Safe Patient Handling and Movement

Purpose

This document provides guidance to perioperative teams for developing, implementing, and maintaining a safe patient handling and mobility (SPHM) program to minimize the incidence and severity of injuries to patients and health care workers. It also provides guidance for procedure-related high-risk ergonomic activities (eg, prolonged standing at the sterile field, moving patient care equipment) to minimize injury to perioperative team members. Although safe patient handling and mobility is the more-common terminology, for this guideline update, the term movement was retained in the title to reflect the procedure-related high-risk ergonomic activities unique to the perioperative environment that occur in addition to traditional SPHM activities. Guidance is provided for

• establishing and sustaining a culture of safety for SPHM;

• establishing a formal facility SPHM program;

• incorporating ergonomic design principles to provide a safe environment of care;

• selecting, installing, incorporating, and maintaining safe patient handling technology in the perioperative setting;

• establishing education, training, and competency verification in safe patient handling techniques and equipment use;

• assessing the patient and the perioperative environment and developing a plan for SPHM;

• collaborating to include reasonable accommodations for post-injury return to work within the comprehensive SPHM program; and

• establishing a comprehensive quality assurance and performance improvement program to evaluate the SPHM program.

Perioperative registered nurses (RNs) and other team members are routinely faced with a wide array of occupational hazards in the perioperative setting that place them at risk for work-related musculoskeletal disorders (MSDs).^1-5  Work-related MSDs are disorders of the muscles, nerves, tendons, ligaments, joints, cartilage, and spinal discs.⁶  The lower back, shoulder, neck, and upper extremities are typically involved in MSDs, with a gradual or chronic onset.⁷  Injuries are the result of overexertion, repetitive motion, manual lifting, and pushing and pulling.^6-9  Physical stressors encountered in health care that contribute to MSDs include forceful exertions,⁷  repetitive motions,⁷  awkward postures,^10,11  static postures,¹²  prolonged standing,^2,12,13  long cumulative work hours (eg, overtime, consecutive shifts), moving or lifting patients and equipment,¹⁴  carrying heavy instruments and equipment,¹⁵  and overexertion.⁷  Research studies have also demonstrated that health care workers with low back pain are more likely to experience work-family conflict, depressive symptoms, decreased mental health-related quality of life, and decreased ability to work.^16,17 

Musculoskeletal disorders are some of the most frequently occurring and costly types of occupational issues affecting nurses. In 2020, RNs working for private health care and social assistance industry employers reported a total of 78,740 workplace injury or illness cases requiring days away from work.¹⁸  This was an increase of 290.8% from the 20,150 workplace injury or illness cases reported in 2019 and is likely associated with the COVID-19 pandemic. Nurses, especially those working for more than 10 years, have an increased occurrence of work-related lumbar disc disease compared to office workers.¹⁹  There is evidence from a meta-regression analysis suggesting that sex, age, and body mass index are not significant predictors of work-related low back injuries in perioperative nurses¹⁵  but that work-related injuries in general increase with age.^20,21 

The prevalence of reported lower back pain and MSDs among perioperative nurses remains high and is a global issue.^1,3-5,15  Perioperative nurses report significantly higher rates of MSDs compared to nurses working outside of the operating room (OR).²²  The most common areas affected by musculoskeletal injuries in perioperative nurses are the lower back, shoulder, waist, and knee.¹⁵  Work-related MSDs also occur frequently in other members of the perioperative team, including surgeons and anesthesia providers.^23-27 

The perioperative setting poses unique challenges related to the provision of patient care and performance of procedure-related tasks.^15,28  This highly technical environment is equipment intensive and involves the lifting and moving of heavy supplies and equipment during the perioperative team member’s work shift. Many of the patients undergoing operative or other invasive procedures are completely or partially dependent on the caregivers because of general or regional anesthesia or sedation. Patients who are in a state of decreased consciousness have a diminished ability to move, sense discomfort, or feel pain, and must be protected from injury. This can require perioperative team members to manually lift the patient or the patient’s extremities several times during a procedure.²⁹ 

The American Nurses Association (ANA) laid the foundation for the prevention of work-related MSDs in 2003 with the release of the position statement The Elimination of Manual Patient Handling to Prevent Work-Related Musculoskeletal Disorders, which was revised in 2008,³⁰  and the development of the Handle With Care campaign.³¹  In 2006, AORN developed the Position Statement for Ergonomically Healthy Workplace Practices.³²  The National Association of Orthopedic Nurses,³³  the Australian College of Operating Room Nurses,³⁴  and the Association of Occupational Health Professionals³⁵  have also developed safe patient handling position statements.

In 2005, AORN continued its commitment to the prevention of MSDs by forming a collaborative arrangement with the National Institute for Occupational Safety and Health (NIOSH) and the ANA to discuss, design, and advance the agenda of an ergonomically healthy workplace for perioperative professionals. The AORN Workplace Safety Task Force examined research, literature, and patient care practices to evaluate and make recommendations to promote patient and caregiver safety in a perioperative setting. Although there are a number of high-risk ergonomic tasks specific to perioperative nurses, the task force identified seven key activities³⁶  as the starting point for developing recommendations. The result of this collaboration was the foundational AORN Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting²⁹  developed by AORN with the assistance of a panel of experts from the Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center, Tampa, Florida; the NIOSH Division of Applied Research and Technology Human Factors and Ergonomics Research Team; and the ANA.

The Ergonomic Tools developed for the guidance document were based on previous work by Audrey Nelson, PhD, RN, FAAN; experts within the Veterans Administration; and nationally recognized researchers. The seven Ergonomic Tools for SPHM were developed based on professional consensus and evidence from research and were designed with the goal of eradicating job-related MSDs in perioperative nurses (See Sections 5 and 6).²⁹ 

In 2021, the ANA published the second edition of Safe Patient Handling and Mobility: Interprofessional National Standards Across the Care Continuum.⁷  The ANA’s eight core standards are:

• Establish a Culture of Safety

• Implement and Sustain a Safe Patient Handling and Mobility (SPHM) Program

• Incorporate Ergonomic Design Principles to Provide a Safe Environment of Care

• Select, Install, and Maintain SPHM Technology

• Establish a System for Education, Training, and Maintaining Competence

• Integrate Patient-Centered SPHM Assessment, Plan of Care, and Use of SPHM Technology

• Include SPHM in Reasonable Accommodation and Post-Occupational Injury Return to Work

• Establish a Comprehensive Evaluation System⁷ 

The ANA standards⁷  provide important guidance for health care organizations to use in implementing safe patient handling practices³⁷  and provide the framework for the sections in this guideline, in which the standards have been adapted to meet the unique needs of the perioperative patients, team members, and environment. The benefits of implementing an SPHM program include reduced work-related MSDs,^7,38-43  improved work practices,⁴²  reduced incidence of lifting and exertion injuries,⁴²  improved patient safety,³⁹  decreased patient falls,⁴⁴  decreased workers’ compensation claims,⁴⁵  and decreased health care costs.⁴⁴ 

The following topics are outside the scope of this document:

• diagnosis and treatment of work-related injuries,

• use of wearable sensors for kinematic worker movement monitoring,^46,47 

• sharps injury prevention (See the AORN Guideline for Sharps Safety),⁴⁸ 

• patient positioning (See the AORN Guideline for Positioning the Patient),⁴⁹ 

• pressure injuries (See the AORN Guideline for Prevention of Perioperative Pressure Injury),⁵⁰ 

• patient skin antisepsis (See the AORN Guideline for Preoperative Patient Skin Antisepsis),⁵¹  and

• progressive mobility of postoperative patients after discharge from the postanesthesia care unit (PACU).