Nursing Home Initiative Inspections Policy and Procedures
The Secretary's Nursing Home Initiative in the seven affected states is being terminated and absorbed into the new OSHA-wide targeting procedures. Effective immediately, the enforcement policies adopted by previous memoranda for the Initiative will be superseded and replaced with the guidance of OSHA Instruction CPL 2-0.119, OSHA High Injury/Illness RateTargeting and Cooperative Compliance Programs. Many of the specific case development and litigation decisions on cases involving ergonomics will still be decided by ongoing consultation during the life of the inspection(s) between the Regional Ergonomics Coordinators and the Directorate of Compliance Programs' Ergonomics Coordinator, Dr. Graciela Perez. In addition, the IMIS recording procedures outlined for the for the Initiative will be carried over for all nursing home inspections in Federal enforcement states. The IMIS recording guidance and Appendices from the original Initiative memorandum are attached for informational purposes. IMIS Recording The guidance below shall be followed for completing enforcement forms
Whenever a visit is made in response to this SEP, Consultation Request, and/or Visit
forms are to be completed as follows:
Appendix ANursing Home Industry Background Information The nursing home industry is one of America's fastest growing industries. Employee population in the industry grew by nearly 50% in the decade between 1982 and 1992. Today nursing homes and personal care facilities employ approximately 1.6 million workers at 21,000 work sites. By the year 2005, industry employment levels will rise to an estimated 2.4 million workers. Nursing homes with an employee population between 50-99 employ a total of more than 400,000 employees, while homes with an employee population between 100-249 account for more than 800,000.Approximately 10% of the employees are represented by unions. The two largest employee representatives are Service Employees International Union and the United Food and Commercial Workers Union with approximately 100,000 and 25,000 workers in the industry, respectively. According to the Bureau of Labor Statistics, in 1994 nursing and personal care facilities reported 221,200 nonfatal occupational injuries and illnesses to their personnel. Among U.S. industries with 100,000 or more nonfatal injury or illness cases, nursing homes have the third highest rate--16.8 injuries and illnesses per 100 full-time workers. Only meat products processing (at 26.5) and motor vehicle/equipment manufacturing (at 25.4) have higher incidence rates. Nursing home workers suffer most of their injuries (51.2 percent) when handling residents. Fifty-eight percent of their injuries are strains and sprains. While back injuries account for 27 percent of all injuries in the private sector, in nursing homes they account for 42 percent of all injuries. According to BLS data for 1993, more than 28,000 lost workday incidents were related to lifting, almost 5,000 injuries were the result of assaults, and approximately 16,000 were due to slips, trips and falls. Of the 10 occupations with the largest number of injuries and illnesses, nursing aides and orderlies are exceeded only by truck drivers and nonconstruction laborers. A significant concern with the industry is the level of regulation under which the industry operates. Governments at all levels exercise regulatory authority over nursing homes. Local governments may have jurisdiction over issues of fire safety, egress, and food service sanitation as these issues pertain to residents. State and local governments may also regulate the industry for licensing and Medicare and Medicaid certification purposes on a yearly basis. Agencies also may respond to residents' complaints with unannounced inspections over patient's rights, patient safety issues, or other conditions in the facility. While it is necessary to be aware of the regulatory concerns of the industry, most of the regulations do not overlap the jurisdiction or issues addressed under OSHA standards. OSHA regulations may address some of the same conditions covered by other Agencies but only as far as they pertain to employee safety and health. The Omnibus Budget Reconciliation Bill of 1987 (OBRA) and many regulations of the Health Care Financing Administration assure residents a level of privacy similar to that which they would enjoy in their homes. Evaluations of workplace safety issues in the nursing homes generally involve some injuries related to the employees' handling residents. The resident handling activities may take place in resident rooms, restrooms, shower and bathing areas. Documenting these actual activities by witnessing, videotaping, and photography requires the resident's consent. Family members or guardians may give consent for residents who are incapable of giving consent. Residents are often approached during other agencies inspections and questioned about issues including residents rights and privacy. The privacy issue should be treated with a high degree of concern and tact during any evaluation of safety and health hazards. Unresolvable conflicts between adequate hazard exposure documentation and resident privacy concerns should be discussed with supervisors, solicitors, and the nursing home initiative coordinators. The daily activity profile for each resident may identify situations which are particularly problematic and make suggestions for specific steps which reduce the potential of injury to the employees and the residents. Many residents are totally dependent on the staff to provide for the activities of daily living such as dressing, bathing, feeding, and toileting. Each of these activities may require multiple interactions with a resident. Typical situations involving employee/resident interaction include transferring between bed and wheelchair, wheelchair to toilet or shower chair, and weighing of residents. Working conditions that may contribute to the risk of accidents include reduced lighting in resident rooms during sleeping hours, solo transfers of non-ambulatory residents without lift assist devices, broken equipment, wet floors, cramped working spaces and staffing levels inadequate to deal with the workload during high activity periods. An additional area of concern which should be addressed on the profile is the problem of combative residents who strike out at employees during interactions. Many nursing home employers already have learned that working safely is a good way to not only help protect their employees, but also affect the bottom line. When one nursing home employer implemented a program to address safe resident handling, worker's compensation premium dropped from $750,000 to $184,000. A similar resident handling program at another nursing home led to a striking reduction in lost workdays --from 2,200 in 1993 to only 31 in 1996. Commonly used terms in to the industry are as follows: Ambulate - walk or help to walk Gait, transfer, or walking belt - a wide belt placed around resident's waist to allow staff member a handhold on resident during transfer operations or walking. Hoyer Lift - mechanical lift assist device used to lift heavy or dependent residents. Many manufacturers currently make similar devices. Sliding board - a slick board used under resident to reduce the friction during transfers of resident from bed to chair or changing position in bed. Geri chair - geriactic chair is a recliner chair used for dependent residents Trapeze lift - a bar device suspended above bed which allows residents with upper muscle strength to reposition themselves. Care plan or Activities of Daily Living (ADL) - written document kept by staff that gives detailed description of residents needs. It should also contain information on degree of assistance required by resident.
Appendix BPROGRAM TO ADDRESS RESIDENT HANDLING If the review of the safety and health program using the general guidance provided by OSHA Instruction 2, Program Evaluation Profile, shows a high rate of musculoskeletal injuries and illnesses, then the tool below may be used to evaluate the resident handling aspects of the facility's program. This evaluation tool has been derived from one developed by the Technical Support Section of OSHA's Region III. It is intended as an example of a safety and health program to address resident handling injuries in nursing homes. While the program is not specific to any one facility, it does address the major elements of an effective program. MANAGEMENT LEADERSHIP AND EMPLOYEE PARTICIPATION. Commitment and involvement are
essential elements of a sound safety and health program. Commitment by management provides
organizational resources and motivating force necessary to deal effectively with resident
handling hazards.
The written program should be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect worker exposure to ergonomic hazards. WORKPLACE ANALYSIS. Workplace analysis identifies existing and potential
hazards. It consists of a literature review, identification of hazard categories,
workplace surveys and an analysis of trends. This should identify conditions and work
habits which create hazards, and areas where hazards may develop. The objective of
workplace analysis is to recognize, identify, and correct resident handling hazards.
ACCIDENT AND RECORD ANALYSIS. An effective program will analyze injury and
illness records for indications of sources and locations of hazards, and jobs that
experience higher numbers of injuries. By analyzing injury and illness trends over time,
patterns with common causes can be identified and prevented. In addition, all accidents
and near miss incidents should be investigated so that their causes and the means for
prevention are identified.
HAZARD PREVENTION AND CONTROL. Resident handling injuries are prevented primarily by proper selection of equipment, effective use of assistive devices, and by implementation of proper work practices. The equipment must be available in sufficient quantities, convenient for use, and properly maintained. RESIDENT HANDLING (ASSISTIVE) DEVICES
WORK PRACTICES / ADMINISTRATIVE CONTROLS.
MEDICAL MANAGEMENT. Proper medical management is necessary both to eliminate or reduce the risk of resident handling injuries through early identification and treatment, and to prevent future problems through rehabilitation and training. Health care providers must be part of the injury prevention team, and after on-site review, regularly interact and exchange information with the management.
SAFETY AND HEALTH TRAINING. The purpose of training and education is to ensure that managers, supervisors, and healthcare providers are sufficiently informed about the ergonomic hazards to which they may be exposed and thus are able to participate actively in their own protection. Training programs should be designed and implemented by qualified persons. The program should include an overview of the potential risk of back and other musculoskeletal injuries, their causes and early symptoms, and means of prevention and treatment. Appropriate "train the trainer" instruction is required for personnel responsible for providing training. Training should be presented in a language, and at a level of understanding, appropriate for the individuals being trained, and should include opportunities for interactive questions and answers with the trainer.
Appendix CIncidence and Severity The minimum information required for calculating incidence and severity rates includes the total number of new cases; the date each case was reported; the number of workers in the same risk group; the number of workers in the entire facility, the number of days of restricted or alternative work duty, and the number of days away from work. Incidence and severity for job types or hazards should be calculated per year from at least three years data when the injuries are identified during the record review.
A yearly total incidence rate normalized to 100 workers is calculated according to the formula below. IR = (# of specific type of injury or incident per year)(200,000 hours) The 200,000 hours represents the average annual hours of 100 full-time workers and allows for comparisons between different groups of workers. If the actual number of hours worked by the subject group is unavailable, than the number of workers in the group may be multiplied by 2000 hours for an estimate. Note that the above rate may calculated either for the Lost Workdays Incident Rate (LWDI) or for total rate. An incident rate should be calculated for the entire facility and specific groups of workers within the facility when the job requirements and injury stressors are similar. Severity comparisons may be used between groups to identify the groups which need the most attention in a facility. One measure of the severity of the hazard can be calculated from the formula below. S = (Number of Lost Workdays)(200,000 hours) Care should be taken with interpreting the severity statistic as one injury resulting in a large number of days off may give a high rate for the facility. The analysis of trends with these statistics should be done so that a decision is based upon the trends of both rather than the either individually. A hazard may exist where where there are increased incidence of similar injuries between the employees in question and a control group, usually an unexposed group of workers at the same facility. However, if the severity of the injuries is decreasing, an increase in incidence may represent an early intervention policy.
Appendix DSTANDARD AVD LANGUAGE FOR RESIDENT TRANSFER HAZARDS Section 5(a)(1) of the Occupational Safety and Health Act: The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were required to perform certain resident transfer tasks resulting in stresses that had caused, were causing, or were likely to cause musculoskeletal injuries:
Among other methods, one feasible and acceptable abatement method to correct this hazard is the implementation of a resident handling program consisting of the following elements.
1) Management commitment and employee involvement - Top management must demonstrate its commitment by following all safety rules and giving visible support to the safety and health efforts of others. Employee participation provides the means through which employees identify hazards, recommend and monitor abatement, and otherwise participate in their own protection. Participation in the decision making process empowers and motivates employees to actively participate in achieving program objectives and goals. 2) Workplace analysis - Workplace analysis describes how management will collect information on current and potential hazards. It consists of a literature review, identification of hazard categories, workplace surveys, and an analysis of trends. The purpose of a workplace analysis is to recognize existing and potential hazards, to identify employees at risk, and to establish and subsequently to evaluate the control measures. Ideally, a hazard analysis should be conducted on all jobs or processes in all departments and should consider the following: To be effective, a hazard analysis must be reviewed and updated periodically, perhaps annually. If an accident, injury, or illness is associated with a specific job or process, the hazard analysis should be reviewed immediately to determine whether changes are needed. 3) Accident and Record Analysis - An effective program will analyze injury and illness records for indications of sources and locations of hazards, and jobs that experience higher numbers of injuries. By analyzing injury and illness trends over time, patterns with common causes can be identified and prevented. In addition, an effective record keeping program will provide for investigation of accidents and "near miss" incidents, so that their causes, and the means for their prevention, are identified. 4) Hazard prevention and control - Work force exposure to all current and potential hazards should be prevented or controlled by using engineering controls wherever feasible and appropriate, work practices and administrative controls, and personal protective equipment. Nursing home policies and procedures should be written to describe the use of appropriate methods of control and to indicate that some methods of controls are preferred over others. Engineering controls include the use of resident lifting hoists, sliding sheets/boards, and inflatable cushions. Administrative controls include the implementation of a "No Unassisted Lift" policy for all non-weight bearing residents. Work practice controls include proper work techniques, new employee conditioning, use of walking and transfer belts with weight bearing residents. The program should include a medical management component which addresses the recognition, evaluation, treatment and referral of resident handling injury cases. 5) Safety and health training - Safety and health training should cover the safety and health responsibilities of all personnel who work at the nursing home. It is most effective when it is incorporated into other training about performance requirements and job practices. It should include all subjects and areas necessary to address the hazards in the nursing home. Training helps employees develop the knowledge and skills they need to understand workplace hazards and how to handle them in order to prevent or minimize their own exposure. 6) Emergency Response - There should be appropriate planning, training/drills, and equipment for response to emergencies. In addition, first aid/emergency care from trained staff should be readily available to minimize harm if an injury or illness occurs. Step 1 - Implementation of an resident handling program which meets the requirements detailed above. Step 2 - Submit to the Area Director a written, detailed plan of abatement outlining a schedule for the implementation of the engineering, administrative and work practice controls selected for the control of the hazards. Step 3 - Implementation of engineering, administrative and work practice controls.
Appendix ESAMPLE 5(a)(1) LETTER FOR RESIDENT TRANSFER TASKS Dear Employer During the Occupational Safety and Health Administration's recent inspection of your facility, the Compliance Officer noted a number of musculoskeletal injuries on the OSHA 200 log associated with resident transfer tasks. While we believe the exposures documented during our investigation do not constitute a violation of the Occupational Safety and Health Act, we have typically found that such injuries are associated with potentially hazardous resident lifting and transfer procedures. The implementation of a resident transfer program should serve to reduce the potential for injury to your staff. Such programs generally include the following elements:
1) Management commitment and employee involvement - Top management must demonstrate its commitment by following all safety rules and giving visible support to the safety and health efforts of others. Employee participation provides the means through which employees identify hazards, recommend and monitor abatement, and otherwise participate in their own protection. Participation in the decision making process empowers and motivates employees to actively participate in achieving program objectives and goals. 2) Workplace analysis - Workplace analysis describes how management will collect information on current and potential hazards. It consists of a literature review, identification of hazard categories, workplace surveys, and an analysis of trends. The purpose of a workplace analysis is to recognize existing and potential hazards, to identify employees at risk, and to establish and subsequently to evaluate the control measures. Ideally, a hazard analysis should be conducted on all jobs or processes in all departments and should consider the following: To be effective, a hazard analysis must be reviewed and updated periodically, perhaps annually. If an accident, injury, or illness is associated with a specific job or process, the hazard analysis should be reviewed immediately to determine whether changes are needed. 3) Accident and Record Analysis - An effective program will analyze injury and illness records for indications of sources and locations of hazards, and jobs that experience higher numbers of injuries. By analyzing injury and illness trends over time, patterns with common causes can be identified and prevented. In addition, an effective recordkeeping program will provide for investigation of accidents and "near miss" incidents, so that their causes, and the means for their prevention, are identified. 4) Hazard prevention and control - Work force exposure to all current and potential hazards should be prevented or controlled by using engineering controls wherever feasible and appropriate, work practices and administrative controls, and personal protective equipment. Nursing home policies and procedures should be written to describe the use of appropriate methods of control and to indicate that some methods of controls are preferred over others. Engineering controls include the use of resident lifting hoists, sliding sheets/boards, and inflatable cushions. Administrative controls include the implementation of a "No Unassisted Lift" policy for all non-weight bearing residents. Work practice controls include proper work techniques, new employee conditioning, use of walking and transfer belts with weight bearing residents. The program should include a medical management component which addresses the recognition, evaluation, treatment and referral of resident handling injury cases. 5) Safety and health training - Safety and health training should cover the safety and health responsibilities of all personnel who work at the nursing home. It is most effective when it is incorporated into other training about performance requirements and job practices. It should include all subjects and areas necessary to address the hazards in the nursing home. OSHA considers safety and health training vital to every workplace and it is an important component of a comprehensive program. Training helps employees develop the knowledge and skills they need to understand workplace hazards and how to handle them in order to prevent or minimize their own exposure. 6) Emergency Response - There should be appropriate planning, training/drills, and equipment for response to emergencies. In addition, first aid/emergency care from trained staff should be readily available to minimize harm if an injury or illness occurs. Our office can provide you with assistance as you develop your program to provide greater safety and health for your employees. If you desire further information on this subject, please feel free to contact us. Sincerely
Appendix FVIDEO GUIDELINES FOR ERGONOMIC EVALUATIONS Obtaining good video documentation for ergonomic evaluations can be difficult as the tasks are often performed in inaccessible areas with poor lighting conditions and a lot of extraneous movement taking place. This guide presents suggestions for capturing effective video documentation of potential ergonomic hazards. PREPARATION Use the OSHA Form 200 logs and 101s, complaint information, and interviews to help prioritize areas for taping. It is desirable to have at least a two person team when performing an evaluation. One person can operate the video camera while the other can record task and employee information. The equipment needed for an ergonomic inspection will generally include:
Other useful items may include:
The following are general suggestions on camera usage which if reviewed prior to going on-site will provide the best video documentation for the analyst and will ensure that all pertinent information is obtained and documented.
VIDEOTAPING TASKS The following items outline the procedures used for obtaining useful video documentation.
ANALYSIS OF VIDEO TAPES It is usually best to contact the Salt Lake Technical Center before you submit a videotape for analysis. This will allow us to provide you with a time frame for analysis completion and to make any pertinent inquiries concerning the nature of the request. Send a copy of the tape rather than the original since we keep all materials for our files, and any written documentation which was obtained about the inspection. Allow plenty of time for analysis as there is generally significant backlog. There is information which can not be readily obtained by visual inspection of the video documentation. The following information should be recorded on the video tape slate at the beginning of the taping sequence or be provided in the written "Request For Tape Evaluation" accompanying the tape.(example attached)
Additionally, the following information should be visually slated at the beginning of each individual task or recorded in a written Supplemental Factors Checklist.(example attached) Written information should be referenced to the video documentation and must accompany the video tape when submitted for analysis.
REQUEST FOR TAPE EVALUATION OF ERGONOMIC FACTORS
SUPPLEMENTAL FACTORS FOR ERGONOMIC TAPE EVALUATION Worker Information: Workstation* Adjustability (mechanism and range of motion, heights, dimensions): Table: ___________________________________________________ __________________________________________________________ Chair: ___________________________________________________ __________________________________________________________ Can work surfaces be tilted or rotated: _____________________ What is the worker standing on (concrete, wood): _______________ Is it slippery: __________________________________________ Can work positions be changed (sit/stand): ___________________ Maximum reach distances: Horizontal: _____________________________ Vertical: _______________________________ * Make a sketch of the workstation layout on separate sheet of paper or reference to area of tape which shows the entire work layout. Tools* Name of tool: ________________________________ Sketch of tool: Type of tool: ________________________________ Torque: ___________________________________ Reciprocating or vibrating: _______________ Other: ____________________________________ Weight of tool: ______________________________ Handle: _______________________________ Span: __________________________________ Length: ________________________________ Material: ______________________________ Are gloves worn, What material: ___________________________________ Source of power: ___________________________________________________ Is tool counter balanced: __________________________________________ Noticeable vibration: _____________________________________________ If air powered, is the exhaust away from the hand: _________________ * Answer these questions and make a sketch or identify the tool on the video segment for each tool used. Use other sheets of paper if needed. Miscellaneous Job and Ergonomic Training
Appendix GReferences Ashford, Nicholas A. and Caldart, Charles C. Technology, Law and the Working Environment. New York: Van Nostrand Reinhold, 1991. Bowman, J. Play it safe in long-term care facilities: health care workers face may hazards, including back injuries and violence. Safety & Health, March: 64-67,1996. Charney, W., Zimmerman, K., and Walara, E. The lifting team: a design method to reduce lost time back injury in nursing. AAOHN Journal, 39(5), 231-234, 1991. Cohen-Mansfield, J., Culpepper, W.J. II & Carter, P. Nursing staff back injuries: prevalence and costs in long term care facilities. AAOHN Journal 44(1):9-17, 1996. Engels, J.A., van der Gulden, J. W. J., Senden, T. F., Hertog, C. A. W. M., Kolk, J. J., & Binkhorst, R. A. Physical work load and its assessment among the nursing staff in nursing homes. JOM 36(3), 338-345, 1994. Gagnon, M., Sicard, C. and Sirois, J.P. Evaluation of forces on the lumbo-sacral joint and assessment of work and energy transfers in nursing aides lifting patients. Ergonomics, 29(3), 407-421, 1986. Garg, A., & Owen, B. Reducing back stress to nursing personnel: an ergonomic intervention in a nursing home. Ergonomics, 35(11), 1353-1375, 1992. Garg, A., & Owen, B. An ergonomic evaluation of nursing assistants' jobs in a nursing home. Ergonomics, 35(9), 979-995, 1992. Garg, A., Owen, B., Beller, D., & Banaag, J. A biomechanical and ergonomic evaluation of patient transferring tasks: wheelchair to shower chair and shower chair to wheelchair. Erognomics, 34(4), 407-419, 1991. Garg, A., Owen, B., Beller, D., & Banaag, J. A biomechanical and ergonomic evaluation of patient transferring tasks: Bed to wheelchair and wheelchair to bed. Ergonomics, 34(3), 289-312, 1991. Gold, M.F. The ergonomic workplace: charting a course for long term care. Provider, 20(2), 20-26, 1991. Halbur, Bernice T. Turnover among nursing personnel in nursing homes. UMI Research Press, 1982. Jansen, R.C. Back injuries among nursing personnel related to exposure. Applied Occupational and Enviromental Hygiene 5(1), 38-45, 1990. Kroll, B. B., and Lowewenhardt, P. M. Staff involvement critical in enhancing a safe environment for care. The Florida Nurse, 43(10), 13-14, 1995. Lusk, S.L. Violence experienced by nurses' aides in nursing homes: an exploratory study. AAOHN Journal 40(5), 237-241, 1992. McCormack, J. Uplifting news for patients, worker safety, and financial returns. Association of Occupational Health Professionals, Jan-Feb. 1-8, 1996. Merritt Company. Nursing home gets lifts. Merrit Workers' Comp News, May 15, 1995. Nelson, M. L., and Olson, D. K. Health care worker incidents reported in a rural health care facility: a descriptive study. AAOHN Journal, 44(3), 115-122, 1996. Nursing homes: What you need to know. Baltimore, Md: Maryland Attorney General's Office, 1990. Forrest, M.B., Forrest, C.B., and Forrest R. Nursing homes: the complete guide. Dallas, Tex.: Taylor Pub. Co., c1993. Owen, B. D., and Garg, A. Reducing risk for back pain in nursing personnel. AAOHN Journal, 39(1), 24-33, 1991. Owen, B. D., & Garg, A. Back stress isn't part of the job. American Journal of Nursing, 93(2), 30-37, 1993. Patcher, Michael A. Excellence in nursing homes: care planning, quality assurance, and personnel management. New York: Springer Pub. Co., 1993. Personick, M. E. Nursing home aides experience increase in serious injuries. Monthly Labor Review, 113(2): 30-37, 1990. Pheasant, S., and Stubbs, D. Back pain in nurses: epidemiology and risk assessment. Applied Ergonomics, 23(4), 226-232, 1992. Ramseyer, R. Handle with care. Maine Workplace, Spring: 20-24, 1995. Resident abuse in nursing homes: resolving physical abuse complaints. Washington, DC: Department of Health and Human Services, USA, Office of Inspector General, Office of Evaluation. Rogers, B. Occupational Health Nursing: Concepts and Practices. W. B. Saunders Co. Philadelphia, 1994. Seifer Consultants. Handle with care. Maine Workplace, Spring: 20-24, 1995. Sluchak, T.J. Erogonomics: Origins, focus, and implementation considerations. AAOHN Journal, 40(3), 105-112, 1992. Spindel, M.P. (1995). Agency pushes for ergonomics rule. Provider, 21(2), 65. Stubbs, D. A., Buckle, P.W., Hudson, M.P., and Rivers, P.M. Back pain in the nursing profession II: the effectiveness of training. Ergonomics, 26, 767-779, 1983. Takala, E.P., & Kukkonen, R. The handling of patients on geriatric wards: a challenge for on-the-job training. Applied Ergonomics, 18(1), 17-22, 1987. Uhl, J. E., Wilkinson, W. E., & Wilkinson, C. S. Aching backs?: a glimpse into the hazards of nursing. AAOHN Journal, 35(1), 13-17, 1987. Venning P. J. Back injury prevention among nursing personnel: the role of education. AAOHN Journal, 36(8), 327-333, 1988. Venning P. J. Back injury prevention: instructional design features for program planning. AAOHN Journal, 36 98), 336-341, 1988. Successful nurse aide management in nursing homes. Jo Ann M. Day and Harry J. Berman, eds. Phoenix, AZ: Oryx Press, 1989. Snook, Stover, The Design of Manual Handling Tasks: Revised Tables of Maximum Acceptable Weights and Forces, Ergonomics, 34(9), 197-1213, 1991. Strahan, Genevieve W. Mental illness in nursing homes. United States Public Health Service, Centers for Disease Control, National Center for Health Statistics, 1991. Venning, P.J., Walter S.D., and Stitt L.W. Personal and Job-Related Factors As Determinants of Incidence of Back Injuries Among Nursing Personnel, Journal of Occupational Medicine, 29(10), 820-825, 1987. Klein, B.P., Jensen, R.C. and Sandeson, L.M. Assessment of Worker's Compensation Claims for Back Strains/Sprains; RC Jensen ed., The Increasing Occupational Injury Rate in Nursing Homes, Advances in Industrial Ergonomics and Safety II (Biman Das Ed.), Taylor and Rancis, 1990. Stobbe, T.J., Plummer, R.W., Jensen, R.C. and Attfield, M.D. Incidence of Low Back Injuries Among Nursing Personnel As A Function of Patient Lifting Frequency. Journal of Safety Research, 19, 21-28, 1988. U.S. Equal Employment Opportunity Commission. U.S. Department of Justice and Civil Rights Division. The Americans with Disabilities Act Questions and Answers. Washington, D.C., July 1991. U.S. Department of Health and Human Services. National Institute for Occupational Safety and Health. Guidelines for Protecting the Safety and Health of Health Care Workers. Washington, D.C.: U.S. Government Printing Office, September 1988. U.S. Department of Labor. Occupational Safety and Health Administration. "Safety and Health Program Management Guidelines; Issuance of Voluntary Guidelines; Notice," Federal Register 54(16); 3904-3916. January 26, 1989. |
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