algorithms, and
reinforcement of training support program effectiveness. In a
study by Sorenson et al. (2011), “an integrated approach, that

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Workplace Health & Safety
attends to workers’ health behaviors as well as the potential for
exposures on the job, holds promise for bolstering the impact of
interventions” (p. 9). Implementation of an organization’s
wellness program suggests hospital leadership support can
optimize the health and well-being of the workforce.
Based on the review completed, necessary elements of a
SPHM program designed for this hospital should include the
following:
•• Education and training
•• Maintaining competence in the use of equipment and
technology
•• Post-injury analysis
•• A formal SPHM policy, which must include a “right to
refuse” procedure for staff to decline patient handling
activities with unacceptable risk of injury.
Education and training was addressed through development
of a computer-based learning (CBL) module, and initially
piloted with a select group of program “champions” or trainers,
to allow for the testing and identification of any process issues.
On full implementation of the program, both new and existing
employees with patient handling responsibilities were trained
using the CBL module. Additional training was also required for
those employees who had patient handling, moving, or
repositioning responsibilities, and included SPHM assessments,
use of algorithms for selecting appropriate equipment, and a
unit-specific equipment competency.
To initiate a post-injury analysis, the reporting process for
injuries sustained and near-miss incidents was completed in a
timely manner and with sufficient detail that corrective and
preventive actions could be identified and an action plan
developed to avoid future injuries.
Templates and sample policies specific to SPHM were used
to draft the organization’s policy. The draft policy was compared
with current standards and legislation to assure the final policy
met all necessary requirements, prior to submission for
leadership approval.
In addition, a SPHM marketing brochure for patients
providing information on SPHM principles was recommended
as an education and safety promotion tool and a way to
promote communication between health care workers, patients,
and their families.
The program targeted a multidisciplinary group of
employees representing 63% (n = 1,452) of the organization’s
staff whose job responsibilities included lifting, moving,
transferring, or repositioning patients. Professional, White
females accounted for 70% of the organization’s employee
population, largely composed of nurses. Obesity among
employees reached 42% of the entire workforce in 2014, and
although age-related data were not available for the
organization, as of 2011, the median age of hospital employees
in the U.S. rose to 43.6 years (OSHA, 2013). Both age and
obesity are known to increase workers’ vulnerability for
musculoskeletal injuries.
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Mon 2016
Implementation
Program implementation began in May 2015. The SPHM CBL
training module used a slide presentation format requested by
leadership, resulting in a training module of 67 slides;
participants reported a completion time of 30 minutes to 45
minutes. Content development was based on learning
objectives, comprehensive SPHM training for applicability to all
employees, and current training recommendations gleaned from
a literature review. A post module learning assessment was
created in collaboration with the nursing education department
and administered directly to participants following completion
of the CBL module. Additional steps included stakeholder
approval of material, partnership with the IT department to
identify CBL module processes, selection of the pilot group,
identification of reporting structures for tracking module
completion, and assessment scoring.
The equipment competency process involved selecting and
approving the SPHM patient assessment tool and SPHM
algorithms for equipment decision, training logs and checklists,
and formal “champion” training on SPHM. To establish a
baseline inventory of equipment and ergonomic data, survey
questionnaires were created to inventory currently available
equipment, ergonomic issues or space constraints, patient
distribution by dependency levels, and clinical staff
characteristics for each unit. Surveys were completed by unit
managers or directors and returned for data compilation.
Patient assessment tools, decision algorithm examples, and
training logs were compiled and submitted to leadership for
review. Local and national training options for “champions”
were researched and compiled.
The injury investigation plan included submission of all
injury reports within 48 hours of injury occurrence. A
questionnaire specific to SPHM injuries was created and
received approval from the Human Resources and Quality
Departments. The questionnaire required detailed information
on patient characteristics, activities at the time of injury, patient
handling methods and/or equipment being used, and the level
of assistance received from the patient or other staff members.
The preferred process for questionnaire distribution and
submission was the new online reporting system. However, a
temporary process was initially implemented during the creation
of the questionnaire in the online system. All new injury reports
were reviewed by the workers’ compensation nurse, then the
questionnaire was emailed to the unit manager with a 48 hour
turnaround time approved by leadership.
A SPHM policy was created by using policy templates and
samples obtained from exemplar organizations, sources of
literature, and a review of applicable legislative requirements.
These documents were used to guide the drafting of the written
SPHM policy; key stakeholders were also included in the policy
development process. The final policy included statements on
its purpose, definitions, the policy’s audience, and procedures
and responsibilities detailed in the document. The SPHM policy
also included a “right to refuse” provision as required by state
vol. XX  ■  no. X
legislation (Illinois General Assembly, 2010). This provision
allows workers to refuse patient handling or movement that
places the health care worker or patient at an unacceptable risk
of severe injury.
Evaluation
A formative evaluation was completed for program
components implemented to date, focusing on whether a
comprehensive SPHM program’s processes (i.e., education
and training, equipment and technology components, post-
injury analysis, and formal SPHM policy enactment) had been
fully initiated. In terms of education and training processes,
the CBL module was assigned to a pilot group that included
nurses, physical therapists, unit managers, and nurse
educators (n = 25); the pilot group reported an 80%
completion rate. Results of a satisfaction survey using a
5-point Likert-type scale completed at the end of the module
revealed that 78% of the pilot participants were dissatisfied
with the length of the module, although highly satisfied with
the content of the slides. This feedback led to a program
variance regarding how initial training was provided;
required training should be offered as a live in-person,
interactive training session. The initial training and
equipment competency was completed during a live 4 hour
training session scheduled for the following fall as part of a
planned safety fair. The safety fair also included SPHM
equipment vendors, allowing employees to explore and rate
potential SPHM equipment options. Unfortunately, no
commitment to champions training was made.
The results of the equipment competency evaluation
confirmed that the organization selected the following tools for
staff use at the onset of training: (a) a patient SPHM assessment
tool, (b) equipment decision algorithms, and (c) training
checklists/logs. Of the equipment inventory and ergonomic
surveys submitted to the clinical units, 88% of the surveys were
completed and returned. Of the surveys received, all clinical
units reported SPHM equipment needs, 67% reported that
storage of SPHM equipment was an issue, and units reporting
the highest rates of patient dependency paralleled the units with
the highest frequency of WMSD injuries.
The post-injury analysis process, including both the SPHM
injury questionnaire and summary report, was approved and
implemented for all new injury reports 1 month into the
implementation process. A TCIR/DART tracker was created,
and the nurse responsible for workers’ compensation claims
calculated scores annually. The 2014 TCIR/DART was used as
the baseline injury rate, and a decreased injury rate of 10%
was based on the injury analysis. An injury summary report
was created by extracting data fields from the injury
questionnaire to facilitate tracking and monitoring of
reported injuries. Morning safety huddles, implemented in
response to patient safety issues, also included reporting on
employee injuries. In addition, a formal employee safety
committee was formed to review all injury reports and
monitor corrective action plans and injury trends.
Workplace Health & Safety
A SPHM policy was drafted and revised with stakeholder
input; the final version was approved by Human Resources,
Quality, and Nursing Administration prior to receipt of executive
approval. The SPHM policy was communicated to employees
during the fall safety fair and incorporated into new employee
orientation.
Discussion
Program implementation and sustainability could be
negatively affected by some environmental challenges within
the organization. The organization’s leadership is experiencing
multiple competing priorities (e.g., upcoming reaccreditation).
Recently, the organization underwent significant changes in an
already volatile health care environment: adapting to a new
facility, implementing a new electronic health record, and key
personnel changes. New key leaders may necessitate extending
the original program timeline to re-establish critical partnerships.
Several steps were taken to enhance the likelihood of
program sustainability: adopting a cost minimization approach
to program development, building diverse partnerships during
program planning, aligning the program with other initiatives
such as patient safety, promoting quality care initiatives, and
aligning with becoming a high-reliability organization. Key to
sustainability includes building leadership awareness of current
and proposed legislation related to employee and patient safety,
and the substantial cost savings to the organization that could
be realized by reducing or eliminating SPHM-related injuries.
Defining fiscal considerations for the organization during
program implementation included (a) a budget adjustment to
accommodate live session training, (b) a capitol budget for the
purchase of additional equipment, and (c) an annual cost
projection for the maintenance and replacement of equipment
and supplies. These cost considerations should be compared
with potential and actual injury expenditures and cost savings
to calculate the organizations return on investment (ROI). The
use of program champions will provide both employees and
new hires with needed support and training for the competent
use of SPHM equipment, while providing a local resource for
questions or issues. The commitment to identifying and training
program champions is a crucial next step. Going forward, the
integration of algorithms and decision tools into patients’ plans
of care could increase accountability and should be carefully
considered. Although training and competency measurements
will continue on an annual basis, and new hires will complete
SPHM training during their orientation periods, it must still be
determined who will provide new hire training and how this
training will be delivered.
The application of a process such as Corrective Action
Preventive Action (CAPA) should be added to the post-injury
analysis. The CAPA process is aligned with the PDCA (Plan-
Do-Check-Act) Cycle (Bulsuk, 2009) that is currently used by
the organization. Use of these tools in the injury investigation
process could support the development of action plans
specifically aimed at injury reduction and prevention. Finally,
although the SPHM marketing brochure was not considered
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Workplace Health & Safety
In Summary
•• Musculoskeletal injury rates for workers in the health
care industry rank among the highest of all
industries within the United States, often resulting
from overexertion when handling patients.
•• Results of a comprehensive assessment were used to
develop a multi-factor Safe Patient Handling and
Mobility (SPHM) program based on a literature review,
standards, and current legislative requirements.
•• Results of a preliminary formative evaluation
indicated implementation of a comprehensive SPHM
program that has been initiated within the
organization, and factors influencing sustainability
and continuous quality improvement had been
successfully linked with other current initiatives
being monitored by executive leadership.
core at the time of program initiation, the brochure could be
considered for development and implementation at a later
date.
In conclusion, continuous ongoing reevaluation of program
effectiveness in reducing WMSD injuries in the workplace
should be conducted. A critical step is to assure additional tools
and processes receive adequate consideration and are tailored
to the unique needs of this organization to promote continuous
quality improvement of the SPHM program design.
Conflict of Interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Linda Przybysz is currently the health services director NA [North
America] for the Kimberly-Clark Corporation in Neenah,
Wisconsin, and is a member of the organization’s strategic team
for workplace health and wellness on regional and global levels.
She completed a DNP in advanced public health nursing from
Rush University and also serves in an Adjunct Faculty role.
Pamela F. Levin is a professor in the Department of Community,
Systems, and Mental Health Nursing at Rush University College
of Nursing, Chicago, Illinois. Her background is in public health
and occupational health nursing. Her scholarship focus is on
public health nursing workforce development and violence
prevention in healthcare settings.