The Business Case for OSHA's Nursing Home Ergonomics Guidelines

While organized labor fumes and experts are lukewarm, what do nursing home operators think about OSHA's ergonomic guidelines? And what does the document reveal about the agency's new approach to ergonomics?

In the aftermath of the bitter controversy over the ergonomics standard, putting the two words "OSHA" and "ergonomics" together in the same sentence is enough to give most employers heartburn.

Whether it's the different politics of a new administration, or simply the fruit of experience, the shadow cast by the rescinded standard appears to be shaping the agency's approach toward producing ergonomics guidelines.

In both the process it followed and the product that resulted, the recently released "Guidelines for Nursing Homes" seems intended not only to prevent workers' repetitive motion injuries. OSHA also wants to avoid doing anything that smacks of a repetition of the old standard, and to repair the agency's battered image with employers. Time and future injury rates will tell how well the guidelines protect workers from musculoskeletal disorders (MSDs). But OSHA appears to have succeeded already in avoiding a repetition of the injury and stress suffered by employers when the agency tried to address ergonomics with a regulation.

An "Appalling" Problem

Critics argue the nursing home guidelines don't go far enough in protecting workers who have some of the highest injury rates in the nation. But under the Bush administration, OSHA appears to have calculated that the best is sometimes the enemy of the good, and that meeting employers where they are will improve safety more than giving labor and other safety advocates what they want.

"I'm happy with the final results," asserts Janice Zalen, director of special programs for the American Health Care Association (AHCA), a Washington, D.C.-based industry group.

How OSHA handled the nursing home assignment provides some indication of what other industries can expect from the agency. In the near future, OSHA plans to release ergonomic guidelines for poultry processing, retail grocers and shipbuilding; other sectors may soon be selected. By beginning with nursing homes, the agency selected an industry that has arguably the biggest musculoskeletal injury problem in the nation.

"Nursing is the only profession where they consider 100 pounds to be light," says Betty Bogue, RN, president of Prevent Inc., a Hickory, N.C. company that helps health care facilities develop a "no manual lift" program. "It's appalling to me that nurses are still lifting and transferring patients by hand."

Healthcare industry workers sustain 4.5 times more overextension injuries than any other type of worker, according to the Premier Safety Institute, which bases its assertion on 2000 data from the Bureau of Labor Statistics. Six of the top 10 professions at greatest risk for back injury are: nurse's aides, licensed practical nurses, registered nurses, health aides, radiology technicians and physical therapists.

In 2001, nursing aides and orderlies ranked second, after truck drivers, in number of injuries and illnesses involving time away from work. Some experts say widespread under-reporting by nurses masks the real extent of the problem.

Zalen concedes that back injury rates are high in her industry, though she isn't sure how much is due to non-work-related activities and an aging population. Still, she said, "a serious workforce shortage," the cost of workers' compensation insurance and safety concerns motivated AHCA and the American Association of Homes and Services for the Aging to work with OSHA.

A Big Yawn?

"It's a lukewarm document that won't get anyone to do anything," asserts Bill Borwegen, MPH, director of occupational health and safety for the Service Employees International Union. "The guidelines might not be better than nothing."

Borwegen, along with James August, director of health and safety for the American Federation of State, County and Municipal Employees, attacked both the process and the final product of the OSHA effort. They both believe the Veterans Administration produced a far stronger set of guidelines concerning ergonomics in health care facilities.

"The whole approach of a pro-active, comprehensive process whereby you engage workers in the identification and control of hazards, with an ongoing evaluation process, is not there," comments August. "It's just ad-hoc, 'you might try this, or you might try that.'"

Asked if he liked anything at all in the document, Borwegen points to a single sentence: "OSHA recommends that manual lifting of residents be minimized in all cases and eliminated where feasible."

"They should have left it at that it's the only meaningful sentence in the document," he contends.

What's missing, say these labor representatives, is any sense of urgency about the gravity of the problem. "It's a dehumanized, sterilized document, with no stories about injured workers, no motivation for employers to act," complains Borwegen. "This document will create a big yawn out in the industry."

But stories about injured workers appeared to be precisely what turned employers off about the first draft of the guidelines.

"The first draft had a negative tone about employers," says Zalen. "We stressed our beliefs that these guidelines are for the employer, and if you want people to use it, be more positive."

A Good Beginning?

The nuances of OSHA's new, more moderate approach to ergonomics are revealed by the way it handled the "no lift" issue in the guidelines.

When Joe Jolliff, administrator of the Wyandot County Nursing Home in Upper Sandusky, Ohio, explains how he changed to a "no lift" policy at his facility, he speaks with the passion of a crusading evangelist seeking converts. "No lift" can be defined in different ways, but at Wyandot it means a person must be 100 percent weight-bearing.

Going to no lift is a win-win-win," he says. "It's better for residents, safer for workers and it saves money. People who come here and have a hands-on experience get so excited they are like kids at Christmas time!"

While calling upon employers to "minimize manual lifting," the guidelines do not insist that nursing homes institute a no-lift policy. OSHA points out that "residents' rehabilitation plans, the need for restoration of functional abilities, other medical contraindications, emergency conditions and residents' dignity and rights" may restrict the application of lifting solutions.

However, OSHA chose no-lift advocate Jolliff's Wyandot facility as the case study in Appendix A of the guidelines.

"It's always wrong for people to lift other people," declares Jolliff flatly.

Trissie Copses's job as vice president for business development at Prevent Inc. is to make the business case for going to no-lift programs. She says it's not a tough sell. "On average, we see greater than a 90 percent reduction in both workers' compensation and costs for lift transfer injuries, a 39 percent overall reduction." For her, the biggest indicator the no-lift program works is that over half of the company's new business comes from existing clients who expand it into other facilities.

Asked about OSHA's nursing home guidelines, Copses chooses her words carefully. "I'm very glad OSHA has put a strong emphasis on the attention that needs to be given to care-giver injuries. This is a good beginning."

Jolliff is also neither critical nor enthusiastic about OSHA's guidelines. "We can be critical of OSHA and industry, but nurses have been taught for years they can lift patients safely," he says. "It's a big job to turn this around. The guidelines are better than what we had in the past, but they are only a start."

Gary Visscher, deputy assistant secretary of labor for OSHA, was deeply involved in the guidelines process. He explains why the agency backed off from a strict no-lift approach: "I'm not disagreeing with Mr. Jolliff, but we based this on the input we received from a range of nursing homes. They wanted flexibility, first because of the difficulty of using lifts in some older facilities, and second because of concerns about how we treat residents."

Visscher did not mention a factor Zalen deemed primary: the initial cost of lifting devices, which can run anywhere from $2,000 for a floor lift to $10,000 for a ceiling lift.

Jolliff counters that the money spent reducing injuries leads to far bigger savings in workers' compensation premium, medical and turnover costs, plus other indirect expenses (see Figure 1).

Carla Lehman, administrator of The Cedars, a health care center in McPherson, Kansas, has had no reported back injuries since the facility adopted a no-lift policy in January 2002. OSHA invited her to participate in the writing of the guidelines. She offers additional evidence that in preparing its first ergonomics document, OSHA under the Bush administration went to great lengths to repair its damaged relationship with employers.

"The guidelines do say that a zero lift policy should be the goal, but the reason it isn't stronger is it's very expensive to go to no lift. That's the impression I came away with," comments Lehman.

Even though the equipment, when used properly, can virtually end expensive back injuries, it can take up to three years for facilities to realize the cost savings because of the time lag in modifying the workers' compensation experience factor.

Residents' Rights vs. Safety?

Labor representatives attacked the guidelines' frequent reference to "residents' dignity and rights," because these critics believe this is an obstacle, or even an excuse, exploited by employers unwilling to protect workers from dangerous lifts.

Lehman says that she did make the case for a no-lift policy in the guidelines. "But the case I mainly was making is that you can't treat a live load as you would a dead load," she says. "Every person is different and when you're dealing with people, you can't mandate how to do a lift step-by-step." A period of education and adjustment may be necessary for some residents to grow accustomed to the lift devices.

Lehman concedes that a no-lift policy is better and safer for residents and that since the guidelines are voluntary, they could not mandate anything in any event.

"Health care is not accustomed to OSHA regulations," she explains "General industry may be used to OSHA rules, but health care is catching up in some of those areas."

She finds the guidelines useful and practical. "What was encouraging and exciting to me about OSHA was that they gave us guidelines, rather than mandating that 'you have to do this.'"

What Happened to Beverly?

Guy Fragala, Ph.D., director of environmental health and safety at the University of Massachusetts Medical Center in Worcester, Mass., is a specialist in applying ergonomic concepts to the health care industry, with over 30 years of experience. He points out that there are two approaches one can take toward ergonomics: prescriptive or performance-based.

"I think with ergonomics, it has to be performance-based," he asserts. "OSHA made some good improvements in the guidelines from the first draft. They provided more information on how one might develop a program." Fragala thinks guidelines are a good start, though he favors a performance-based regulation requiring employers to have an ergonomics management program.

What surprised Fragala about OSHA's ergonomic guidelines is the scant reference to the agency's settlement agreement with Beverly Enterprises, a large health care employer with some serious ergonomic issues.

OSHA drew on Fragala's expertise in fashioning the settlement agreement, and the agency touted the settlement, achieved early on in the Bush administration, as a sign of its new enforcement strategy. According to OSHA administrator John Henshaw, the new approach is geared more to changing workplaces, rather than punishing employers.

"The one reference to the Beverly settlement is technical," comments Fragala. "I thought it would have been very helpful to include in the guidelines the real meat of the approach used in the Beverly settlement, but they didn't use what they learned there."

By the "real meat," Fragala is referring to specific guidance about how to lift and transfer residents, based on a classification of the residents' dependency as well as any special medical conditions. The guidelines do have a section of algorithms that Fragala says provide some helpful information about these issues.

While he maintains the overall approach used in the guidelines is consistent with Beverly, Visscher concedes the guidelines don't specifically make the connection with the settlement agreement.

A long paragraph at the very beginning of the nursing home guidelines excluding any connection between the document and enforcement may provide a clue as to why OSHA soft-pedaled Beverly. The Beverly enforcement action was taken under the General Duty Clause, the only kind of enforcement possible without an ergonomics standard. Chris Tampio, director of employment policy at the National Association of Manufacturers (NAM), has already voiced concern the abatement suggestions in OSHA's most recent ergonomic enforcement action against a nursing home (Alpha Health Services Inc., Post Falls, Idaho) bears a striking similarity to portions of the guidelines.

The fact NAM has no nursing home members shows how seriously the association takes the danger that OSHA could use the voluntary "best practices" in any ergonomic guidelines to hammer industry. Referring explicitly to the Beverly enforcement action in the guidelines could exacerbate these industry fears. Once again, OSHA apparently listened to employers.

The Future of Ergo Guidelines

"As far as the process we used, this will be the model for future ergonomic guidelines," says Visscher. That means gathering information, putting out a proposal, having stakeholder meetings and a public comment period, followed by the final document. OSHA expects to continue to do some on-site visits and to work with unions as well as employer groups.

When it comes to the substance of future guidelines, once again the concerns of employers about the rescinded ergonomics rule may provide some clues about what to expect.

The "one-size-fits-all" accusation, the argument that the rule failed to allow for the variety of workplaces and circumstances, was one of industry's biggest complaints about the ergonomics standard. OSHA seeks to avoid this charge by emphasizing the "industry-specific" nature of all its guidelines.

"There will be some similarities in the overall framework," says Visscher, "but nursing homes are somewhat unique because one task, the handling of residents, is the largest concern."

The argument that nursing homes are different from other sectors is how Visscher responds to another labor complaint about the nursing home guidelines: its failure to refer to and build on OSHA's first effort at ergonomic guidelines, the Red Meat Guidelines. He adds that when OSHA comes out with guidelines for the poultry industry, there will be references to what was done with red meat.

OSHA appears focused now on the next task: convincing employers to use the guidelines. "Getting these guidelines out was the easy part," comments Visscher. "Selling it is the hard part. That's where making the business case needs to come in."

OSHA's moderate, business-friendly approach to ergonomics may be in harmony with the pace of change in the nursing home industry. While Jolliff calls for a "paradigm shift" in order to stop nurses from lifting patients, Betty Bogue sees it a little differently.

"This is an evolution," she says, "not a revolution."

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