How Do We Take Care of the Caretakers?

Our previous post in the series addressed system-level learning points for healthcare from the fast food industry’s recent business model changes. In contrast, this entry specifically focuses on what healthcare can learn from the construction industry to help reduce the frequency and severity of nurse staff injuries.

It is well documented that construction-related roles are physically demanding, requiring workers to lift heavy materials for several hours daily. Although it is less frequently acknowledged, nursing is also a strenuous occupation, given the number of hours and physical tasks nurses perform daily. Examples include lifting and transferring patients, who can weigh several hundred pounds, and standing for several hours at a time, resulting in back strain and sore feet. Therefore, the potential back injuries from their work range from pain inducing to career altering.

According to the Department of Labor’s Bureau of Labor Statistic (BLS) data on musculoskeletal disorders, nursing assistants have a yearly incidence rate of 208 injuries per 10,000 workers among nursing assistants; this sharply contrasts with the yearly incidence rate of 72 injuries per 10,000 construction workers. Furthermore, in terms of sheer number of injuries, the BLS musculoskeletal data indicates that nursing professionals are injured more often than any other profession.

This begs the question, what is contributing to the rate of back injuries in nursing staff?

One potential explanation is the difference in the availability and structure of industry safety guidelines. However, research demonstrates that construction guidelines and nursing guidelines for the use of equipment and heavy lifting are similar in nature. This indicates, at the least, the existence of safety guidelines is not the key driver of the injury rate differential between the industries.

Another potential explanation is that healthcare does not have the appropriate equipment to help nurses with physical tasks, as construction workers do in completing their tasks. However, this is misleading, given that a range of medical devices are available in the market for tasking, such as moving patients. In addition, there are instructions and processes to indicate how a specific instrument should be used in various situations, similar to construction’s best practices for equipment use.

If appropriate guidelines and equipment exist in both industries, what is a potential root cause?

The immediate argument would be that nursing guidelines are not as detailed or that the equipment they have available is not as effective in achieving the desired objectives. While this may be a contributing factor, it is difficult to argue that such a large gap in injury rates can exist due to such minute differences. Instead, the answer lies in the nature of each industry.

In construction roles, heavy lifting generally surrounds a regimented and documented process. Workers know, in advance, when and where they need to lift objects and how heavy the material will be. This allows them to more easily organize groups to assist with lifting or acquiring the right equipment at the needed window of time.

In contrast, nursing is a high-touch field, in which patients’ emotions are often factored into decisions. In addition, the need to move a patient can occur sporadically, given that patients do not feel ill or need to use the bathroom at pre-specified times. Therefore, equipment is not always readily available. Even if it is, nurses can make judgment calls to not use it, because they feel it can be dehumanizing for a patient to be moved like an object. As the Safety and Wellness Director at the American Nurses Association acknowledges, patients are not objects and do not have handles. Thus, nurses can rightfully hesitate to treat them as such.

So, what can nursing learn from construction to mitigate this complex problem?

Three specific solutions are evident:

  1. Nursing workplaces need to create and adopt systems by which nurses can request aid to move patients. It is unreasonable to expect nurses to suddenly begin using regimented processes, given the nature of their work. However, a system that communicates the need to lift a patient, the patient’s weight, and the current location, can begin to help organize staff efficiently. This will serve to mimic, at a reasonable level, the processes construction has surrounding heavy lifting.
  2. Enforceable rules, not guidelines, need to be enacted to ensure that the available equipment is used. Training nurses in doing so will help reduce the number of judgments calls, which if incorrect, can often lead to injury. If one needs a rationale for implementing this change, it should be considered that in the construction industry, objects that weigh far less than patients are always moved by using equipment, without question.
  3. Nurses must set expectations with patients regarding these rules at the beginning of a patient’s stay. It is understandable that nurses consider patients’ emotions. However, it is also vital for nurses to consider their physical capacity as they perform their duties. Taking the time to explain to patients how different situations will be handled, which equipment will be used, or that staff will be called, can help patients understand how their needs are being met. At the same time, it helps them understand that the choices are being made to help protect nurses.

Although these changes require significant time, effort, and monetary investment, enacting them can drastically reduce the injuries nurses face in the long term. Reducing injuries has a number of follow-on benefits including career longevity, reduced insurance and staffing costs for health systems, and better quality care through best practices adherence. Healthcare is an industry where workers encounter events that require situational judgments, in whether or not to apply these best practices. Regimenting this decision making process is a critical step forward in both cost savings and quality of care.

2 Comments

  • I. Elnatour April 14, 2015 2:22 pm

    Raghav and Nathan ,
    A great article and you are correct on all points; I do think there are some underlying effects that rarely come into consideration that I would like to shed some light on. 3 points I would like to touch upon.

    1. Physical abilities and inabilities. You state:
    “However, it is also vital for nurses to consider their physical capacity as they perform their duties. Taking the time to explain to patients how different situations will be handled, which equipment will be used, or that staff will be called, can help patients understand how their needs are being met. At the same time, it helps them understand that the choices are being made to help protect nurses.”
    This addresses the physical inabilities of a nurse, but fails to mention or acknowledge the abilities of the construction worker/physical skilled laborers. Those in the skilled labor industry are frequently tasked with their heavy lifting and as you mentioned nurses do it “sporadically” and infrequently (like my current workout plan…). With this and specifically in developing abilities as someone partakes in physically strenuous workouts in a controlled and structured environment they become stronger and more capable; also adding to the effect of a less likelihood of sustaining physical injury; the more you work out the more you can safely lift and the more your body can withstand and protect itself.

    2. The medical knowledge of a nurse vs that of a construction worker.
    Nurses are very familiar and see on a regular basis injuries and their diagnoses. They understand how one could get an injury, what an injury looks and a feels like, and how to determine or get diagnosed. I imagine that someone who has access to and understands the way to properly diagnose an injury are properly those who get them most often. I probably roll my ankle and hurt an elbow or a shoulder or a knee just as often as a nurse, a doctor, or an athlete, but unlike them a minor injury doesn’t become serious until it becomes debilitating or threatening. A nurse and other medical professionals understand injuries better and can diagnose a contusion or sprain/strain and will treat it also. An athlete on the other hand has much to lose/gain in keeping in tip top shape and so will also treat injuries in a different light. Lacking in this knowledge is the first barrier against proper treatment and assessment and so many injuries will go unnoticed and untouched.

    3. Social Stigma and stereotypes.
    In the construction and skilled labor industry it is commonly viewed as an industry with gusto and macho-ism to an extent. This macho-ism isn’t limited to men, but simply put you get a bunch of people in one place/field/industry acting one way and all others will mimic this behavior. The stigma is only half of the dilemma, but social stigma dictates that many in the skilled labor industry will “push/power through” the struggle and slowly nurse themselves back to health, excuse the pun. Similarly an injury may just be a light pressure and for many skilled labors this could mean the end of a job and put on permanent disability. As anyone in the medical field will know this lack of hope is devastating to a good psyche and a speedy recovery. Social stigma to get through the struggle and the potential to lose a respectable and high paying job are motivation enough for many people especially when everyone around them is doing the same.

    I hope I have shed some light on this.

    • Raghav Girijala April 15, 2015 9:29 am

      Elnatour,

      Thanks for reading! It’s good to see you’re dissecting and understanding the article through your own experiences.

      Reading your comment, I agree that there is a physical ability difference in the nurse and construction worker population. This does play a role in the incidence rate because, as you note, increased physical strength diminishes the likelihood of sustaining injury.

      At the same time, the issues we touch upon are musculoskeletal injuries specifically, which are generally debilitating in nature. From my understanding, although nurse reporting may be higher due to injury awareness and construction workers may report less due to social stigma for discussing injuries, the type of injury incurred would require treatment for any individual.

      Overall, I do agree with you that a combination of social stigma and physical abilities play a role in the injury rates of the two groups we’re discussing. Thanks for sharing your thoughts!

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