Back injuries and back pain are an important concern for nursing staff and healthcare organizations. It has a negative impact on the well-being and quality of life of the worker and affects the productivity of the organization (Gropelli & Corle, 2011)

I. Magnitude of the Problem
Healthcare workers as a whole are more likely to experience a musculoskeletal disorder (MSD) than workers in construction mining or manufacturing (Centers for Disease Control [CDC], 2009). Among nurses, 52 percent complain of chronic back pain (American Nurses Association [ANA], 2012) with a lifetime prevalence up to 80% (Edlich, Winters, Hudson, Britt, & Long, 2004). 38% report having occupational-related back pain severe enough to require leave from work (ANA, 2012). Back pain is so ubiquitous in the profession that many nurses accept musculo-skeletal pain as part of their job (Gropelli & Corle, 2011); 12% of nurses leaving the profession report back pain as a main contributory factor (ANA, 2012; Li, Wolf, & Evanoff, 2004) and 20% have reported changing to a different unit, position, or employment because of back pain.

II. Costs
The cost of all this pain is financial as well. Employers feel the pinch of slowed production, employee turnover, and medical cost reimbursement (Edlich et al, 2004). The average worker's compensation cost for back pain is $10,698 per case (DHHS, 2009) and nursing personnel have the highest incidence rate of workers compensation claims for back injuries of any occupation (Edlich et al, 2004; ANA, 2012). In 2010, nursing aides, orderlies, and attendants had the highest rates of MSDs of all occupations with an incidence of 249 compared to 34 per 10,000 for all workers (US Dept of Labor, 2012). The financial burden of back injuries in the healthcare industry is estimated to add up to $20 billion annually (CDC, 2009).

III. Trends
While previously work-related MSDs in nursing continued to rise despite improving rates of most occupational injuries; starting in 1992, the BLS show that sprains strains, or tears due to overexertion in lifting requiring days away from work declined 19.5% from 2003-2007 in the healthcare and social assistance industry (Janocha & Smith, 2010). A third of these injuries were attributable to a health care patient as the source.

IV. Variables
In healthcare, the most frequent cause of injury is the manual handling of patients (DHHS, 2009; Gropelli & Corle, 2011). MSDs are aggravated by working in awkward postures with very repetitive or static forceful exertions (DHHS, 2009). Patients lack the convenience of handles, even distribution of weight, and have been known to become combative during the lift process (Nelson, 2004).
Transferring a patient may be made more difficult by the working environment. Performing a patient transfer in a restricted space (like a small bathroom) increases time required to perform the transfer. One study showed this type of transfer increased the time spent in medium to high risk postural position by 14% (Holman, Blackburn, & Maghsoodloo, 2010).
Obesity Epidemic
According to the CDC, the prevalence of obesity has dramatically increased over the last 20 years. Over a third of adults are overweight and there is a significant increase in obesity as we age (DHHS, 2012). The growing prevalence of obesity is prohibitive of manual lifting as NIOSH guidelines recommend that the maximum recommended weight to be lifted by women in the 90th percentile of strength is 46 lbs (Edlich et al., 2004). The cumulative weight lifted by a nurse in one typical 8-hour shift is equivalent to 1.8 tons (Nelson, 2004). This statistic represents repetitive work which surely exceeds NIOSH guidelines.
Inadequate Staffing
With the changing healthcare environment, health care institutions have been required to become more efficient. One way they have tried to do this is by decreasing staffing and increasing patient loads which are associated with increased rates of worker injury (Trinkoff, Johantgen, Muntaner, & Rong, 2005). Many institutions have also decreased the number of RNs utilized (who are generally higher paid than LPNs or CNAs). A study of 21 hospitals in the Twin Cities found that when RN positions were decreased by 9%, work-related illnesses and injuries among nurses increased by 65% (Trinkoff, et al., 2005). Another study found that total nursing hours spent per nursing home resident day were significantly associated with worker injury rates (Trinkoff, et al., 2005).

Shortage of Nurses
The average age of an RN in the United States is approximately 47 years (DHHS, 2009). Many nurses in the workforce are nearing retirement and 12-18% leave the profession annually due to chronic back pain. The occupational injury rates may aggravate a shortage which will likely result in longer hours and more demanding schedules for practicing nurses (DHHS, 2009). Fewer registered nurses may mean increased risk of occupational injuries.

V. Factors that Have Limited Progress
When I was studying nursing as an undergraduate, proper body mechanics and technique while repositioning or transferring a patient were emphasized and strongly enforced. While I don't believe body mechanics should be eliminated from nursing curriculum, the teaching of manual lifting techniques has not been successful in affecting injury rates (Nelson & Baptiste, 2004). As previously discussed, patient characteristics and workplace environment may make it difficult to employ perfect technique. Even if proper technique is used, patient weight may exceed NIOSH lifting guidelines.
Other factors that have limited progress have been barriers to the use of equipment and use of inappropriate equipment. There is evidence that back belts will not be effective in the prevention or nursing injuries (Li et al., 2004; Nelson & Baptiste, 2004). Other barriers to the use of equipment have been patient aversion of the equipment, operationally difficult to use equipment, storage issues, inadequate access to equipment, time constraints and inadequate number of lifting devices, inadequate device training, space restrictions to control equipment, and weight limitations.

VI. Interventions for Injury Prevention
When considering potential interventions for reducing back injuries (see Haddon's Matrix), use of engineering controls which create permanent changes that eliminate risks at the source (Nelson & Baptiste, 2004) show the most promise.
Behavioral interventions which look to change the patient, like reducing the obesity rates in the United States or decreasing the number of patients in the hospital through health promotion, are beyond the ability of the healthcare facility. Interventions which look to make the nurse more resilient, physically fit, or more aware of body mechanics may help, but do not consistently insulate the nurse from risk. There is evidence that lift teams reduce injury rates, but are not available at all times for all patient handling tasks (Li et al., 2004).
On the other hand, many studies have shown that availability and use of mechanical patient lifts significantly reduce back injuries and other musculoskeletal injuries (Li et al., 2004). In fact, OSHA recommends that manual lifting of residents in nursing homes be minimized in all cases and eliminated when feasible (Dept of Labor, 2012). Engineering controls like room design and use of adjustable equipment (beds, chairs, poles, etc) also provide consistent prevention when used appropriately by preventing unhealthy body postures.
Of course, healthcare administrators or safe patient handling committees must make smart decisions with room design, general equipment purchase and patient lift equipment to make interventions effective. Several studies support the need for training on patient handling equipment to prevent injuries (Nelson & Baptiste, 2004). It makes sense that equipment must be accessible, clean, and well maintained to encourage use. Staffing must also be adequate so that nursing staff will use the patient handling equipment and not perform lifts or transfers manually simply to save time.

VII. Progress
MN statute 182.6553 required health care facilities to have adopted written safe patient handling policies and a safe patient handling committee by July 2008 to be achieved by January 1, 2011. These committees' duties were to assess hazards, identify problems and solutions, assess injury rates, make recommendations regarding patient handling equipment purchases, assess interventions, and recommend processes to ensure proper use of patient lift mechanisms in room designs during remodels (MN Office of the Revisor of Statutes, 2012).

VIII. Opportunities for Research
Enhancing existing surveillance systems to gather data on specific occupations and track disparities across at-risk populations would be helpful. It would also allow researchers to better describe trends, focus interventions appropriately and assess results (DHHS, 2009). Richer state level surveillance of occupational injuries would also be beneficial in assessing the effectiveness of relatively recent legislation and targeting populations which may need assistance.

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