2. Waters’s Contribution to Health Care Ergonomics 727
work focused on nurses in the long-term care
and home health care sectors.
Method
The aim of the current review was to evalu-
ate the scientific merit of the articles published
by Waters in health care ergonomics by deter-
mining the contribution they had in the field
through cited work. The first step of the review
was to use Waters’s NIOSH curriculum vitae to
develop a list of his published articles focusing
on health care ergonomics or safe patient han-
dling. In addition, a search on Google Scholar
and ISI Web of Science identified and verified
the total number of articles that Waters pub-
lished in health care. The search was completed
between January and March of 2015 and thus
included all articles up to March 31, 2015. The
search included only articles written in English.
The papers identified were further evaluated to
identify any peer-reviewed articles citing one of
Waters’s articles. These articles were the focus
of the current review with respect to Waters’s
contribution to health care ergonomics.
An Excel worksheet was developed for the
articles with at least one citation and included
information on title, author, journal, study popu-
lation, and summary of results. The articles were
also classified by publication type, such as pam-
phlet, training material, article, and textbook
content material. Articles were further classified
by theme to provide more understanding of the
areas impacted by Waters’s research.
The Waters articles cited more than 16 times
were evaluated for quality using the Mixed Meth-
ods Appraisal Tool (MMAT). A cut point of 16
citations was chosen to ensure a reasonable num-
ber of articles for discussion and to capture the
articles that had the most contribution and reach in
the field. MMAT is a critical appraisal tool that
assesses the quality of study designs. Each article
was reviewed to determine the study type: qualita-
tive, quantitative randomized controlled, quantita-
tive nonrandomized, quantitative descriptive, and
mixed methods. For each study type, there were
quality criteria an article had to meet, and each cri-
terion equaled one point. The number of points the
article scored was then divided by the total num-
ber of criteria items and multiplied by 100, provid-
ing a percentage.Articles that cited Waters’s work
were rated as 1 = low, less than 25% on quality
scores; 2 = medium, between 25% and 75% on
quality scores; and 3 = high, greater than 75% on
quality scores (Pluye & Hong, 2014). Several cita-
tion articles did not fit the review criteria as they
were either review articles or opinion pieces, thus
could not be rated for quality and were eliminated
from this part of the review. References for the
articles included in the review of quality are
included in supplemental data and can be provided
upon request.
The high-quality articles were further
assessed for centrality based on Waters’s cited
research. A 1-to-5 scale was used and described
as the following: 1 = extremely central, 2 =
semi-central (75% of the article centrally
related to original work), 3 = neutral (50% of
article centrally related to original work, 4 =
semi-unrelated (25% of the article centrally
related to original work, and 5 = completely
unrelated. This was used to provide an under-
standing of the contribution of Waters’s
research and the continuation of his findings
through other studies.
Results
The Google Scholar and ISI Web of Science
search yielded 27 articles, and the secondary
review for quality evaluation yielded 15 articles
with at least one citation. In total, these 15
articles were cited 498 times. Review of the
citations resulted in a total of 358 citations after
filtering for English publications and repeat list-
ings. Waters’s 27-article portfolio contained a
variety of research methods, including literature
reviews (13), field studies (four), laboratory
studies (two), and opinion pieces (eight). Table
1 provides details about the citations for each
article: study population of Waters’s article,
number of citations, and study population for
citation article.
Waters’s top-cited articles focused on MSDs
and safe patient handling. The top-cited article
(Waters, Collins, Galinsky, & Caruso, 2006)
reported on efforts to prevent MSDs in the health
care industry (65 citations). Waters’s top-cited
articles focused on MSDs and the need to not lift
patients manually—safe patient handling.
Although his work was cited 88% of the time by
articles that had a sample population in the
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3. 728 August 2016 - Human Factors
Table 1: Summary of Articles That Cite Waters’s Work on Health Care and Safe Patient Handling
Article Study Population Citations
Study Population for Citation
Article (Number of Articles)
“NIOSH Research Efforts to
Prevent Musculoskeletal
Disorders in the Healthcare
Industry” (Waters, Collins,
Galinsky, & Caruso, 2006)
Health care workers
Orthopedic nurses
65 Nurses (18), health care workers
(11), patients (4), physical
therapists (4), nursing assistants
(3), military personnel (2), hospital
nurses (2), workers (2), bariatric
nurses (2), pediatric nurses (2),
occupational therapists (2), home
caregivers (2), pregnant nurses
(1), nursing home caregivers (1),
EMS workers (1), ophthalmologic
patients (1), orthopedic nurses
(1), radiologic patients (1),
robotic nurses (1), nonnursing
health care (1), health care
environment (1), clinical nurses
(1), day care workers (1)
“When Is It Safe to Manually
Lift a Patient?” (Waters,
2007)
Nurses
Health care workers
57 Health care workers (20), nurses
(15), home health care (6),
physical therapists (3), operative
staff (3), bariatric caregivers
(3), occupational therapists (2),
orthopedic nurses (2), geriatric
caregivers (1), physiotherapists
(1), military personnel (1), railroad
industry (1)
“A Review of Work Schedule
Issues and Musculoskeletal
Disorders With an Emphasis
on the Health Care Sector”
(Caruso & Waters, 2008)
Health care workers 34 Hospital nurses (12), health
care workers (5), workers
(3), rehabilitation nurses (2),
dental students (2), cleaners
(1), construction workers (1),
industrial workers (1), physical
therapists (1), petroleum workers
(1), mechanics (1), surgeons (1),
hotel workers (1), low-income
women (1), patients (1), geriatric
patients (1)
“Patient Handling Tasks
With High Risk for
Musculoskeletal Disorders
in Critical Care” (Waters,
Nelson, & Proctor, 2007)
Critical care nurses 29 Nurses (14), health care workers
(6), physical therapists (1),
occupational therapists (1),
radiologists (1), bariatric caregivers
(1), male cameramen (1), physical
therapist students (1), home health
care workers (1), female at home
washing clothes (1), workers (1)
(continued)
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4. Waters’s Contribution to Health Care Ergonomics 729
Article Study Population Citations
Study Population for Citation
Article (Number of Articles)
“Overexertion Injuries
in Home Health Care
Workers and the Need for
Ergonomics” (Galinsky,
Waters, & Malit, 2001)
Home health care
workers
28 Home health care workers (13),
nurses (3), physical therapists
(2), hospital nurses (2), health
care workers (2), teachers (1),
chiropractors (1), orthopedic
nurses (1), pharmaceutical sales
(1), EMS (1), hospital nurses (1),
consumer product designer (1),
cold case investigation (1)
“Preventing Musculoskeletal
Disorders in Nurses: A
Safe Patient Handling
Curriculum Module for
Nursing Schools” (Menzel,
Hughes, Waters, Shores, &
Nelson, 2007)
Nurses 19 Nurses (8), health care workers
(3), occupational therapists (1),
physical therapists (1), nursing
students (1), patients (1), health
care (1), physiotherapists (1), air
transportation (1) orthopedic
nurses (1), critical care nurses (1)
“Development of the
National Association
of Orthopaedic Nurses
Guidance Statement on
Safe Patient Handling
and Movement in the
Orthopaedic Setting”
(Sedlak, Doheny, Nelson, &
Waters, 2009)
Orthopedic nurses 19 Nurses (9), health care workers (6),
physiotherapist (1), occupational
therapist (1), orthopedic nurses
(1), patients (1)
“Safe Patient Handling
for Rehabilitation
Professionals” (Waters &
Rockefeller, 2010)
Physical therapists
Rehabilitation nurses
15 Nurses (8), physical therapists (6),
occupational therapists (1)
“Comparison of Required
Operating Forces Between
Floor-Based and Overhead-
Mounted Patient Lifting
Devices” (Rice, Woolley, &
Waters, 2009)
Patient transfer staff 15 Health care workers (7), nurses
(2),physical therapists (1),
construction workers (1), 16-
and 17-year-old workers (1),
occupational therapist (1), elderly
patients (1), long-term care (1)
“Effectiveness of an
Evidence-Based Curriculum
Module in Nursing Schools
Targeting Safe Patient
Handling and Movement”
(Nelson, Waters, et al.,
2007)
Nursing educators and
students
8 Health care workers (3), nurses (2),
optometry students (1), physical
therapy students (1), nursing
students (1)
Table 1: (continued)
(continued)
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5. 730 August 2016 - Human Factors
health care field, it was also referenced by 37
articles from non–health care worker popula-
tions, including military personnel, construction
workers, manufacturing personnel, patients,
designers, technicians, and industrial workers.
In all, his work had a wide reach on not only
health care but other industries.
Citations from Waters’s top-cited articles
were analyzed for quality, and their major
themes from their conclusions were classified.
For this analysis, articles cited more than 16
times were selected, resulting in seven articles
(Table 2). In all, 266 articles cited these seven
Waters articles and were rated for quality. How-
ever, 95 did not fit review criteria and were
excluded from Table 2.
Most of the citations were rated at medium or
high quality (99% of cited articles), and Waters’s
content was positively referenced (Table 2). The
Waters et al. (2006) article was cited by two
Article Study Population Citations
Study Population for Citation
Article (Number of Articles)
“Suggestions for Preventing
Musculoskeletal Disorders
in Home Health Care
Workers. Part 2: Lift and
Transfer Assistance for
Non-Weight-Bearing Home
Care Patients” (Parsons,
Galinsky, & Waters, 2006b)
Home health care
workers
7 Home health care workers (5),
health care workers (1), EMS (1)
“Suggestions for Preventing
Musculoskeletal Disorders
in Home Health Care
Workers. Part 1: Lift and
Transfer Assistance for
Partially Weight-Bearing
Home Care Patients”
(Parsons, Galinsky, &
Waters, 2006a)
Home health care
workers
7 Home health care workers (6),
health care workers (1)
“Recommendations for
Turning Patients With
Orthopaedic Impairments”
(Gonzalez, Howe, Waters,
& Nelson, 2009)
Nurses
Patient caregivers
7 Health care workers (5), ER nurses
(1), home health care nurses (1)
“Introduction to Ergonomics
for Healthcare Workers”
(Waters, 2010)
Health care workers 5 Health care workers (2), nurses (2),
rehabilitation nurses (1)
“Recommended Weight
Limits for Lifting and
Holding Limbs in the
Orthopaedic Practice
Setting” (Waters et al.,
2009)
Nurses
Patient caregivers
3 Surgeons (1), nurses (1), females (1)
Note. EMS = emergency medical services; ER = emergency room.
Table 1: (continued)
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6. Waters’s Contribution to Health Care Ergonomics 731
Table 2: Quality Rankings, Study Populations, and Conclusions From Articles Citing Waters’s Most-
Cited Articles
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
“NIOSH Research
Efforts to Prevent
Musculoskeletal
Disorders in the
Healthcare Industry”
(Waters, Collins,
Galinsky, & Caruso,
2006)
0
0
0
2
1
1
1
1
3
Nurses Ergonomic programs need
participatory teams and
patient-handling devices to
reduce injuries
Ceiling lifts should be utilized
over floor lifts when reducing
musculoskeletal injuries
Evidence-based safe patient-
handling curriculum is
beneficial for faculty and
students
0 1 0 Rotating two-shift system is
significantly associated with
sleeping issues
0 1 0 Safe patient-handling
programs benefit patients
and workers, no hindrance to
rehabilitation
0 2 3 Combination of different
safe patient-handling
interventions is the best
method for handling tasks
0 1 0 Age is not a risk factor for
perceived poor general or
emotional health
0 0 1 Nurses are at risk of injury
when trying to balance work
and family expectations
0 1 0 Health care
workers
Musculoskeletal injury
prevention programs
are necessary for patient
handling
0 0 1 Social relationship and job
control are important factors
of successful intervention
efforts
0 1 0 Patient handling is the only
significant risk factor among
all risk factors based on 7
years claims data
(continued)
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7. 732 August 2016 - Human Factors
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 1 0 Patient mobilization through
the use of body mechanics
alone increases the risk of
injury
0 1 0 Computerization saves time
but requires monitoring to
avoid errors
1 1 0 Perception of physical exertion
effects outcome of chronic
pain
0 1 0 Interventions should take into
account environmental,
cultural, social, and health-
related issues
0 1 0 Patients Increased economic burden for
older hospital workers due
to medical treatment
0 2 1 Nursing
assistants
Nursing assistants are exposed
to the same MSD risk factors
as nurses; African Americans
and Hispanics are less likely
to report injuries or have
health insurance
0 1 1 Military
personnel
Matrix developed to
categorize MSD injuries and
conditions
0 1 0 MSDs in the knee, foot,
shoulder, forearm, ankle, and
lower leg are prevalent in
armed personnel
0 1 0 Workers Sociodemographic
characteristics and job
traits may be predictors of
compensation claims
0 0 2 Physical
therapists
Older physical therapists are
more at risk of WMSDs
0 0 1 Adaption of job factors
should include psychometric
properties for physical
therapists
0 0 1 Orthopedic
nurses
Body mechanics are no
longer sufficient methods to
prevent MSD injuries; need
lift assist device
Table 2: (continued)
(continued)
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8. Waters’s Contribution to Health Care Ergonomics 733
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 1 0 Bariatric
caregivers
Growing bariatric patient
population suggests a need
for more patient-handling
and injury research
0 1 0 Pediatric nurses Daily caregivers of pediatrics
are at risk of suffering MSDs
during caretaking activities
0 1 0 Occupational
therapists
Occupational therapists and
assistants experience MSDs
at similar rates to physical
therapists and nursing
practitioners
0 0 1 Home
caregivers
Institutional health care
facilities have higher rates of
violence on caregivers than
home health care
0 1 0 Personal assistance services
providers are at increased
risk for WMSDs
0 1 0 Nursing home
caregivers
Patient handling is physically
demanding and associated
injuries are more likely to
result in days away from
work
0 0 1 EMS workers Intervention programs benefit
EMS workers with patient-
handling tasks
0 0 1 Ophthalmology
patients
Alternative slit lamp
biomicroscope will reduce
overall muscular demands
and non-neutral postures of
the neck and shoulder region
among ophthalmologists
0 1 0 Robotic nurses Robotic nursing systems will
prevent exposure to MSD
risk factors
0 1 0 Non-nursing
health care
Psychosocial and physical
hazards are important to
predict WMSD risk
1 1 0 Health care
environment
Natural lighting or views of
nature for patient caregivers
result in more alert and less
stressed staff
Table 2: (continued)
(continued)
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9. 734 August 2016 - Human Factors
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 3 Bed design features have
effect on physical demands
and usability
0 0 1 Day care
workers
Child care tasks involve
exposure to MSD risks
through lifting and awkward
postures
“When Is It Safe to
Manually Lift a
Patient?” (Waters,
2007)
0
0
0
2
3
2
Health care
workers
Ceiling-based lifts are
preferable to floor-based
patient transfer systems
Safe patient handling
programs reduce health
care worker MSDs without
impacting patient’s
functional outcomes
0 1 0 Use of a mechanical lift device
must consider patient status,
caregiver, and environment
0 0 1 Sliding patients up in bed may
contribute to increased risk
of musculoskeletal injuries in
caregivers
0 0 1 Injury rates were significantly
reduced at post-training of
STEPS safe patient-handling
program
0 0 1 Spine shrinkage is dependent
on posture in health care
workers
0 1 0 Patient air transporters need
research and development
of safe patient-handling
procedures
0 0 1 Mechanical lift devices, if not
implemented properly, have
the potential to increase risk
for nurses
0 0 2 Nurses MSDs are significantly
associated with patient-
handling tasks
0 0 1 Successful adoption of patient
lift-assist devices varies based
on the hospital and unit
Table 2: (continued)
(continued)
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10. Waters’s Contribution to Health Care Ergonomics 735
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 1 Workers’ compensation claims
reduced when compared
to pre-implementation
incidence rates
0 1 0 Nurses prefer manual patient-
handling techniques over
safe patient-handling
techniques
0 1 0 Major need for research
into diagnostic studies for
pressure-related tissue death
0 0 2 Multifaceted and
comprehensive approach to
developing an ergonomic
program is needed
0 0 1 Nurses underestimate the
amount of patient-handling
tasks performed, especially
repositioning
0 1 0 Home health
care
It is difficult to determine injury
risk for home health care
workers; continued research
is needed
0 1 0 Informal caregivers experience
significant MSD discomfort,
which interferes with ability
to provide care
0 1 0 Bariatric patients need special
care when transferring from
the hospital to home health
care
0 1 0 MSD discomfort is significant
for informal caregivers;
interferes with ability to
provide care
0 0 1 Physical
therapists
Physical therapists have more
LBP than nurses due to
performing more manual
transfers
0 1 0 LBP is the most significant for
physical therapist under the
age of 30
Table 2: (continued)
(continued)
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11. 736 August 2016 - Human Factors
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 1 0 Operative staff Potential intervention is
a multifunctional bed
designed to reduce MSDs in
caregivers
0 1 1 Bariatric
caregivers
Effective patient-handling
systems are needed to
reduce the risks associated
with bariatric patient
0 0 1 Assessment tool for
emergency departments
to determine readiness for
bariatric patients
0 0 1 Orthopedic
nurses
Clinical tool to assist facilities
with recommended weight
limits for lifting and holding
limbs
0 1 0 Geriatric
caregivers
Combination of biomechanical
aids with lower friction
between patient and
surfaces is recommended
0 0 1 In developing countries, health
care workers benefit from
low-cost mechanical transfer
devices
0 0 1 Military
personnel
Military staff have MSDs in the
low back, neck, knee, and
shoulders
0 1 0 Railroad
industry
Biomechanical applications
utilized in industry are useful
to better understand and
control MSDs
“A Review of Work
Schedule Issues and
Musculoskeletal
Disorders with an
Emphasis on the
Healthcare Sector”
(Caruso & Waters,
2008)
0
0
0
0
1
1
Hospital
nurses
Middle- and high-stress groups
had higher pain than the
low-stress group for all body
areas
Consecutive shifts of 2 or
more days and a variety of
cumulative shifts over a week
and month period were
associated with increased
injury rates
Table 2: (continued)
(continued)
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12. Waters’s Contribution to Health Care Ergonomics 737
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 1 0 Patient Transfer Assessment
Instrument was found to be
an appropriate tool for MSD
risk identification for patient
handling
0 1 0 Health care
workers
Implementation of the FINALE
program improved job
performance and reduced
MSDs
0 3 1 Home health care workers
experience more MSDs
comparable to nursing
homes and hospitals
0 0 1 Greater risk for violent assaults
to workers in home health
care than in nursing homes
or hospitals
0 1 0 Transformational leadership in
home health care improves
performance and reduces
injuries
0 1 0 Informal caregivers
need improved hazard
assessments and training to
reduce MSDs
0 1 0 Frequent housecleaning and
manual patient handling
are most common tasks for
home health care
0 0 1 One successful approach for
home health care workers
is Community of Practice
and Safety Support for total
worker health
0 0 1 Workers Physical load can be used to
determine the persistence of
multisite pain
0 1 0 Sleep deprivation increases
risk of injury
0 0 1 Female
homemakers
Ergonomic stressor, such as
large number of housework
hours, is associated with back
pain and discomfort in the
upper and lower extremities
Table 2: (continued)
(continued)
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13. 738 August 2016 - Human Factors
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 1 Dental students Dentists have a high
prevalence of skeletal
muscle system legions due
to job tasks and require
an occupational health
program to prevent injuries
throughout their careers
0 3 0 Cleaners,
construction
and industrial
workers
Implementation of the
FINALE program displayed
improvement job
performance and reduced
MSDs
0 0 1 Physical
therapists
Physical therapists were
susceptible to LBP and hand
injuries with muscle strain
0 0 1 Petroleum
workers
Shift type and sleep duration
associated with age and
workers in swing and normal
shifts
0 1 0 Patients Increased patient weight
places health care workers at
risk when performing patient
handling
0 1 0 Geriatric
patients
MSDs are associated with
impairments in psychological
well-being
“Patient Handling
Tasks With High Risk
for Musculoskeletal
Disorders in Critical
Care” (Waters,
Nelson, & Proctor,
2007)
0
0
0
1
1
0
Nurses Ceiling mounted patient lift
systems are considered
safe based on lumber spine
forces
Nursing activities exposed
nurses to increased risk of
LBD regardless of nursing
techniques, personal
characteristics, and non-
work-related factors
0 1 0 Top 10 most demanding
patient-handling tasks were
identified; repositioning
most frequent
Table 2: (continued)
(continued)
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14. Waters’s Contribution to Health Care Ergonomics 739
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 1 Nighttime nurses have lower
heart rates and muscle
activity
0 0 1 Shift workers have a higher
rate of MSDs than day
workers
0 0 1 Shift determines muscle load,
heart rate, and time pressure
for health care workers
0 1 0 Overtime work is associated
with poor or falling patient
safety resulting in work left
uncompleted
0 1 0 Health care
workers
Focus group of health care
providers identified MSD
risk factors: work postures
and movements, lifting and
carrying, patient-related
factors, and repetitive tasks
0 0 3 Intervention group had
38% lower odds of having
repeated injury compared to
the control group
0 0 1 Bed design: steering lock
and adjustable height
reduced demands during
transportation tasks
0 1 0 Longer intervention times for
patient-handling programs
are beneficial
0 2 1 Movement and Assistance of
Hospital Patients screening is
potentially beneficial tool to
estimate risk associated with
handling patients
0 1 0 Surgeons Increased risk of MSDs for
surgeons as a result of
personal and occupational
condition
0 1 0 Dental
students
Dental students have high
body twisting and cervical
flexion when obtaining vision
of patients
Table 2: (continued)
(continued)
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15. 740 August 2016 - Human Factors
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 1 Mechanics Injuries among automobile
repair workers were
increased in poor work
environments, issues with
machinery and tools, poor
health and psychosocial
stressors
0 1 0 Workers MSD prevention efforts should
be directed to non–patient
care occupations
0 1 0 Carpal tunnel syndrome is
higher for women and
increases linearly with age
0 0 1 Hotel workers: MSDs were
1.9 times higher among
male hotel kitchen
workers than among room
workers; posture and sleep
satisfaction had an effect on
injury rates
“Overexertion Injuries
in Home Health
Care Workers
and the Need
for Ergonomics”
(Galinsky, Waters, &
Malit, 2001)
0
0
0
1
1
0
Home health
care workers
Need to improve health and
safety for low-income elderly
and disabled patients in
home health care
Health care workers are
exposed to musculoskeletal
risks while caring for patients
0 0 1 Hospital nurses Powered beds resulted in
significantly lower muscle
activation levels than manual
pushing
0 0 1 Low back, shoulder, and neck
were the top injury regions
in LPN activities
0 1 0 Health care
workers
Physiotherapists have a high
rate of MSDs as a result of
exposures related to their
profession
0 1 0 Both manual and safe patient-
handling methods are taught
in most occupational therapy
programs
Table 2: (continued)
(continued)
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16. Waters’s Contribution to Health Care Ergonomics 741
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 2 Manually repositioning
patients with draw sheets
increased friction and
transfer time, low-friction
slider systems reduce
muscular and perceived
effort
0 2 0 Multidimensional approach to
manual patient handling is
encouraged
0 1 0 Teachers Teachers are at risk of pain in
the neck, shoulders, low-
back regions; reduction
requires elimination of heavy
loads, awkward postures,
repetitive motions, and
psychosocial stressors
0 0 1 Chiropractors Chiropractic doctors have
increased injury risk due to
lateral flexion of back during
manipulations
0 1 0 Cameramen Most serious MSDs of male
cameramen was for the
shoulder
0 0 1 Physical
therapists
High prevalence of MSDs for
physical therapy students
0 0 1 ER Effective assessment tool
developed to assist ER staff
for morbidly obese patients
“Preventing
Musculoskeletal
Disorders in Nurses:
A Safe Patient
Handling Curriculum
Module for Nursing
School” (Menzel,
Hughes, Waters,
Shores, & Nelson,
2007)
0
0
0
2
1
0
1
0
1
Nurses Evidence-based safe patient-
handling nursing curriculum
module found to be
beneficial
Clinical nurse specialist can
promote safe patient
handling to reduce injury
rates
High prevalence of MSDs was
associated with psychosocial
stress
Table 2: (continued)
(continued)
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17. 742 August 2016 - Human Factors
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 1 0 Health care
workers
Safe patient handling was
found to be effective in
reducing exposures and
injuries
0 1 0 Occupational
therapists
Patient transfers should
be taught with both safe
patient-handling and
mechanical lifts
0 0 1 Physical
therapists
Training improved confidence
in assessment of patient
and appropriate safe
patient-handling technique/
equipment
0 1 0 Nursing
students
Integration of behavior change
theory and knowledge/skills
in a curriculum will result
best program
0 1 0 Patients Existing services in airline
industry do not meet
assistance needs for
immobile passengers
0 1 0 Health care Detecting existing tissue
damage early will assist with
implementing appropriate
care plans
0 0 1 Critical care
nurses
Ergonomic assessments in
critical care and nursing
homes are beneficial tools
“Development of the
National Association
of Orthopaedic
Nurses Guidance
Statement on Safe
Patient Handling
and Movement in
the Orthopaedic
Setting” (Sedlak,
Doheny, Nelson, &
Waters, 2009)
0
0
1
1
0
0
Nurses Evidence-based safe patient-
handling programs benefit
the safety of the nurse and
patients, reduce injuries,
and decrease workers’
compensation costs
Nurse-driven protocol is a
beneficial intervention
found to improve patient
outcomes, reduce immobility
complications, and decrease
cost
Table 2: (continued)
(continued)
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18. Waters’s Contribution to Health Care Ergonomics 743
Waters Article Title
Quality Rankings
Study
Population ConclusionLow Medium High
0 0 1 Therapist Perceived risk factors, such
as work postures and
movements, lifting or
carrying, and repetitive tasks,
limit the capacity of health
professionals to work in
physically demanding roles
0 0 1 Rehabilitation Safe patient-handling
programs do not inhibit
patient recovery; therefore
mechanical lifting and
transferring devices do
not interfere with patient
treatment plans
0 1 0 Orthopedic The orthopedic clinical tool
for lifting and holding limb
should be used; was found
to provide guidance with
decision by utilizing patient
body weight
0 1 0 Ergonomic tool designed
to assist caregivers in
determining when patient-
handling equipment should be
incorporated into ambulation
in an orthopedic setting,
found to increase safety for
both the caregiver and the
patient, while also reducing
unnecessary variation in
common practices
0 1 0 Health care
industry
Change to programs requires
collaborative practice
and interactions of key
components, including
individual practitioners,
needs and interests of the
organizational leaders, and
manufacturers
Note. EMS = emergency medical services; ER = emergency room; LBD = low-back disorder; LBP = low-back pain;
LPN = licensed practical nurse; MSD = musculoskeletal disorder; WMSD = work-related MSD.
Table 2: (continued)
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19. 744 August 2016 - Human Factors
low-, 29 medium-, and 23 high-quality articles.
The top conclusions for these articles were that
(a) safe patient handling programs are effective
if they utilize lift assist devices, (b) patient han-
dling is demanding and places workers at risk,
(c) patient handling is not the only risk factor for
MSDs, (d) demands in health care are more
demanding on older workers, and (e) safe patient
handling needs to be in curricula.
Waters (2007) recommended that there was
no way to safely lift a patient, and the recom-
mended level of weight for patient handling
should be 16 kg (35 lbs.). Fifteen citing articles
were rated at medium quality, and 22 were rated
high quality. The articles concluded that (a) lift
devices, when used correctly, are effective in
controlling MSDs; (b) special patient popula-
tions (aging and bariatric) will affect safe patient
handling; and (c) patient handling is a risky
activity for health care workers.
Caruso and Waters (2008) published a review
of work schedules in the health care sector. The
paper concluded there is a potential relationship
between work schedule and MSDs. However,
the literature review revealed limited studies
that adequately examined the relationship and
goes on to express the importance of additional
research in this area. The papers that cited this
paper were all rated at medium or better quality
(14 medium and 10 high quality). The takeaway
messages from these papers were that (a) home
health care workers have different exposures
than long-term and hospital health care workers,
(b) shift work affects the health of workers, and
(c) high physical demands have an impact in
many industries.
The Waters, Nelson, and Proctor (2007) arti-
cle documented patient handling in the critical
care setting. The article recommended critical
care nurses be provided with appropriate equip-
ment and techniques to safely perform patient-
handling tasks and reduce MSD injuries. Over-
all, articles citing the Waters et al. (2007) article
were rated as medium (11) and high (11) quality.
The general conclusions of these articles were
that (a) patient-handling tasks are related to
MSD development, and repositioning patients is
the riskiest task; (b) shift work has an impact on
health care worker health; and (c) intervention
can be effective in controlling MSDs.
Authors of another paper (Galinsky, Waters,
& Malit, 2001) investigated overexertion inju-
ries in home health care workers and determined
introducing ergonomic solutions as the most
promising injury prevention approach. Appro-
priate implementation is beneficial for the safety
for the workers and patients. Articles citing this
paper were rated at or above medium for all arti-
cles citing the paper (zero low, seven medium,
and eight high). The concluding themes of these
citing articles were that (a) there is a need to
reduce heavy demands for health care workers,
(b) lift-assist devices are effective in reducing
risk to health care workers, and (c) nurses are
not the only ones at risk of low-back injuries;
physical therapists and chiropractors are at ele-
vated risk.
Menzel, Hughes, Waters, Shores, and Nelson
(2007) assessed the outcomes of a safe patient-
handling curriculum model for nursing school
participants. This case study concluded with
supporting the inclusion of safe patient-handling
information in the nursing curriculum to benefit
the future nursing workforce. Citing articles
were rated as medium (eight) and high (four)
quality. General conclusions were that (a) safe
patient handling is effective in reducing MSDs,
(b) nurses should be trained in both manual and
equipment-based patient handling techniques,
and (c) high prevalence of MSDs is associated
with psychosocial stress.
The Sedlak, Doheny, Nelson, and Waters
(2009) article provided guidelines for safe
patient handling in orthopedic settings, includ-
ing orthopedic algorithms for safe patient han-
dling. In total, there were five medium- and
two high-quality articles citing the Sedlak
et al. article. Based on these articles, the fol-
lowing conclusions were provided: (a) safe
patient-handling programs, including mechan-
ical devices, do not inhibit recovery for reha-
bilitation patients; (b) evidence-based safe
patient-handling programs benefit caregivers
and patients; and (c) perceived risk factors
limit the capacity of nurses to work in physi-
cally demanding roles.
High-quality articles were further assessed to
rate centrality of the Waters article on a scale of
1 to 5. The scale is broken down using the fol-
lowing descriptions:
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20. Waters’s Contribution to Health Care Ergonomics 745
1 = extremely central
2 = semi-central (75% of the article centrally related
to original work)
3 = neutral (50% of article centrally related to origi-
nal work)
4 = semi-unrelated (25% of the article centrally
related to original work
5 = completely unrelated
Waters’s article “NIOSH Research Efforts
to Prevent Musculoskeletal Disorders in the
Healthcare Industry (Waters et al., 2006) was
cited by 23 high-quality studies. Sixty percent
of these articles were found to be extremely cen-
tral, and only 8% were semi-unrelated. “When
Is It Safe to Manually Lift a Patient?” (Waters,
2007) was cited by 23 high-quality studies
and resulted in 43% of the articles being semi-
central and 35% extremely central. Waters’s
review of the relationship between work sched-
ule and musculoskeletal disorders in the health
care sector (Caruso & Waters, 2008) was cited
by 14 high-quality studies. Thirty-five percent
were extremely central and 35% were semi-
unrelated. Waters, Nelson, and Proctor’s (2007)
research on patient handling in critical care was
cited by 10 high-quality articles, with 70% rated
as semi-central. Six high-quality articles cited
overexertion injuries in home health care work-
ers and the need for ergonomics (Galinsky et al.,
2001), with 50% of them rated as extremely cen-
tral. Waters’s article investigating the prevention
of musculoskeletal disorders in nurses was cited
four times by high-quality studies, with 50%
rated as semi-central and 25% extremely cen-
tral. Sedlak et al.’s (2009) guidance statement
was cited by two high-quality studies, with both
being rated as extremely central.
Overall, 40% of the high-quality studies were
rated as extremely central and 35% rated as
semi-central. None of the studies were rated as
completely unrelated. Based on this rating sys-
tem, 75% of the high-quality studies that cited
Waters were extremely central or semi-central to
the original work, furthering his contributions to
the health care industry (Table 3).
Discussion
The impact of Waters’s research has reached
far beyond his work on the popular Revised
NIOSH Lifting Equation. As seen from this
review, Waters’s work has made a tremendous
contribution to the health care industry, specifi-
cally, safe patient-handling initiatives. Although
other articles may be more highly cited, Waters
had a very relevant impact on the field of health
care ergonomics and often collaborated with
other pioneers in this research area. He worked
on developing guidelines for major nursing asso-
ciations for safe patient handling as well as
developing curriculum standards for nursing pro-
grams in higher education. One of the most
impressive aspects of Waters’s work in health
care and safe patient handling was that although
this work focused on the health care worker and
nurses, it was oftentimes utilized as relevant
Table 3: High-Quality Studies Centrality Rating
Article
High-Quality
Studies
Extremely
Central
Semi-
Central Neutral
Semi-
Unrelated
Extremely
Unrelated
Waters, Collins, Galinsky, &
Caruso (2006)
23 60% 17% 13% 9% 0%
Waters (2007) 23 35% 44% 4% 17% 0%
Caruso & Waters (2008) 14 36% 29% 0% 36% 0%
Galinsky, Waters, & Malit (2001) 6 50% 33% 0% 17% 0%
Waters, Nelson, & Proctor (2007) 10 10% 70% 0% 20% 0%
Menzel, Hughes, Waters, Shores,
& Nelson (2007)
4 25% 50% 0% 25% 0%
Sedlak, Doheny, Nelson, &
Waters (2009)
2 100% 0% 0% 0% 0%
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21. 746 August 2016 - Human Factors
evidenceformorethan30otherindustries.Another
strong indication of the impact of Waters’s work is
the high percentage of good-quality papers (98%
at medium or high quality) referring to his work.
High-quality studies were found to be extremely
or semi-central in 75% of the articles. This find-
ing means the original works of Waters continued
to be supported through similar-themed research,
signifying his continued contribution to the health
care industry.
Waters’s work was positively referenced by all
citations. His research served as foundational evi-
dence to many of these citing articles. The linkage
between his work and the citing articles lead to
more diverse conclusions than what was con-
cluded in his work. Some of the important themes
of these conclusions were as follows: (a) Safe
patient handling is effective in reducing MSDs in
health care workers, (b) shift work has a negative
impact on nurses, (c) there is no safe way to manu-
ally lift a patient, and (d) nurse curricula should
contain safe patient handling. Each of these has
the potential to have continued impact on the field
of health care, well beyond the career of Waters.
Although the literature reviewed in this
unique review provided some general insights
into several of the major concerns for health care
workers, the review does have a few limiting
concerns. First, for each of the concluding
themes, the review was not comprehensive,
which does not allow a true understanding of the
evidence for these themes. Other research could
provide further insight that may or may not sup-
port these themes. This review was not meant to
be a completely conclusive review but rather
was intended to identify the key areas to which
Waters contributed and his impact in the field of
health care ergonomics. Second, the impact of
Waters’s work will continue to grow and expand,
which means the current themes and the strength
of the evidence supporting them will change
over time. The main purpose of this review was
to provide insight into the impact of the work of
Tom Waters. It was clear that his work has and
will be an everlasting contribution to the world
of health care ergonomics.
Key Points
•• This article provided insight into the contribution
of Tom Waters’s work.
•• Review of the literature detailed his contributions
to the world of health care ergonomics.
•• Industries benefiting from his research were also
identified.
•• His research contributions will continue to influ-
ence health care ergonomics through future proj-
ects by other researchers.
Supplementary Material
See the online appendix at http://hfs.sagepub
.com/supplemental for list of reviewed articles in
addition to these references.
References
Caruso, C. C., & Waters, T. R. (2008). A review of work schedule
issues and musculoskeletal disorders with an emphasis on the
healthcare sector. Industrial Health, 46, 523–534.
Galinsky, T., Waters, T., & Malit, B. (2001). Overexertion injuries
in home health care workers and the need for ergonomics.
Home Health Care Services Quarterly, 20, 57–73.
Gonzalez, C. M., Howe, C. M., Waters, T. R., & Nelson, A. (2009).
Recommendations for turning patients with orthopaedic
impairments. Orthopaedic Nursing 28(2 Suppl.), S9–12.
Menzel, N. N., Hughes, N. L., Waters, T., Shores, L. S., & Nelson,
A. (2007). Preventing musculoskeletal disorders in nurses: A
safe patient handling curriculum module for nursing schools.
Nurse Educator, 32, 130–135.
Nelson, A. L., Collins, J., Knibbe, H., Cookson, K., De Castro, A.
B., & Whipple, K. L. (2007). Safer patient handling. Nursing
Management, 38(3), 26–32.
Nelson, A. L., Waters, T. R., Menzel, N. N., Hughes, N., Hagan, P. C.,
Powell-Cope, G., Sedlak, C., & Thompson, V. (2007). Effective-
ness of an evidence-based curriculum module in nursing schools
targeting safe patient handling and movement. International Jour-
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Parsons, K. S., Galinsky, T. L., & Waters, T. (2006a). Suggestions
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weight-bearing home care patients. Home Healthcare Nurse,
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Parsons, K. S., Galinsky, T. L., & Waters, T. (2006b). Suggestions
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Tiffany Poole Wilson is a risk assessment and
safety validation engineer with L’Oréal in Florence,
Kentucky, and a recent graduate of the University of
Cincinnati. She received her PhD in occupational
safety and ergonomics from the University of Cin-
cinnati, College of Medicine, Department of Envi-
ronmental Health.
Kermit G. Davis is an associate professor at the Uni-
versity of Cincinnati in the College of Medicine,
Department of Environmental Health, where he also
directs the Low Back Biomechanics and Workplace
Stress Laboratory. He received his PhD in occupa-
tional ergonomics from The Ohio State University,
College of Engineering, Department of Industrial
and Systems Engineering. He is a certified profes-
sional ergonomist (CPE).
Date received: October 7, 2015
Date accepted: April 11, 2016
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