Healthcare Ergonomics Waters Review

Objective: The aim of this study was to assess the contributions of Thomas Waters’s work in the field of health care ergonomics and beyond.

Background: Waters’s research of safe patient handling with a focus on reducing musculoskeletal dis-orders (MSDs) in health care workers contributed to current studies and prevention strategies. He worked with several groups to share his research and assist in developing safe patient handling guidelines and curricu-lum for nursing students and health care workers.

Methods: The citations of articles that were pub-lished by Waters in health care ergonomics were evaluated for quality and themes of conclusions. Qual-ity was assessed using the Mixed Methods Appraisal Tool and centrality to original research rating. Themes were documented by the type of population the citing articles were investigating.

Results: In total, 266 articles that referenced the top seven cited articles were evaluated. More than 95% of them were rated either medium or high quality. The important themes of these citing articles were as follows: (a) Safe patient handling is effective in reduc-ing MSDs in health care workers. (b) Shift work has negative impact on nurses. (c) There is no safe way to manually lift a patient. (d) Nurse curriculums should contain safe patient handling.

Conclusion: The research of Waters has contrib-uted significantly to the health care ergonomics and beyond. His work, in combination with other pioneers in the field, has generated multiple initiatives, such as a standard safe patient-handling curriculum and safe patient-handling programs.

Keywords: safe patient handling, shift work, lift assist devices, musculoskeletal disorders

IntroductIonDuring his 30-plus years working at the

National Institute for Occupational Safety and Health (NIOSH), Thomas Waters made major contributions to the field of occupational ergonomics. Although his contributions were impactful in many industries, his passion was evident for the health care industry, where he was an active researcher and promoter of safe patient-handling practices. Waters is one of many pioneers and leaders of health care ergonomics and safe patient handling. Others, such as Audrey Nelson, Bernice Owen, Arun Garg, and Guy Fragala, have also worked exten-sively in protecting nurses and advocating for safer workplace practices in health care facili-ties (Potts, 2014). These pioneers have been instrumental in researching the key factors that relate to musculoskeletal disorders (MSDs) for nurses in a wide variety of health care settings: hospitals, long-term care, and home care. Their research has led to numerous nationwide nurse safety and training initiatives, including the Nurse and Healthcare Worker Protection Act (Nelson, Collins, et al., 2007). Waters’s work in health care ergonomics was instrumental in setting standards for health care workers who commonly lift patients (e.g., need some type of list assist device if patient weighs over 35 lbs.) as well as setting the standard for curricula for safe patient handling in nursing schools.

The current review focused on the contribu-tion of Waters’s work in health care ergonomics. Waters published articles that focus on health care ergonomics and safe patient handling, many of which were cited by peer-reviewed research studies. Of those 27 articles, 15 were cited a total of 358 times by peer-reviewed papers from vari-ous researchers and practitioners in health care and safe patient handling. His work in health care ergonomics has also been referenced in other fields, such as the automotive and con-struction industries. In general, his published

648553 HFSXXX10.1177/0018720816648553Human FactorsWaters’s Contribution to Health Care Ergonomics

Address correspondence to Kermit G. Davis, PhD, University of Cincinnati, Low Back Biomechanics and Workplace Stress Laboratory, 3223 Eden Ave., Kettering Lab, Cincinnati, OH 45267-0056, USA; e-mail: [email protected].

Health Care Ergonomics: Contributions of Thomas Waters

Tiffany Poole Wilson and Kermit G. Davis, University of Cincinnati, Ohio

HUMAN FACTORSVol. 58, No. 5, August 2016, pp. 726 –747DOI: 10.1177/0018720816648553Copyright © 2016, Human Factors and Ergonomics Society.

SPECIAL SECTION: Impact of Thomas Waters on the Field of Ergonomics

by guest on July 6, 2016hfs.sagepub.comDownloaded from

http://hfs.sagepub.com/

Waters’s Contribution to HealtH Care ergonomiCs 727

work focused on nurses in the long-term care and home health care sectors.

MethodThe aim of the current review was to evalu-

ate the scientific merit of the articles published by Waters in health care ergonomics by deter-mining the contribution they had in the field through cited work. The first step of the review was to use Waters’s NIOSH curriculum vitae to develop a list of his published articles focusing on health care ergonomics or safe patient han-dling. In addition, a search on Google Scholar and ISI Web of Science identified and verified the total number of articles that Waters pub-lished in health care. The search was completed between January and March of 2015 and thus included all articles up to March 31, 2015. The search included only articles written in English. The papers identified were further evaluated to identify any peer-reviewed articles citing one of Waters’s articles. These articles were the focus of the current review with respect to Waters’s contribution to health care ergonomics.

An Excel worksheet was developed for the articles with at least one citation and included information on title, author, journal, study popu-lation, and summary of results. The articles were also classified by publication type, such as pam-phlet, training material, article, and textbook content material. Articles were further classified by theme to provide more understanding of the areas impacted by Waters’s research.

The Waters articles cited more than 16 times were evaluated for quality using the Mixed Meth-ods Appraisal Tool (MMAT). A cut point of 16 citations was chosen to ensure a reasonable num-ber of articles for discussion and to capture the articles that had the most contribution and reach in the field. MMAT is a critical appraisal tool that assesses the quality of study designs. Each article was reviewed to determine the study type: qualita-tive, quantitative randomized controlled, quantita-tive nonrandomized, quantitative descriptive, and mixed methods. For each study type, there were quality criteria an article had to meet, and each cri-terion equaled one point. The number of points the article scored was then divided by the total num-ber of criteria items and multiplied by 100, provid-ing a percentage. Articles that cited Waters’s work

were rated as 1 = low, less than 25% on quality scores; 2 = medium, between 25% and 75% on quality scores; and 3 = high, greater than 75% on quality scores (Pluye & Hong, 2014). Several cita-tion articles did not fit the review criteria as they were either review articles or opinion pieces, thus could not be rated for quality and were eliminated from this part of the review. References for the articles included in the review of quality are included in supplemental data and can be provided upon request.

The high-quality articles were further assessed for centrality based on Waters’s cited research. A 1-to-5 scale was used and described as the following: 1 = extremely central, 2 = semi-central (75% of the article centrally related to original work), 3 = neutral (50% of article centrally related to original work, 4 = semi-unrelated (25% of the article centrally related to original work, and 5 = completely unrelated. This was used to provide an under-standing of the contribution of Waters’s research and the continuation of his findings through other studies.

resultsThe Google Scholar and ISI Web of Science

search yielded 27 articles, and the secondary review for quality evaluation yielded 15 articles with at least one citation. In total, these 15 articles were cited 498 times. Review of the citations resulted in a total of 358 citations after filtering for English publications and repeat list-ings. Waters’s 27-article portfolio contained a variety of research methods, including literature reviews (13), field studies (four), laboratory studies (two), and opinion pieces (eight). Table 1 provides details about the citations for each article: study population of Waters’s article, number of citations, and study population for citation article.

Waters’s top-cited articles focused on MSDs and safe patient handling. The top-cited article (Waters, Collins, Galinsky, & Caruso, 2006) reported on efforts to prevent MSDs in the health care industry (65 citations). Waters’s top-cited articles focused on MSDs and the need to not lift patients manually—safe patient handling. Although his work was cited 88% of the time by articles that had a sample population in the

(text continues on p. 730)



728 August 2016 - Human Factors

TAblE 1: Summary of Articles That Cite Waters’s Work on Health Care and Safe Patient Handling

Article Study Population CitationsStudy Population for Citation Article (Number of Articles)

“NIOSH Research Efforts to Prevent Musculoskeletal Disorders in the Healthcare Industry” (Waters, Collins, Galinsky, & Caruso, 2006)

Health care workersOrthopedic nurses

65 Nurses (18), health care workers (11), patients (4), physical therapists (4), nursing assistants (3), military personnel (2), hospital nurses (2), workers (2), bariatric nurses (2), pediatric nurses (2), occupational therapists (2), home caregivers (2), pregnant nurses (1), nursing home caregivers (1), EMS workers (1), ophthalmologic patients (1), orthopedic nurses (1), radiologic patients (1), robotic nurses (1), nonnursing health care (1), health care environment (1), clinical nurses (1), day care workers (1)

“When Is It Safe to Manually Lift a Patient?” (Waters, 2007)

NursesHealth care workers

57 Health care workers (20), nurses (15), home health care (6), physical therapists (3), operative staff (3), bariatric caregivers (3), occupational therapists (2), orthopedic nurses (2), geriatric caregivers (1), physiotherapists (1), military personnel (1), railroad industry (1)

“A Review of Work Schedule Issues and Musculoskeletal Disorders With an Emphasis on the Health Care Sector” (Caruso & Waters, 2008)

Health care workers 34 Hospital nurses (12), health care workers (5), workers (3), rehabilitation nurses (2), dental students (2), cleaners (1), construction workers (1), industrial workers (1), physical therapists (1), petroleum workers (1), mechanics (1), surgeons (1), hotel workers (1), low-income women (1), patients (1), geriatric patients (1)

“Patient Handling Tasks With High Risk for Musculoskeletal Disorders in Critical Care” (Waters, Nelson, & Proctor, 2007)

Critical care nurses 29 Nurses (14), health care workers (6), physical therapists (1), occupational therapists (1), radiologists (1), bariatric caregivers (1), male cameramen (1), physical therapist students (1), home health care workers (1), female at home washing clothes (1), workers (1)

(continued)





“Overexertion Injuries in Home Health Care Workers and the Need for Ergonomics” (Galinsky, Waters, & Malit, 2001)

Home health care workers

28 Home health care workers (13), nurses (3), physical therapists (2), hospital nurses (2), health care workers (2), teachers (1), chiropractors (1), orthopedic nurses (1), pharmaceutical sales (1), EMS (1), hospital nurses (1), consumer product designer (1), cold case investigation (1)

“Preventing Musculoskeletal Disorders in Nurses: A Safe Patient Handling Curriculum Module for Nursing Schools” (Menzel, Hughes, Waters, Shores, & Nelson, 2007)

Nurses 19 Nurses (8), health care workers (3), occupational therapists (1), physical therapists (1), nursing students (1), patients (1), health care (1), physiotherapists (1), air transportation (1) orthopedic nurses (1), critical care nurses (1)

“Development of the National Association of Orthopaedic Nurses Guidance Statement on Safe Patient Handling and Movement in the Orthopaedic Setting” (Sedlak, Doheny, Nelson, & Waters, 2009)

Orthopedic nurses 19 Nurses (9), health care workers (6), physiotherapist (1), occupational therapist (1), orthopedic nurses (1), patients (1)

“Safe Patient Handling for Rehabilitation Professionals” (Waters & Rockefeller, 2010)

Physical therapistsRehabilitation nurses

15 Nurses (8), physical therapists (6), occupational therapists (1)

“Comparison of Required Operating Forces Between Floor-Based and Overhead-Mounted Patient Lifting Devices” (Rice, Woolley, & Waters, 2009)

Patient transfer staff 15 Health care workers (7), nurses (2),physical therapists (1), construction workers (1), 16- and 17-year-old workers (1), occupational therapist (1), elderly patients (1), long-term care (1)

“Effectiveness of an Evidence-Based Curriculum Module in Nursing Schools Targeting Safe Patient Handling and Movement” (Nelson, Waters, et al., 2007)

Nursing educators and students

8 Health care workers (3), nurses (2), optometry students (1), physical therapy students (1), nursing students (1)

TAblE 1: (continued)

(continued)




health care field, it was also referenced by 37 articles from non–health care worker popula-tions, including military personnel, construction workers, manufacturing personnel, patients, designers, technicians, and industrial workers. In all, his work had a wide reach on not only health care but other industries.

Citations from Waters’s top-cited articles were analyzed for quality, and their major themes from their conclusions were classified.

For this analysis, articles cited more than 16 times were selected, resulting in seven articles (Table 2). In all, 266 articles cited these seven Waters articles and were rated for quality. How-ever, 95 did not fit review criteria and were excluded from Table 2.

Most of the citations were rated at medium or high quality (99% of cited articles), and Waters’s content was positively referenced (Table 2). The Waters et al. (2006) article was cited by two


“Suggestions for Preventing Musculoskeletal Disorders in Home Health Care Workers. Part 2: Lift and Transfer Assistance for Non-Weight-Bearing Home Care Patients” (Parsons, Galinsky, & Waters, 2006b)


7 Home health care workers (5), health care workers (1), EMS (1)

“Suggestions for Preventing Musculoskeletal Disorders in Home Health Care Workers. Part 1: Lift and Transfer Assistance for Partially Weight-Bearing Home Care Patients” (Parsons, Galinsky, & Waters, 2006a)


7 Home health care workers (6), health care workers (1)

“Recommendations for Turning Patients With Orthopaedic Impairments” (Gonzalez, Howe, Waters, & Nelson, 2009)

NursesPatient caregivers

7 Health care workers (5), ER nurses (1), home health care nurses (1)

“Introduction to Ergonomics for Healthcare Workers” (Waters, 2010)

Health care workers 5 Health care workers (2), nurses (2), rehabilitation nurses (1)

“Recommended Weight Limits for Lifting and Holding Limbs in the Orthopaedic Practice Setting” (Waters et al., 2009)

NursesPatient caregivers

3 Surgeons (1), nurses (1), females (1)

Note. EMS = emergency medical services; ER = emergency room.





TAblE 2: Quality Rankings, Study Populations, and Conclusions From Articles Citing Waters’s Most-Cited Articles

Waters Article Title

Quality RankingsStudy

Population ConclusionLow Medium High

“NIOSH Research Efforts to Prevent Musculoskeletal Disorders in the Healthcare Industry” (Waters, Collins, Galinsky, & Caruso, 2006)

0

0

0

2

1

1

1

1

3

Nurses Ergonomic programs need participatory teams and patient-handling devices to reduce injuries

Ceiling lifts should be utilized over floor lifts when reducing musculoskeletal injuries

Evidence-based safe patient-handling curriculum is beneficial for faculty and students

0 1 0 Rotating two-shift system is significantly associated with sleeping issues

0 1 0 Safe patient-handling programs benefit patients and workers, no hindrance to rehabilitation

0 2 3 Combination of different safe patient-handling interventions is the best method for handling tasks

0 1 0 Age is not a risk factor for perceived poor general or emotional health

0 0 1 Nurses are at risk of injury when trying to balance work and family expectations

0 1 0 Health care workers

Musculoskeletal injury prevention programs are necessary for patient handling

0 0 1 Social relationship and job control are important factors of successful intervention efforts

0 1 0 Patient handling is the only significant risk factor among all risk factors based on 7 years claims data

(continued)







0 1 0 Patient mobilization through the use of body mechanics alone increases the risk of injury

0 1 0 Computerization saves time but requires monitoring to avoid errors

1 1 0 Perception of physical exertion effects outcome of chronic pain

0 1 0 Interventions should take into account environmental, cultural, social, and health-related issues

0 1 0 Patients Increased economic burden for older hospital workers due to medical treatment

0 2 1 Nursing assistants

Nursing assistants are exposed to the same MSD risk factors as nurses; African Americans and Hispanics are less likely to report injuries or have health insurance

0 1 1 Military personnel

Matrix developed to categorize MSD injuries and conditions

0 1 0 MSDs in the knee, foot, shoulder, forearm, ankle, and lower leg are prevalent in armed personnel

0 1 0 Workers Sociodemographic characteristics and job traits may be predictors of compensation claims

0 0 2 Physical therapists

Older physical therapists are more at risk of WMSDs

0 0 1 Adaption of job factors should include psychometric properties for physical therapists

0 0 1 Orthopedic nurses

Body mechanics are no longer sufficient methods to prevent MSD injuries; need lift assist device


(continued)







0 1 0 Bariatric caregivers

Growing bariatric patient population suggests a need for more patient-handling and injury research

0 1 0 Pediatric nurses Daily caregivers of pediatrics are at risk of suffering MSDs during caretaking activities

0 1 0 Occupational therapists

Occupational therapists and assistants experience MSDs at similar rates to physical therapists and nursing practitioners

0 0 1 Home caregivers

Institutional health care facilities have higher rates of violence on caregivers than home health care

0 1 0 Personal assistance services providers are at increased risk for WMSDs

0 1 0 Nursing home caregivers

Patient handling is physically demanding and associated injuries are more likely to result in days away from work

0 0 1 EMS workers Intervention programs benefit EMS workers with patient-handling tasks

0 0 1 Ophthalmology patients

Alternative slit lamp biomicroscope will reduce overall muscular demands and non-neutral postures of the neck and shoulder region among ophthalmologists

0 1 0 Robotic nurses Robotic nursing systems will prevent exposure to MSD risk factors

0 1 0 Non-nursing health care

Psychosocial and physical hazards are important to predict WMSD risk

1 1 0 Health care environment

Natural lighting or views of nature for patient caregivers result in more alert and less stressed staff


(continued)







0 0 3 Bed design features have effect on physical demands and usability

0 0 1 Day care workers

Child care tasks involve exposure to MSD risks through lifting and awkward postures

“When Is It Safe to Manually Lift a Patient?” (Waters, 2007)

0

0

0

2

3

2

Health care workers

Ceiling-based lifts are preferable to floor-based patient transfer systems

Safe patient handling programs reduce health care worker MSDs without impacting patient’s functional outcomes

0 1 0 Use of a mechanical lift device must consider patient status, caregiver, and environment

0 0 1 Sliding patients up in bed may contribute to increased risk of musculoskeletal injuries in caregivers

0 0 1 Injury rates were significantly reduced at post-training of STEPS safe patient-handling program

0 0 1 Spine shrinkage is dependent on posture in health care workers

0 1 0 Patient air transporters need research and development of safe patient-handling procedures

0 0 1 Mechanical lift devices, if not implemented properly, have the potential to increase risk for nurses

0 0 2 Nurses MSDs are significantly associated with patient-handling tasks

0 0 1 Successful adoption of patient lift-assist devices varies based on the hospital and unit


(continued)







0 0 1 Workers’ compensation claims reduced when compared to pre-implementation incidence rates

0 1 0 Nurses prefer manual patient-handling techniques over safe patient-handling techniques

0 1 0 Major need for research into diagnostic studies for pressure-related tissue death

0 0 2 Multifaceted and comprehensive approach to developing an ergonomic program is needed

0 0 1 Nurses underestimate the amount of patient-handling tasks performed, especially repositioning

0 1 0 Home health care

It is difficult to determine injury risk for home health care workers; continued research is needed

0 1 0 Informal caregivers experience significant MSD discomfort, which interferes with ability to provide care

0 1 0 Bariatric patients need special care when transferring from the hospital to home health care

0 1 0 MSD discomfort is significant for informal caregivers; interferes with ability to provide care


Physical therapists have more LBP than nurses due to performing more manual transfers

0 1 0 LBP is the most significant for physical therapist under the age of 30


(continued)







0 1 0 Operative staff Potential intervention is a multifunctional bed designed to reduce MSDs in caregivers

0 1 1 Bariatric caregivers

Effective patient-handling systems are needed to reduce the risks associated with bariatric patient

0 0 1 Assessment tool for emergency departments to determine readiness for bariatric patients

0 0 1 Orthopedic nurses

Clinical tool to assist facilities with recommended weight limits for lifting and holding limbs

0 1 0 Geriatric caregivers

Combination of biomechanical aids with lower friction between patient and surfaces is recommended

0 0 1 In developing countries, health care workers benefit from low-cost mechanical transfer devices

0 0 1 Military personnel

Military staff have MSDs in the low back, neck, knee, and shoulders

0 1 0 Railroad industry

Biomechanical applications utilized in industry are useful to better understand and control MSDs

“A Review of Work Schedule Issues and Musculoskeletal Disorders with an Emphasis on the Healthcare Sector” (Caruso & Waters, 2008)

0

0

0

0

1

1

Hospital nurses

Middle- and high-stress groups had higher pain than the low-stress group for all body areas

Consecutive shifts of 2 or more days and a variety of cumulative shifts over a week and month period were associated with increased injury rates


(continued)







0 1 0 Patient Transfer Assessment Instrument was found to be an appropriate tool for MSD risk identification for patient handling


Implementation of the FINALE program improved job performance and reduced MSDs

0 3 1 Home health care workers experience more MSDs comparable to nursing homes and hospitals

0 0 1 Greater risk for violent assaults to workers in home health care than in nursing homes or hospitals

0 1 0 Transformational leadership in home health care improves performance and reduces injuries

0 1 0 Informal caregivers need improved hazard assessments and training to reduce MSDs

0 1 0 Frequent housecleaning and manual patient handling are most common tasks for home health care

0 0 1 One successful approach for home health care workers is Community of Practice and Safety Support for total worker health

0 0 1 Workers Physical load can be used to determine the persistence of multisite pain

0 1 0 Sleep deprivation increases risk of injury

0 0 1 Female homemakers

Ergonomic stressor, such as large number of housework hours, is associated with back pain and discomfort in the upper and lower extremities


(continued)







0 0 1 Dental students Dentists have a high prevalence of skeletal muscle system legions due to job tasks and require an occupational health program to prevent injuries throughout their careers

0 3 0 Cleaners, construction and industrial workers

Implementation of the FINALE program displayed improvement job performance and reduced MSDs


Physical therapists were susceptible to LBP and hand injuries with muscle strain

0 0 1 Petroleum workers

Shift type and sleep duration associated with age and workers in swing and normal shifts

0 1 0 Patients Increased patient weight places health care workers at risk when performing patient handling

0 1 0 Geriatric patients

MSDs are associated with impairments in psychological well-being

“Patient Handling Tasks With High Risk for Musculoskeletal Disorders in Critical Care” (Waters, Nelson, & Proctor, 2007)

0

0

0

1

1

0

Nurses Ceiling mounted patient lift systems are considered safe based on lumber spine forces

Nursing activities exposed nurses to increased risk of LBD regardless of nursing techniques, personal characteristics, and non-work-related factors

0 1 0 Top 10 most demanding patient-handling tasks were identified; repositioning most frequent


(continued)







0 0 1 Nighttime nurses have lower heart rates and muscle activity

0 0 1 Shift workers have a higher rate of MSDs than day workers

0 0 1 Shift determines muscle load, heart rate, and time pressure for health care workers

0 1 0 Overtime work is associated with poor or falling patient safety resulting in work left uncompleted


Focus group of health care providers identified MSD risk factors: work postures and movements, lifting and carrying, patient-related factors, and repetitive tasks

0 0 3 Intervention group had 38% lower odds of having repeated injury compared to the control group

0 0 1 Bed design: steering lock and adjustable height reduced demands during transportation tasks

0 1 0 Longer intervention times for patient-handling programs are beneficial

0 2 1 Movement and Assistance of Hospital Patients screening is potentially beneficial tool to estimate risk associated with handling patients

0 1 0 Surgeons Increased risk of MSDs for surgeons as a result of personal and occupational condition

0 1 0 Dental students

Dental students have high body twisting and cervical flexion when obtaining vision of patients


(continued)







0 0 1 Mechanics Injuries among automobile repair workers were increased in poor work environments, issues with machinery and tools, poor health and psychosocial stressors

0 1 0 Workers MSD prevention efforts should be directed to non–patient care occupations

0 1 0 Carpal tunnel syndrome is higher for women and increases linearly with age

0 0 1 Hotel workers: MSDs were 1.9 times higher among male hotel kitchen workers than among room workers; posture and sleep satisfaction had an effect on injury rates

“Overexertion Injuries in Home Health Care Workers and the Need for Ergonomics” (Galinsky, Waters, & Malit, 2001)

0

0

0

1

1

0


Need to improve health and safety for low-income elderly and disabled patients in home health care

Health care workers are exposed to musculoskeletal risks while caring for patients

0 0 1 Hospital nurses Powered beds resulted in significantly lower muscle activation levels than manual pushing

0 0 1 Low back, shoulder, and neck were the top injury regions in LPN activities


Physiotherapists have a high rate of MSDs as a result of exposures related to their profession

0 1 0 Both manual and safe patient-handling methods are taught in most occupational therapy programs


(continued)







0 0 2 Manually repositioning patients with draw sheets increased friction and transfer time, low-friction slider systems reduce muscular and perceived effort

0 2 0 Multidimensional approach to manual patient handling is encouraged

0 1 0 Teachers Teachers are at risk of pain in the neck, shoulders, low-back regions; reduction requires elimination of heavy loads, awkward postures, repetitive motions, and psychosocial stressors

0 0 1 Chiropractors Chiropractic doctors have increased injury risk due to lateral flexion of back during manipulations

0 1 0 Cameramen Most serious MSDs of male cameramen was for the shoulder


High prevalence of MSDs for physical therapy students

0 0 1 ER Effective assessment tool developed to assist ER staff for morbidly obese patients

“Preventing Musculoskeletal Disorders in Nurses: A Safe Patient Handling Curriculum Module for Nursing School” (Menzel, Hughes, Waters, Shores, & Nelson, 2007)

0

0

0

2

1

0

1

0

1

Nurses Evidence-based safe patient-handling nursing curriculum module found to be beneficial

Clinical nurse specialist can promote safe patient handling to reduce injury rates

High prevalence of MSDs was associated with psychosocial stress


(continued)








Safe patient handling was found to be effective in reducing exposures and injuries

0 1 0 Occupational therapists

Patient transfers should be taught with both safe patient-handling and mechanical lifts


Training improved confidence in assessment of patient and appropriate safe patient-handling technique/equipment

0 1 0 Nursing students

Integration of behavior change theory and knowledge/skills in a curriculum will result best program

0 1 0 Patients Existing services in airline industry do not meet assistance needs for immobile passengers

0 1 0 Health care Detecting existing tissue damage early will assist with implementing appropriate care plans

0 0 1 Critical care nurses

Ergonomic assessments in critical care and nursing homes are beneficial tools

“Development of the National Association of Orthopaedic Nurses Guidance Statement on Safe Patient Handling and Movement in the Orthopaedic Setting” (Sedlak, Doheny, Nelson, & Waters, 2009)

0

0

1

1

0

0

Nurses Evidence-based safe patient-handling programs benefit the safety of the nurse and patients, reduce injuries, and decrease workers’ compensation costs

Nurse-driven protocol is a beneficial intervention found to improve patient outcomes, reduce immobility complications, and decrease cost


(continued)







0 0 1 Therapist Perceived risk factors, such as work postures and movements, lifting or carrying, and repetitive tasks, limit the capacity of health professionals to work in physically demanding roles

0 0 1 Rehabilitation Safe patient-handling programs do not inhibit patient recovery; therefore mechanical lifting and transferring devices do not interfere with patient treatment plans

0 1 0 Orthopedic The orthopedic clinical tool for lifting and holding limb should be used; was found to provide guidance with decision by utilizing patient body weight

0 1 0 Ergonomic tool designed to assist caregivers in determining when patient-handling equipment should be incorporated into ambulation in an orthopedic setting, found to increase safety for both the caregiver and the patient, while also reducing unnecessary variation in common practices

0 1 0 Health care industry

Change to programs requires collaborative practice and interactions of key components, including individual practitioners, needs and interests of the organizational leaders, and manufacturers

Note. EMS = emergency medical services; ER = emergency room; LBD = low-back disorder; LBP = low-back pain; LPN = licensed practical nurse; MSD = musculoskeletal disorder; WMSD = work-related MSD.





low-, 29 medium-, and 23 high-quality articles. The top conclusions for these articles were that (a) safe patient handling programs are effective if they utilize lift assist devices, (b) patient han-dling is demanding and places workers at risk, (c) patient handling is not the only risk factor for MSDs, (d) demands in health care are more demanding on older workers, and (e) safe patient handling needs to be in curricula.

Waters (2007) recommended that there was no way to safely lift a patient, and the recom-mended level of weight for patient handling should be 16 kg (35 lbs.). Fifteen citing articles were rated at medium quality, and 22 were rated high quality. The articles concluded that (a) lift devices, when used correctly, are effective in controlling MSDs; (b) special patient popula-tions (aging and bariatric) will affect safe patient handling; and (c) patient handling is a risky activity for health care workers.

Caruso and Waters (2008) published a review of work schedules in the health care sector. The paper concluded there is a potential relationship between work schedule and MSDs. However, the literature review revealed limited studies that adequately examined the relationship and goes on to express the importance of additional research in this area. The papers that cited this paper were all rated at medium or better quality (14 medium and 10 high quality). The takeaway messages from these papers were that (a) home health care workers have different exposures than long-term and hospital health care workers, (b) shift work affects the health of workers, and (c) high physical demands have an impact in many industries.

The Waters, Nelson, and Proctor (2007) arti-cle documented patient handling in the critical care setting. The article recommended critical care nurses be provided with appropriate equip-ment and techniques to safely perform patient-handling tasks and reduce MSD injuries. Over-all, articles citing the Waters et al. (2007) article were rated as medium (11) and high (11) quality. The general conclusions of these articles were that (a) patient-handling tasks are related to MSD development, and repositioning patients is the riskiest task; (b) shift work has an impact on health care worker health; and (c) intervention can be effective in controlling MSDs.

Authors of another paper (Galinsky, Waters, & Malit, 2001) investigated overexertion inju-ries in home health care workers and determined introducing ergonomic solutions as the most promising injury prevention approach. Appro-priate implementation is beneficial for the safety for the workers and patients. Articles citing this paper were rated at or above medium for all arti-cles citing the paper (zero low, seven medium, and eight high). The concluding themes of these citing articles were that (a) there is a need to reduce heavy demands for health care workers, (b) lift-assist devices are effective in reducing risk to health care workers, and (c) nurses are not the only ones at risk of low-back injuries; physical therapists and chiropractors are at ele-vated risk.

Menzel, Hughes, Waters, Shores, and Nelson (2007) assessed the outcomes of a safe patient-handling curriculum model for nursing school participants. This case study concluded with supporting the inclusion of safe patient-handling information in the nursing curriculum to benefit the future nursing workforce. Citing articles were rated as medium (eight) and high (four) quality. General conclusions were that (a) safe patient handling is effective in reducing MSDs, (b) nurses should be trained in both manual and equipment-based patient handling techniques, and (c) high prevalence of MSDs is associated with psychosocial stress.

The Sedlak, Doheny, Nelson, and Waters (2009) article provided guidelines for safe patient handling in orthopedic settings, includ-ing orthopedic algorithms for safe patient han-dling. In total, there were five medium- and two high-quality articles citing the Sedlak et al. article. Based on these articles, the fol-lowing conclusions were provided: (a) safe patient-handling programs, including mechan-ical devices, do not inhibit recovery for reha-bilitation patients; (b) evidence-based safe patient-handling programs benefit caregivers and patients; and (c) perceived risk factors limit the capacity of nurses to work in physi-cally demanding roles.

High-quality articles were further assessed to rate centrality of the Waters article on a scale of 1 to 5. The scale is broken down using the fol-lowing descriptions:




1 = extremely central2 = semi-central (75% of the article centrally related

to original work)3 = neutral (50% of article centrally related to origi-

nal work)4 = semi-unrelated (25% of the article centrally

related to original work5 = completely unrelated

Waters’s article “NIOSH Research Efforts to Prevent Musculoskeletal Disorders in the Healthcare Industry (Waters et al., 2006) was cited by 23 high-quality studies. Sixty percent of these articles were found to be extremely cen-tral, and only 8% were semi-unrelated. “When Is It Safe to Manually Lift a Patient?” (Waters, 2007) was cited by 23 high-quality studies and resulted in 43% of the articles being semi- central and 35% extremely central. Waters’s review of the relationship between work sched-ule and musculoskeletal disorders in the health care sector (Caruso & Waters, 2008) was cited by 14 high-quality studies. Thirty-five percent were extremely central and 35% were semi-unrelated. Waters, Nelson, and Proctor’s (2007) research on patient handling in critical care was cited by 10 high-quality articles, with 70% rated as semi-central. Six high-quality articles cited overexertion injuries in home health care work-ers and the need for ergonomics (Galinsky et al., 2001), with 50% of them rated as extremely cen-tral. Waters’s article investigating the prevention of musculoskeletal disorders in nurses was cited

four times by high-quality studies, with 50% rated as semi-central and 25% extremely cen-tral. Sedlak et al.’s (2009) guidance statement was cited by two high-quality studies, with both being rated as extremely central.

Overall, 40% of the high-quality studies were rated as extremely central and 35% rated as semi-central. None of the studies were rated as completely unrelated. Based on this rating sys-tem, 75% of the high-quality studies that cited Waters were extremely central or semi-central to the original work, furthering his contributions to the health care industry (Table 3).

dIscussIonThe impact of Waters’s research has reached

far beyond his work on the popular Revised NIOSH Lifting Equation. As seen from this review, Waters’s work has made a tremendous contribution to the health care industry, specifi-cally, safe patient-handling initiatives. Although other articles may be more highly cited, Waters had a very relevant impact on the field of health care ergonomics and often collaborated with other pioneers in this research area. He worked on developing guidelines for major nursing asso-ciations for safe patient handling as well as developing curriculum standards for nursing pro-grams in higher education. One of the most impressive aspects of Waters’s work in health care and safe patient handling was that although this work focused on the health care worker and nurses, it was oftentimes utilized as relevant

TAblE 3: High-Quality Studies Centrality Rating

ArticleHigh-Quality

StudiesExtremely

CentralSemi-

Central NeutralSemi-

UnrelatedExtremely Unrelated

Waters, Collins, Galinsky, & Caruso (2006)

23 60% 17% 13% 9% 0%

Waters (2007) 23 35% 44% 4% 17% 0%Caruso & Waters (2008) 14 36% 29% 0% 36% 0%Galinsky, Waters, & Malit (2001) 6 50% 33% 0% 17% 0%Waters, Nelson, & Proctor (2007) 10 10% 70% 0% 20% 0%Menzel, Hughes, Waters, Shores,

& Nelson (2007)4 25% 50% 0% 25% 0%

Sedlak, Doheny, Nelson, & Waters (2009)

2 100% 0% 0% 0% 0%




evidence for more than 30 other industries. Another strong indication of the impact of Waters’s work is the high percentage of good-quality papers (98% at medium or high quality) referring to his work. High-quality studies were found to be extremely or semi-central in 75% of the articles. This find-ing means the original works of Waters continued to be supported through similar-themed research, signifying his continued contribution to the health care industry.

Waters’s work was positively referenced by all citations. His research served as foundational evi-dence to many of these citing articles. The linkage between his work and the citing articles lead to more diverse conclusions than what was con-cluded in his work. Some of the important themes of these conclusions were as follows: (a) Safe patient handling is effective in reducing MSDs in health care workers, (b) shift work has a negative impact on nurses, (c) there is no safe way to manu-ally lift a patient, and (d) nurse curricula should contain safe patient handling. Each of these has the potential to have continued impact on the field of health care, well beyond the career of Waters.

Although the literature reviewed in this unique review provided some general insights into several of the major concerns for health care workers, the review does have a few limiting concerns. First, for each of the concluding themes, the review was not comprehensive, which does not allow a true understanding of the evidence for these themes. Other research could provide further insight that may or may not sup-port these themes. This review was not meant to be a completely conclusive review but rather was intended to identify the key areas to which Waters contributed and his impact in the field of health care ergonomics. Second, the impact of Waters’s work will continue to grow and expand, which means the current themes and the strength of the evidence supporting them will change over time. The main purpose of this review was to provide insight into the impact of the work of Tom Waters. It was clear that his work has and will be an everlasting contribution to the world of health care ergonomics.

Key PoInts • This article provided insight into the contribution

of Tom Waters’s work.

• Review of the literature detailed his contributions to the world of health care ergonomics.

• Industries benefiting from his research were also identified.

• His research contributions will continue to influ-ence health care ergonomics through future proj-ects by other researchers.

suPPleMentary MaterIalSee the online appendix at http://hfs.sagepub

.com/supplemental for list of reviewed articles in addition to these references.

referencesCaruso, C. C., & Waters, T. R. (2008). A review of work schedule

issues and musculoskeletal disorders with an emphasis on the healthcare sector. Industrial Health, 46, 523–534.

Galinsky, T., Waters, T., & Malit, B. (2001). Overexertion injuries in home health care workers and the need for ergonomics. Home Health Care Services Quarterly, 20, 57–73.

Gonzalez, C. M., Howe, C. M., Waters, T. R., & Nelson, A. (2009). Recommendations for turning patients with orthopaedic impairments. Orthopaedic Nursing 28(2 Suppl.), S9–12.

Menzel, N. N., Hughes, N. L., Waters, T., Shores, L. S., & Nelson, A. (2007). Preventing musculoskeletal disorders in nurses: A safe patient handling curriculum module for nursing schools. Nurse Educator, 32, 130–135.

Nelson, A. L., Collins, J., Knibbe, H., Cookson, K., De Castro, A. B., & Whipple, K. L. (2007). Safer patient handling. Nursing Management, 38(3), 26–32.

Nelson, A. L., Waters, T. R., Menzel, N. N., Hughes, N., Hagan, P. C., Powell-Cope, G., Sedlak, C., & Thompson, V. (2007). Effective-ness of an evidence-based curriculum module in nursing schools targeting safe patient handling and movement. International Jour-nal of Nursing Education Scholarship, 4, Article26.

Parsons, K. S., Galinsky, T. L., & Waters, T. (2006a). Suggestions for preventing musculoskeletal disorders in home health-care workers: Part 1. Lift and transfer assistance for partially weight-bearing home care patients. Home Healthcare Nurse, 24, 158–164.

Parsons, K. S., Galinsky, T. L., & Waters, T. (2006b). Suggestions for preventing musculoskeletal disorders in home healthcare workers: Part 2. Lift and transfer assistance for non-weight-bearing home care patients. Home Healthcare Nurse, 24, 227–233.

Pluye, P., & Hong, Q.-N. (2014). Combining the power of stories and the power of numbers: Mixed methods research and mixed studies reviews. Annual Review of Public Health, 35, 29–45.

Potts, L. (2014). The importance of the safe patient handling and mobility movement today. Rifton, NY: Rifton.

Rice, M. S., Woolley, S. M., & Waters, T. R. (2009). Comparison of required operating forces between floor-based and overhead-mounted patient lifting devices. Ergonomics, 52, 112–120.

Sedlak, C. A., Doheny, M. O., Nelson, A., & Waters, T. R. (2009). Development of the National Association of Orthopaedic Nurses guidance statement on safe patient handling and move-ment in the orthopaedic setting. Orthopaedic Nurse, 28(2 Suppl.), S2–8.


http://hfs.sagepub.com/supplemental

http://hfs.sagepub.com/supplemental



Waters, T. R. (2007). When is it safe to manually lift a patient? American Journal of Nursing, 107(8), 53–58.

Waters, T. R. (2010). Introduction to ergonomics for healthcare workers. Rehabilitation Nursing, 35, 185–191.

Waters, T., Collins, J., Galinsky, T., & Caruso, C. (2006). NIOSH research efforts to prevent musculoskeletal disorders in the healthcare industry. Orthopaedic Nursing, 25(6), 380–389.

Waters, T. R., Nelson, A., & Proctor, C. (2007). Patient handling tasks with high risk for musculoskeletal disorders in critical care. Critical Care Nursing Clinics of North America, 19, 131–143.

Waters, T. R., & Rockefeller, K. (2010). Safe patient handling for rehabilitation professionals. Rehabilitation Nursing, 35, 216–222.

Waters, T. R., Sedlak, C. A., Howe, C. M., Gonzalez, C. M., Doheny, M. O., Patterson, M., & Nelson, A. (2009). Recom-mended weight limits for lifting and holding limbs in the orthopaedic practice setting. Orthopaedic Nurse, 28(2 Suppl.),

S28–32.

Tiffany Poole Wilson is a risk assessment and safety validation engineer with L’Oréal in Florence,

Kentucky, and a recent graduate of the University of Cincinnati. She received her PhD in occupational safety and ergonomics from the University of Cin-cinnati, College of Medicine, Department of Envi-ronmental Health.

Kermit G. Davis is an associate professor at the Uni-versity of Cincinnati in the College of Medicine, Department of Environmental Health, where he also directs the Low Back Biomechanics and Workplace Stress Laboratory. He received his PhD in occupa-tional ergonomics from The Ohio State University, College of Engineering, Department of Industrial and Systems Engineering. He is a certified profes-sional ergonomist (CPE).

Date received: October 7, 2015Date accepted: April 11, 2016



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Healthcare Ergonomics Waters Review