Good afternoon. My name is Mary Foley, President of the American Nurses Association (ANA). ANA is the only full-service professional organization representing the nations 2.6 million registered nurses through 53 state associations. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing and by lobbying Congress and regulatory agencies on health care issues affecting nurses and the public.

ANA appreciates this opportunity to comment on the proposed Ergonomics Standard, released by the Occupational Safety and Health Administration in November of 1999 and we applaud OSHA's persistence in the promulgation of this standard, despite formidable opposition. We are grateful to the many federal workers and other rule making participants who, over the last 10 years have dedicated themselves to making an OSHA ergonomics standard a reality.

As President of the ANA and also an occupational health nurse. I have a privileged perspective as I travel around the country -- BOTH seeing and hearing firsthand the stories of injured nurses who desperately want to be caring for patients but can't because of disabling musculoskeletal disorders, particularly back injuries. . . AND understanding the principles of prevention that need to be in place in their work sites to prevent these tragedies. It is heartbreaking to repeatedly encounter disabled nurse members, but it is empowering to tell them that ANA is strongly advocating on their behalf. As the nation encounters greater nursing shortages due in part to intolerable working conditions, I submit to you that the (health care consuming) public cannot afford to lose a single nurse due to these disabling but PREVENTABLE disorders.

Recent changes in the health care environment have lowered staffing levels (downsizing) requiring individual nurses to care for more patients and with fewer people to assist. (According to Suzanne Gordon) between 1994 and 1997, there was an 8.8% increase in the average number of patients for which and RN cared, a 7.2% decrease in the number of RNs employed, and a 7.7% jump in the number of patients per staffed bed between 1995 and 1998.

ANA has strong evidence that current working conditions in health care are contributing to increased injury and disease among nurses. In 1995, the Minnesota Nurses Association decided to look very closely at the OSHA Injury and Illness Logs of the hospitals where their nurses worked. They looked at the time period between 1990 and 1994, a time period when RN positions in study hospitals had been reduced by 9.2%. The Minnesota nurse investigators found that a disturbing 65.2% increase in the number of injuries and illnesses among nurses occurred during this time period. These nurses were injured in multiple hospital settings and while performing varied and assorted tasks.

The ANA recognizes that employers are faced with exorbitant costs for Workers Compensation expenses related to musculoskeletal disorders (MSDs). The ANA looks to OSHA to assist the highest levels of management to understand the true cost of work-related injuries and the benefits of hazard control strategies and early interventions. When the costs inherent in workers compensation are compared with the actual cost of mechanical lifting devices and trained teams (which are the most appropriate interventions to protect nurses and other HCWs) the positive economic value of the Ergonomics Standard will become apparent. With even earlier intervention than the proposed standard currently advocates, namely the use of signs and symptoms and not just covered MSDs as a trigger for ergonomic programs and MSD management, ANA believes that these preventive benefits would become significantly more apparent. The true cost of compensation involves the time, expertise and expense involved in a long list of activities other than medical and wage compensation to the injured worker.

(EXAMPLES)

-preparing and submitting injury reports

-diagnosing injuries

-providing treatment and rehabilitation therapies

-arranging for disability evaluations and independent medical exams (IMEs)

-preparing for litigation to defend and deny claims

-defending and denying claims

-submitting wage information

-evaluating unsafe conditions

-correcting unsafe conditions

-locating and training replacement workers

-developing work hardening and return-to-work programs

-defending and denying Americans with Disabilities claims

-plotting video surveillance and monitoring the whereabouts of injured workers

-supporting an entire (workers comp) judicial system

Waiting for an OSHA recordable injury to occur rather that treating early signs and symptoms of MSDs is just asking for these extra costs. All of the activities listed require trained personnel, AND, while marketed as cost-effective controls for managing care, in actuality serve to perpetuate the industry. We urge that OSHA reconsider true early intervention and good public health practice by intervening early - when signs and symptoms are reported and not waiting for disease to occur.

In addition to the system and cost view described above, the reality of workers compensation for injured nurses following MSD's is also dismal. Workers Compensation, once the safety net for injured workers, has eroded to the point that many disabled workers are systematically and intentionally starved out of the system. Frustrated by delays, depositions, IMEs and court appearances, lawyers may encourage them to take unrealistic settlements, just to end the case. These nurses may or may not find employment in less physically demanding settings outside healthcare. Their years of education and experience lost to themselves and of no benefit to the industry or the patients. Those who do not settle, may eventually receive benefits often in the range of 30% of their previous income instead of two thirds of their average weekly wage that is noted in many state regulations (Consumer Reports article). ANA strongly supports OSHAs proposed medical removal protection provisions for MSDs. While this represents a deviation from existing OSHA standards that do not address compensating injured workers, it sends a strong message and stronger incentive to employers that workers must be protected. Along with other unions, we believe that workers reporting an injury should not lose pay or benefits. Employees placed on work restriction protection should maintain their pre-injury pay and not face adverse tax consequences as a result of it. We DO NOT agree that a 6 month time limit should be imposed on the injured workers.

ANA recognizes the importance of OSHA's proposed hazard information and reporting provisions. Having an established system is the first step in encouraging employee reporting of symptoms. Employers should strive to assure that reports of MSDs are made and received in a non-threatening and non-judgmental setting and that reports can be made without fear of retaliation. Fear of retaliation may result in continued exposure to hazardous conditions and more serious injuries. Delay in treatment can result in less than optimum recovery. Early recognition, evaluation, treatment and recovery and return to work in a safer environment should be the goal following any MSD.

While OSHA's proposals aim at ensuring a solid system for injury reporting at the workplace, and that need cannot be disputed, ANA is dismayed that OSHA has deviated from its history of promulgating standards that seek to eliminate the HAZARDS in the workplace, not just recognize and treat the resulting disease.

As health professionals striving for gains in disease prevention, we must support placement of valuable resources at eliminating to root causes. We must support true prevention. Existing OSHA standards have not required employee illness or injuries to be reported before an employer must implement protective actions. If this provision were allowed in the Asbestos Standard, it would leave employees exposed to this potentially deadly fiber for 30 years until a case of mesothelioma, a deadly cancer, were diagnosed and reported. Only then and with untold numbers of workers exposed would worker protections be instituted. ANA urges OSHA to remain consistent with its mandate in the General Duty Clause and require employers to provide employees a place of employment free from recognized hazards.

When employees DO need to report health problems related to ergonomic hazards, OSHA is proposing that employers "must evaluate employee reports of MSD signs and symptoms to determine whether a covered MSD has occurred." ANA strongly encourages OSHA to require that employers place the responsibility for evaluating MSDs with licensed health care providers. Evaluating signs and symptoms and determining whether an injury has occurred is the responsibility and within the scope of practice of licensed health care providers. The supervisor/worker relationship is not a relationship that should involve diagnosing physical injuries.

If the employer erroneously decides that a covered MSD has not occurred, continuing to perform the hazardous job would result in a delay in evaluation and treatment and could intensify the injury and seriously compromise recovery. Permitting managers and supervisors to assume these activities places the employer and/or manager at risk for litigation for practicing medicine without a license or for denying medical attention to an injured person.

Work restrictions should be identified by the Professional Licensed Health Care Provider who performs the evaluation on the basis of the information which the Proposed Standard says must be supplied, including the opportunity to do a workplace walk through if necessary. OSHA should assist this process by providing standardized summary materials to forward to the health care provider. ANA agrees with the components that the written opinion must contain but is concerned about the process with which communication of work restrictions between ergonomics program managers and supervisors occur. Injured nurses often become their own advocates when returning to a modified or light duty job. They must negotiate with fellow employees to assure that they are not required to perform hazardous tasks during their work restriction time or before ergonomic controls are instituted. The employer should ensure that the written recommendations are appropriately implemented and that the employees' supervisors are supported regarding the modifications needed.

As with the evaluation of MSD signs and symptoms just discussed, identification and control of risk factors in a work setting is a skill that requires training and education. OSHA must require that employers show evidence that Ergonomics Program managers have been trained and educated before they attempt to identify ergonomic risk factors in any job setting. Training for persons setting up and managing the Ergonomics Program and those responsible for implementing effective hazard controls should reflect specific training requirements, such as those described in OSHA's Hazardous Waste and Emergency Response Standard. Only with a solid educational base can program managers make useful assessments of ergonomic risk factors and implement appropriate hazard controls.

In patient care settings, individual jobs may be quite varied but the risks of injuries to backs and shoulders from lifting and pulling are omnipresent. Certain jobs, particularly in the Operating Room and radiology have specific risks associated with hands and wrists. Without proper training, program managers may readily address controls for back and shoulder injuries but overlook hazards that affect the hands and wrists. Employers and program managers must also understand that due to individual susceptibility (height, strength, etc.), an ergonomic risk factor may affect one worker and not another.

Ergonomic controls are not new topics in hospital safety In 1997, Charney reported an injury reduction rate of 70% in a ten hospital project that implemented lifting teams for all total patient transfers. In one facility alone, the lift team averaged 55 lifts per shift. All ten facilities reported excellent nursing satisfaction with the team. Charney states "over 20 lifting team members participated in the program evaluation. None of the team members had a reportable injury over the course of the program evaluation period. It is believed that mandating mechanization for total body transfers is the reason lifting team members were not injured.

Though increasingly well-documented, many nurses are unaware of these valuable control measures. When they are available, having the controls available when and where needed is often a challenge. In addition, the engineering controls chosen and made available must be the right ones. Identifying and evaluating MSD hazards when changing, designing and purchasing equipment is an important concept for employers to understand. Many injuries will be prevented when employers understand the value of evaluating materials and processes before they are introduced into the work environment. Nurses and other healthcare workers must be included in these evaluations.

In most industries, the weight and size of the product requiring a manual lift can be adjusted or controlled, thus the potential for MSDs can be substantially reduced. In health care settings, this variable cannot be controlled. Back schools and other behavioral controls have had very limited success in healthcare settings as the weight of the patient is an uncontrolled variable and ergonomics professionals recommend that women in the 90th percentile of strength lift no more than 46 pounds at a single time (Schuldenfrei, 1998).

ANA advocates engineering controls such as mechanized lifting devices and administrative controls such as lift teams and adequate staffing levels as the appropriate methods of eliminating and/or substantially reducing opportunities for MSDs. A strong Ergonomic Standard will drive the market to develop more and better patient lifting and moving equipment at competitive prices. ANA supports OSHA's statement that "back belts and wrist splints are not considered protective equipment" since they are not scientifically documented prevention methods.

Timely and effective worker training is an integral part of health and safety. ANA is very active and involved with Frontline Worker Training in the area of safer needle devices. I have personal experience with the TDICT project.

ANA recommends that all workers in health care settings who have any patient care duties be included in the training and that this training be required by OSHA PRIOR to covered MSDs occurring, so that employees may truly benefit from the training by recognizing and reporting hazards and early signs and symptoms.

Ergonomics Program training should be required annually rather than every three years as currently proposed. The frequency of the training should be consistent with the Bloodborne Pathogens, Respiratory Protection and Noise Exposure Standards which all require annual training. All new hires should receive ergonomics training at the time of their initial assignment regardless of whether they've had training at another job. Persons involved in developing and managing ergonomics programs must show evidence of education and training in ergonomic issues, ideally in the same or a similar industry. This includes outside consultants.

ANA's strong opinions about the need for worker participation have shaped our opinions about OSHA's proposed language on incorporating pre-existing ergonomics programs and giving employers a "quick fix" option. ANA supports accepting effective pre-existing ergonomic programs if those programs have included and continue to include employee participation in all phases including program development, implementation, evaluation and selection of assistive devices and the development of lift teams. ANA does not support the quick-fix option as it includes limited employee participation in resolving the problem of MSDs and does not apply corrective action to other jobs at risk for MSDs. The quick fix program is too limited in scope and activity to resolve the problem of MSDs in an industry with such an extremely high incidence of MSDs as healthcare.

In closing, I'd like to reiterate that ergonomics hazards and ergonomic controls are not new topics in occupational safety and these injuries are not a new phenomenon. In fact, the introductory comments to the proposed standard, OSHA itself identifies a substantial body of scientific evidence that supports efforts to provide workers with ergonomic protections. For the past several decades, there have been discussions, seminars, and even graduate training programs related to MSDs and ergonomic conditions, engineering controls and their relation to hundreds of thousands of work-related injuries and multi-millions of dollars of Workers Compensation Costs. OSHA has released several publications related to ergonomic conditions and the association with lifting - the 1982 bulletin Back Injuries Associated with Lifting and the 1993 Meatpacking Guidelines. OSHA has addressed unsafe ergonomic conditions for 30 years. The information, controls and potential to improve the health and welfare of workers have been documented repeatedly. Therefore, any further delay in releasing a full ergonomic standard is unconscionable.

Existing OSHA standards have eliminated hazardous working conditions for hundreds of thousands of workers. Strong requirements and aggressive enforcement of OSHA standards have saved the fingers and hands of workers in the manufacturing industry and the lungs of workers in coal mines and cotton mills. Their lives have been saved. The American Nurses Association believes a strong, enforceable Ergonomics Standard, consistent with existing OSHA standards, will save the backs of nurses and other health care workers and allow them to continue productive and profitable lives.

I am happy to answer any questions you have.

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