May 25, 2007

Background of Injuries in Caregivers

Written accounts of occupational injuries associated with care giving have been described as early as the 1700’s. In 1713 , Bernardino Ramazzini authored the first book on occupational risks in 1713, describing the occupational risks for midwives and wet-nurses, both occupations that can be considered forerunners of the current nursing profession. Ramazzini notes that backpain is one of the primary occupational hazards in currered by these forerunners of nurses{{717 Ramazzini, Bernardino 1964;}}.
In the late 1800’s and early 1900’s, the period when the first nursing text books were published, there is also mention of back injuries being a risk factor when providing nursing care. These text associate the risk of injury with lifting patients, back injuries are considered an inherent risk of the nursing profession and is caused when nurses use incorrect lifting techniques. {{413 Lewis,Percy George 1892;412 Robb,Isabel Hampton 1916;}} The belief that the nurses incorrect body posture is the main cause for back pain and injuries led schools of nursing and medical institutions to implement body mechanics educational as primary strategy to prevent these injuries of occurring. However, a century of educating nurses in proper body mechanics did not decrease the number of reported injuries, to the contrary, injury rates have continued to gradually increase {{30 Owen,B.D. 1999; }}.
It was not until the early 1990’s that the approach toward preventing back and musculoskeletal injuries (MSI’s) changed. Owens and Garg (1991), a nurse and ergonomist team, were the first to break away from the previous mentioned paradigm in which body mechanics education is seen as the solution to preventing MSI’s. In their initial research Owen and Garg (1991), identified the 16 tasks (Table A) performed by nursing assistants in a long term care facility, which increased the strain on the musculoskeletal system of these care givers. The list of 16 “most physically stressful patient-handling tasks? tasks was a compilation of 158 tasks which were identified by the nursing assistants{{34 Owen,B.D. 1991;}}. Laboratory tests confirmed that these tasks indeed caused high levels of musculoskeletal strain. In an effort to find solutions to these back injuries. Building on the study findings, the focus and effort to decrease the number of MSI’s moved from body mechanics education to decreasing the phyisical stress care givers are exposed to by replacing manual lifting with mechanical lifting devices. This approach was not new as it had been successfully implemented in other industries (e.g construction) in which workers were exposed to high-level of physical stress {{34 Owen,B.D. 1991;}}. Laboratory studies which examined the impact of using equipment in lue of manual techniques, confirmed that mechanical lifting decreased physical stress on the caregiver {{280 Marras,W.S. 1999;}}.
Building on the findings that there are certain tasks that cause increased levels of stress on the musculoskeletal system (Owen and Garrg 1991, 1992) and that the use of mechanical lifting devices decreases this stress (Owen and Garg 1992, Marras 1999), Nelson, advocated form implementing a standardized approach how patients should be transferred when performing any of the 16 high stress tasks. A safe patient handling program was established within the Veterans Administration was established, as a part of this program, algorithms were developed meant to guide nurses how to handle (formally called lift) patients using mechanical lifting devices {{487 Patient Safety Center of Inquiry (Tampa, FL), Veterans Health Administration and Department of Defense 2001;}. The introduction of these algorithms required healthcare institutions to purchase costly lifting equipment and care givers to abandon past practices and to adopt a standardized practice around handling patients.
On September 17th 2003, The American Nurses Association (ANA), Launched the “Handle with Care? Campaign. This initiative adopted the approach developed by Nelson at the Verterans administration. The campaign promotes the use of algorithms in an effort to standardized how care tasks are performed using mechanical equipment versus manual lifting. This program also focuses on changing the education nurses receive in their training programs, by teaching nurses how to handle patients according to the algorithms and focus on teaching the use of equipment versus manual handling {{729 American Nurses Association 2003;}}.
In an effort to convince healthcare institutions to purchase costly equipment and nurses to change their practice four prong approach was used. First , a case was made to show the financial benefits for institutions when by decreasing the number of injury reports. Studies showed that by decreasing the number of reported injuries, organizations can drastically decrease both the direct costs (e.g worker compensation claims) and indirect costs (e.g staff replacement expenses, overtime ). {{462 Siddharthan,K. 2005;344 Chhokar,R. 2005;}}. Secondly, a legislative approach was taken in which law makers required institutions to implement safe patient handling programs, thus effectively mandating the purchase of equipment by institutions and requiring care givers to utilize the equipment as determined by institutional policies{{473 Hudson,M.A. 2005;496 State of Texas 2005;}}.Thirdly, there is an effort to change the practice of caregivers taking care of patients. Garg and Collins noted that the largest decrease in reported injuries occurred if institutions implemented safe handling programs and held staff accountable to follow the policies, using punitive action if needed {{ 466 Garg, Arun 2006; 49 Collins,J.W. 2004; }}.
Evidence is evolving that the using an approach that includes healthcare institutions purchasing patient lifting equipment in conjunction with the implementation of policies requiring the use of mechanical equipment and ensuring that staff is educated on the use of equipment is resulting in decreases in the number of staff injuries reported injuries. This is especially true when a so called “multi facetted approach? is implemented. {{49 Collins,J.W. 2004; }}.

August 6, 2006

Initial Thoughts

Have decided to do my research using Institutional Ethnography. When I applied to the PhD program, I wanted to use a Feminist / Marxist paradigm. After years of quantitative research classes and stats... the circle is closing.
Using the works of Dorothy Smith. When I have been reading her works it is great to see how she has been able to transform her convictions and beliefs in a research method that is well respected w/o loss of idealism.
As a male nurse I guess I will never truly understand what it means to be marginalized to the same extent as most of my colleagues. Yet, the longer I am in the profession, the clearer it has become how many decisions are made based on gender bias. E.g. If nurses bring up concerns regarding patient safety or even personal safety, I have frequently seen it be explained as that they are resistant to change or not willing to think critically.
What are the real forces that are determining how care is being delivered? It is truly “evidence based? and even if studies support a certain practice is that because the studies that might dispute that same point remained unfunded or considered “not of interest?.