Nursing home OHS – a 2001 interview with Kathleen Rockefeller

The last time I spoke with Kathleen Rockefeller was in 2001 on the eve of her speaking at a conference organised by the Ergonomics Society of Australia.  At that time Kathleen was a physical therapist and ergonomist within the Washington State Department of Labour & Industries.  Her latest profile says that she is now in Florida (via Chicago) as an Assistant Professor at the School of Physical Therapy & Rehabilitation Sciences at University of South Florida.

Kathleen’s career may have progressed (as probably has her tan) but the hazards and control solutions that we discussed in 2001, sadly remain relevant.  I have reproduced some of the interview I conducted with Kathleen in those early days when no-lift policies were radical and  patient-handling equipment was expensive and rare.

SAW: Around the world the no-lift policy is being introduced but why is that policy the most popular risk control measure?

KR: I don’t know where it actually originated or where the term “no-lift” came from. It’s a horrible term because everyone in healthcare knows that it is a little unrealistic. I think some people have been turned off by the name. I prefer to call it “low-lift” or “minimal-lift”.

Looking at the literature and research clearly shows that decreasing the amount of times per day that the human body has to act like a derrick is a good idea. Each episode exposes the body to forces of a magnitude high enough to potentially be injurious. Anyone who has nursed or worked in nursing homes knows that lifting is not the only activity that carries physical risk. There are tasks like leaning over the bed to delivering treatment to changing clothing, repositioning—these activities can be stressful as well. I wish it were simple to say “let’s get rid of the lifting” but it is an important first step.

SAW: In Australia the no-lift push came from the unions in order to push management to get into action on a whole range of manual handling issues.

KR: I’ve heard a rumour over here, and I don’t know how true it is, that the equipment manufacturers began using the term “zero-lift” but I really don’t know.

SAW: Your research shows that financial incentives were used to encourage the purchasing of new equipment. Were the incentives really necessary?

KR: Washington State is unique in the US in that the workers compensation insurance is handling by a State agency. So the insurance is handled by us unless the company meets the requirements for self-insurance. The agency has monitored the data and monitored the trends to try some initiatives with a number of different industries, nursing homes were chosen for a research project. They were hurting financially. A major reason for not buying lifting equipment was financial.

The agency decided to allocate some of their funds to the nursing home industry and to see if offering some of the funds allocated for injury prevention projects would help. The funds weren’t handouts but discounts on the workers’ compensation premium in return for investing in equipment and beginning a manual handling improvement process. The program was designed as a trial project to see what effect this type of incentive might have.

SAW: How applicable is your research to other States, given Washington’s unique processes?

KR: Many recommendations will be applicable as the program wasn’t just on the financial incentives. The study was a state-wide and industry wide look at how nursing homes were doing overall in implementing zero-lift programs. The research has identified the problems of implementing a large-scale intervention and we can all learn from these problems.

SAW: Other than manual handling what are the major OHS risks in nursing homes?

KR: Of course, patient handling has various tasks and the higher risks are certainly the physical transferring but also the repositioning, delivering incontinence care to residents, changing their clothing. The other thing I noticed in the homes while following nursing assistants and doing sampling is the total amount of time they stand or walk. I think that fatigue must be a contributing factor, both local muscle and total-body fatigue. There is very little recovery time. I knew this already but doing the research really emphasised this.

SAW: Did you observe a high stress level? Was resident violence an issue?

KR: Those are certainly issues as well. The issues of staffing and turnover is huge. The turnover for nursing assistants is an industry average of 100% a year and can go much higher. The constant turnover creates turmoil.

An unexpected element was the huge turnover in management personnel. This was striking. When you think of a facility trying to keep stable processes and procedures and the head person leaves within 3 years or even one year— that is a real problem.

I heard a lot from the nursing assistants and through the literature about the importance of knowing the residents. You mentioned potential problems with the residents but if you work with the resident for a while you get to know them and then you may be able to pick up warning signs on behaviour. If you’re a short term agency nurse and you don’t know the residents, it may increase your vulnerability.

SAW: Perhaps the no-lift policy has been introduced due to the throughput of staff rather than dealing with a root cause of the manual handling injuries? Perhaps because no-lift can give immediate results?

KR: Expecting a zero-lift program to have miraculous results in light of these other issues leading to instability is an unreal unrealistic expectation. I think introducing the program and getting it to work as best you can while at the same time, people who can affect change, maybe us baby boomers, need to start screaming very loudly because our parents are next.

Injuries related to manual handling have a number of causes and efforts to decrease these injuries require multi-faceted approaches. The point is well taken because if you are going to expect a zero-lift program in itself to have miraculous results in light of these other issues leading to problems and instability, it is not a realistic expectation.

Kevin Jones