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A Systems’ Approach to Safer Caregiving

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The personal impacts of work-related injuries to caregivers—including certified nursing assistants (CNAs), home health aides, and family caregivers—can often be severe. While the care setting may differ, be it a nursing home, a residential care facility or a family home, the risks and physical load associated with caring for others are shared.  One certified nursing assistant (CNA) who sprained her knee while helping a resident get dressed reflected on what her injury meant for her family.

It's hard. I have a five-year-old son and we just started teaching him how to ride his bike.  I couldn't be the one to do that.

Work-related musculoskeletal disorders (WMSDs) include a wide range of injuries, and are often associated with cumulative trauma exposure—small stresses on the muscles, tendons/ligaments, nerves and joints of the body that build up over time. These injuries can be debilitating and remain all too common in the health care industries.Over the past five years, my colleagues and I have had the opportunity to learn from certified nursing assistants and other caregivers about the rewards and risks of caring for their clients.

We are an occupational health and safety research team in Washington State, the SHARP Program, whose focus includes the prevention of sprains and strains and other WMSDs. We have spent many hours observing caregivers in nursing homes and assisted living communities, and have conducted in-depth interviews with injured caregivers regarding the nature of the job, circumstances surrounding injuries, and the impacts these injuries have had on their lives. In one case, a CNA had sprained her knee squatting to pick up a pile of soiled linens off the floor when she was changing a resident. Besides missing over five weeks of work, her injury left her fearful of the future:

To find out that I'm going to have to have surgery on my knee, and that I might end up having issues running or just walking—for the rest of my life—that was very scary.

Using “proper body mechanics” was mentioned during several interviews as the standard for working safely. As one CNA said:

We have monthly meetings about proper lift transfers, proper body mechanics.  They have in-services monthly about how to transfer properly and do things properly.

However, while body mechanics and lifting techniques may seem likely to reduce injury risk, research points in a different direction. The most advantageous body mechanics simply cannot compensate for the prolonged exposure to the physical forces created from manually handling patients.  In addition to reducing or eliminating the manual handling of patients, addressing issues at the system’s level is important to preventing these types of injuries. Interactions among physical, organizational, technological and personnel subsystems impact health and safety at the worker level.

The onset of sprains and strains and other WMSDs can be difficult to predict, but the contributing risk factors that lead to them can be reduced. Most of the CNAs we spoke to had been injured simply by doing what they do each and every day. However, the circumstances they reported as having contributed to their injuries comprised several recurring themes:

These themes are consistent with research that points to the importance of systems-level factors.While our interview participants consisted mostly of certified nursing aides, we examined Washington State Workers’ Compensation data regarding four primary caregiving professions (aka “caregivers”) by standard occupation code (SOC). These included Home Health Aides, Nursing Aides, Orderlies and Attendants, Psychiatric Aides, and Personal and Home Care Aides.

While the focus of our analysis centered on these four professions, the physical risk factors encountered are no different from those faced by family caregivers as well.

Between 2010 and 2012, 45 percent of all state-fund compensation claims for caregivers were classified as WMSDs, accounting for 56 percent of all direct workers’ compensation claims costs. Not surprisingly, as compared to all occupations combined, caregivers’ injuries are more frequently: diagnosed as sprains, strains or tears; the result of physical over exertions; and/or caused by someone other than themselves.

The Right Tool for the Job

From total lifts (like Hoyer lifts) and sit-to-stands to draw sheets and bed wedges, caregivers in any setting—from nursing care facilities to family homes—can benefit from specialized equipment designed to make care tasks safer for themselves and their clients. However, when equipment is not available, not functioning properly, or when caregivers are not trained properly to use new equipment, the risk of injury may increase. One caregiver with a back injury suggested her employer did not adequately provide staff with the tools they needed:

Some facilities have beds that go up and down and you can put it at the level that you need to be to roll the person correctly and not hurt your back. We have beds that you have to crank.

Another CNA had a lower back strain that cost her over two years of lost work time. She pointed out that while there are plenty of tools on the market, accessing them can sometimes be difficult for front line workers:

If you have patients that are wheelchair bound and they're dead weight, they should have a lift for the employees. That would prevent a lot of the injuries. And they should be mandatory.

 The Right People for the Job

Multiple caregivers told us their jobs often required them to care for too many people at one time—that had there been more staff on hand. they may not have been injured. One CNA who sprained her back while trying to keep a resident from falling out of bed suggested that:

On the day that I injured myself, there were only five of us for 66 people. That night, I was doing 15 to 20 people. So just not having enough staff can get you easily injured.

Her injury left her in chronic pain, relying on her family to help her with household activities. She continued to work when she could, but by each weekend:

I'm saving my good days for work, and then on my days off, I'm just spending it recuperating.

Planning Ahead

While the CNAs we spoke to typically formed personal bonds with their residents, they often found themselves working with people they did not know—whether the resident was newly admitted or the caregiver was covering a coworker’s shift in a different area. Whatever the case, caregivers must often base their transfer decisions on the most recent assessment of that patient’s abilities, and the frequency of assessments can vary depending on the facility. One home health care aide tore her rotator cuff when she was helping a new client go to the bathroom:

She didn't tell me that she was going to fall or that she couldn't stand. She didn't say anything. It just happened. I think it had to do with me being with a client I had never been with before.

This home health care aide described weeks of chronic pain and difficult physical therapy which took a toll on her mental health as well:

I've been kind of depressed…and moody a little bit, just because I know that there's no end to it, it seems like. Because everything I've heard, this injury takes a long time to heal.

There are many factors that can contribute to a sprain or strain or other WMSDs, but there is no single fix that can make them go away. If you are concerned about getting hurt or think your job may expose you to cumulative trauma that may lead to a serious injury, talk about it with someone—your family, your employer, your coworkers. 

Try to develop alternative work methods or processes that will let you continue to provide care while minimizing the risks of injury.

Make sure to report pain early, before a major injury occurs. Seek to implement systems’ changes to address these risk factors:

  1. improperly functioning equipment;
  2. manageable caregiver-to-patient ratios;
  3. infrequent or inaccurate assessment of patient capabilities.

Because even using the best body mechanics can’t keep you safe and working when these are left un-checked.
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