Ergonomics

ISSN: 0014-0139 (Print) 1366-5847 (Online) Journal homepage: http://www.tandfonline.com/loi/terg20

Hospital ward patient-lifting tasks F. BELL , M.E. DALGITY , M.-J. FENNELL & R.C.B. AITKEN To cite this article: F. BELL , M.E. DALGITY , M.-J. FENNELL & R.C.B. AITKEN (1979) Hospital ward patient-lifting tasks, Ergonomics, 22:11, 1257-1273, DOI: 10.1080/00140137908924700 To link to this article: http://dx.doi.org/10.1080/00140137908924700

Published online: 24 Oct 2007.

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ERGONOMICS, 1979, VOL. 22, NO. II, t257-1273

Hospital ward patient-lifting tasks By F. BELL, M. E. DALGITY, M.-J. FENNELL, and R. C. B. AITKEN

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Rehabilitation Studies Unit, University of Edinburgh, Princess Margaret Rose Orthopaedic Hospital, Edinburgh From a questionnaire survey of the nursing staff in charge of 362 wards in Scotland and 363 wards in England, covering every major medical speciality, information was collected on five major tasks which involve lifting patients. The reliability of six parameters, namely, the method used for lifting patients, the number of patients requiring lifting, the number of staff required per patient per lift, the importance of the task. the frequency and the physical effort involved, was measured for each task and found to be acceptable. These parameters were then used to rank the five tasks within and between wards. It is concluded that current manual lifting methods are unsatisfactory and that priority should be given to detailed investigations of the problems of lifting patients in and out of chairs. repositioning patients within chairs and beds, lifting patients on and off toilets, lifting patients in and out of beds and lifting patients in and out of baths, in that order.

1. Introduction In 1965, in a leading article in the Lancet, a plea was made for the then Ministry of Health to promote more ergonomic research into the physical requirements of the nurse's day, with particular emphasis on the problem of lifting patients (Lancet 1965). This article reflected concern about the problem of' the nurse's load' and the associated problem of lower back injury, That concern continues today as evidenced by the establishment in 1977 by the Royal College of Nursing of a Working Party on the causes of back pain among members of the nursing profession (Lloyd 1979). In 1977 an inquiry into the related problem of the use and suitability of patientlifting equipment, in particular, patient hoists, in hospitals in the United Kingdom, was undertaken by the authors with the financial support of the Department of Health and Social Security (Bell et al. 1979). In pursuing this inquiry it was necessary to attempt to define the problem of' the nurse's load'. This involved identifying the major patient-lifting tasks carried out routinely by ward staff, and quantifying these tasks in terms of the ' load' imposed over a relatively large number ofwards comprising all of the medical specialities found in hospitals. The study of patient-lifting equipment is not yet complete, but the interim results on the lifting tasks presented in this paper are sufficiently extensive to provide a useful reference framework on the size and variation of' the nurse's load' in patientlifting tasks. No comparable study of this type within hospitals in the United Kingdom has been published.· .

2. Patient hoists Apart from manual lifting the only other method of lifting patients in hospital wards, which is used to any great extent at present, involves the use of mobile patient hoists. In the survey described here, it was found that mobile hoists comprised 98% of ward lifting equipment (Bell et al. 1979). There are a number of models of mobile hoists commercially available in the United Kingdom. However, these fall broadly into two basic types as illustrated in Figure I, one type with a rigid seat support and one type with a fabric sling support. 0014.0139/79/2211 1257 S02.0U ,("') 1979 Taylor & Francie Ltd

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1258

F. Bell, M. E. Dalqity, M.-J. Fennell, and R. C. B. Aitken

(a)

Figure \.

(h)

Mobile hoist with (a) a sling and (b) rigid scat.

Lifting of patients with these devices is normally achieved by a manually operated lever or wheel which operates a hydraulic lift mechanism or a mechanical screw or chain-wheel mechanism, which in turn raises and lowers the seat or sling.

3. Method 3.1. Questionnaire design For each common patient-lifting ward task, information on the method most used for lifting, the number of patients requiring lifting, the number of staff required per lift, ratings of importance, frequency and physical effort per lift was to be elicited. Pilot studies and questionnaire validation trials were carried out in two hospitals in the Lothian area in 16 wards which included geriatric. orthopaedic, paediatric, and maternity specialities. Five common lifting tasks were identified associated with lifting patients in and out of chairs, beds, baths, on and off toilets, and repositioning patients within chairs or beds. The validity of the final questionnaire was assessed by interviewing eight ward sisters after their completion of the questionnaire. The format of the section dealing with the chair task is reproduced in Figure 2. A similar format was used for the other four tasks, however, where rating scales are used the order of the scale points was reversed for consecutive tasks to attempt to prevent a pattern of responses being adopted by the respondent. Analysis of question (c), (Figure 2), dealing with the hypothetical use of hoists is not presented in this paper. 3.2. Suroev population With the exception of the two hospitals involved in the pilot and validation studies, every ward administered by the Lothian Health Board in Scotland and the five Area Health Authorities of Tyne & Wear in England, administered by the Northern Regional Health Authority, were surveyed. The Tyne & Wear group comprise Gatcshead, Newcastle, North Tyneside, South Tyneside, and Sunderland Area Health Authorities. This constituted a total hospital population of 725 wards in 85 hospitals with a total bed complement of about 18,000. The number of wards in the Scottish and English samples were 362 and 363 respectively. The respondents were the nurses in charge of each ward at the time of the survey. 3.3. Survey design The major specialities in each hospital to be surveyed were examined in detail in

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Figure 6. -Distnbution of responses on the importance of the five tasks.

Table 6.

Mean ratings of importance. Ward category

Moderate

Slight

Task Chair (manual) Bed (manual) Bath (hoist) Toilet (manual) Repositioning (manual)

Nos. of

wards

Mean importance rating

wards

Mean importance rating

335 343 340 280 342

4·6 4-6 4·3 4'3 4·6

110 110 110 110 110

4·7 4'7 4'5 4·6 4·6

Nos. of

wards

Mean importance rating

28 40 52 25 50

4·2 4·2 4'4 4-4 4·3

Nos. of

Great

Note: The rating scale used for each task is that shown in Figure 2, question (b).

Hospital ward patient-lifting tasks (a) Chair, toilet

1267 (d) Beth task

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Ibl Bed task

Bath task (manual lifting)

& repositioning

(hoist)

tasks

80

80

60

60

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40

80

80

60

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Figure 7.

Distribution of responses on the frequency of the five tasks. Table 7.

Mean frequency scale points. Ward category

Slight

Task Chair (manual) Bed (manual) Bath (manual) Bath (hoist) Toilet (manual) Repositioning (manual)

Moderate

Great

Mean

Mean

Mean

frequency

frequency

Nos. of wards

scale point

110 109 61 49 108 110

4'6 J.3 1·8 1'4 4'5 4'4

Nos, of wards

scale point

Nos. of wards

frequency scale point

28 40 52 0 23 49

4') 3'5

335 343 261 65 270 342

4'4 3'6 2'4 1·7 4'3 4·6

2'6 I~I

4·7 4'5

Note: The frequency scale used for each task is that shown in Figure 2, question (d). (bl Chair and bed tasks

(a) Toilet and repositioning

(c)

(dl Bath task (hoist)

Bath task (manual lifting)

tasks

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Note: The physical effort rati~g scale used for each task is that shown in Figure 2. question (g)

Figure 8.

Distribution of responses on the physical effort involved in the five tasks.

1261;

F. Bell, M. E. Dalqity, M.-J. Fennell, and R. C. B. Aitken

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of the histogram corresponds to the scale point 3, i.e. . moderate' effort. For the chair and bed tasks, the mode corresponds to scale point 4, i.e . • considerable' physical effort. The range of results over these four tasks is indicated by the shaded portions of the histograms in Figures 8A and 8B. The bath task has been subdivided according to the method of lifting; for manual lifting the mode corresponds to scale point. i.e. • considerable' effort and for lifting with a hoist the mode corresponds to point 3, i.e . . moderate' effort, Figures 8C and 80 respectively. The mean rating results for each of the three ward categories, . slight', . moderate', and' great' are summarized in Table 8. It can be seen that the mean rating of . effort where a hoist is used is identical for the' moderate' and' great' ward categories. 4.9. Ranking oftasks where physical effort is high Those respondents who had indicated that manual lifting was the method most used, and who had rated the physical effort involved as either' considerable' (point 4) or . excessive' (point 5) were selected as a sub-sample. For each of these respondents the product of the number of patients requiring lifting and the frequency rating for each task was computed; this variable is referred to as . patient-frequency' for convenience. Student 's . I . test 'was computed for pairs of these variables associated with the five tasks. The results are summarized in Table 9A. Positive correlations did exist between all paired variables. The individual tasks are ranked in Table 9B. No statistically significant differences could be determined between the chair, toilet or repositioning tasks and these are ranked as being of equal first priority. The bed and bath tasks are ranked as of second and third priority respectively. 4.10. Ranking oftasks regardless ofphysical effort All respondents who had indicated that they had at least one patient in the ward requiring lifting for a specific task were selected. The variable' patient-frequency' was again computed for each case for each task. As it is apparent from Figure 7 that there is a difference in the frequency of the bathing task between those who use manual lifting and those who use a hoist for bathing, these two groups of respondents were selected out for separate analysis. Again t-tests were applied to paired •patientfrequency' variables for the five tasks. The results for the chair, bed, toilet, and repositioning tasks are summarized in Table lOA. The results for all five tasks where manual lifting is used for bathing are summarized in Table lOB, and the results for the five tasks where a hoist is used for bathing are summarized in Table lac. No statistically significant differences could be determined between the chair and repositioning tasks and these are ranked as of equal first priority. The toilet, bed, and bath tasks are ranked as of second, third, and fourth priority respectively, Table 100. 4.11. Ranking oftasks within ward cateqories The procedure described above was repeated with two modifications. Firstly, the respondents were subdivided according to the three ward categories of •slight', 'moderate', and' great '. Secondly, the variable' patient-frequency' was modified by multiplying it by the rating scale of' importance', for each case and each task. This product of' importance '. ' frequency' and' patient numbers' is referred to as . need ', The t-tests for the chair, toilet, and repositioning tasks for the' moderate' and , great' ward categories only are presented in Table I IA although the ranking of all five tasks for all three categories indicated in Table I I B was confirmed by t-tests on all tasks in each ward category.

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Hospital ward patient-liftinq tasks Table 8.-Mean ratings of physical effort. Ward category Slight

Moderate

Nos. of wards

elTort rating

Nos. of wards

Mean physical effort rating

28 40 52 0 23 49

2-9 2·9 3·0

335 343 261 65 270 342

H H H 2-8 3·2 H

Mean physical

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Task

Great

Chair (manual) Bed (manual) Bath (manual) Bath (hoist) Toilet (manual) Repositioning (manual)

2-8 2'7

Mean physical

Nos. of wards

rating

110 109 61 49 108 110

3-6 3'5 st 2'8 3'5 3-6

effort

Note: The rating scale used for each task is that shown in Figure 2, question (g).

5.

Discussion

If a broad overview of the results is taken then for each of the five tasks one could summarize that manual lifting is most often used (Table 3), each task is considered to be of comparable importance to patient care (Figure 6, Table 6), two members of staff are generally required for lifting (Figure 5, Table 5) and the physical effort involved is rated to be high (Figure 8, Table 8). The number of patients requiring lifting and the frequency of each task does vary considerably. The bath and bed tasks involve the greatest number of patients (Table 4) but are less frequently undertaken than the other tasks (Table 7). Although manual lifting, overall, is the most common method of lifting patients there are, nevertheless, a fairly large number of wards, 114, where hoists are used for bathing patients. This number can either be expressed as representing 17 % of all of the respondents or, more meaningfully, 23 % of all those respondents who had at least one patient who required lifting for bathing. When a comparison is made between the two groups of wards where manual lifting and hoists are used for bathing it is apparent that the majority of respondents in both cases (80%) indicated that two members of staff are required for lifting. Manual lifting tends to require slightly more Table 9.

Ranking of tasks where physical elTort is high. (a) Student's t-tests

Mean Task Pairs

chair vs bed chair us toilet chair us repositioning chair us bath bed us toilet bed us repositioning bed vs bath toilet us repositioning toilet vs bath repositioning us bath

Degrees of

. patient-frequencies'

57-4 vs 45·8 57-4 vs 55'1 57-4 vs 58·1 57·7 v.f 28·2 45·8 IJS 55·1 45·8 vs 58·1 46·0 vs 28·2 55'1 vs 58'1 55-4 vs 28·2 58·0 vs 28·2

value

freedom

2-tail probability

5·67 0·84 -0,34 7-70 -2-80 -5,47 5·17 -0,88 5'95 7-63

67 67 67 66 67 67 66 67 66 66

p < 0·001

1

(b) Ranking I. Chair, toilet, repositioning

2. Bed 3. Bath

p

P P p p p

n.s. n.s. < 0·001 < 0·01 < 0·001 < 0·001 n.s. < 0·001 < 0·001

1270

F. Bell, M. E. Dalqity, M.-J. Fennell, and R. C. B. A itk en Table 10. Ranking of tasks regardless of physical effort. Mean . patient-frequencies'

Task Pairs

I

value

Degrees of freedom

2-tail probability

(a) All respondents who indicated manual lifting for chair, bed, toilet and repositioning tasks chair V.I' bed chair us toilet

40·8 44·3 41·7 36'1 34'1 39·6

chair us repositioning bed vs toilet

bed us repositioning toilet us repositioning

9·07 5·32 -0'27 -2,86 -7'60 -2'93

vs 33·8 vs 39·5 vs 42·0 vs 39·2 vs41·6 vs 43·5

468 394 444 400 457 394

I' < 0·001 I' < 0·001 n.s. I' < 0·0\ I' < 0'001 I' < 0·01

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(b) All respondents who indicated manual lifting for the bath task . bath bath bath bath

vs bed vs toilet vs repositioning vs chair

bath bath bath bath

vs bed vs toilet us repositioning v chair

20·3 21·7 20-4 20·3

-9,23 -6-46 -11,08 -10,33

vs 31·0 vs32·6 vs 37·4 vs 35·8

332 277 316 318

I' I' I' I'

< 0·001 < 0·001 < 0·001 < 0·001

(c) All respondents who indicated use of a hoist for the bath task -10,37 -12'17 -10'19 -13·59

24·2 vs 44·7 24·0 vs 56·3 23'7 vs 53·3 24·0 vs 58·6

107 108 105 108

I' < 0·001

" < 0,001 I' < 0·001 I' < 0·001

(d) Ranking I. Chair, repositioning

2. Toilet 3. Bed 4. Bath

Table II.

.

Ranking of tasks within ward categories. (a) Student's t.tests

Task pairs

Mean' need'

I

value

Degrees of freedom

2-tail probability

. Moderate' ward category chair us toilet chair DS repositioning toilet us repositioning

168·5 vs 135·2 159·4 vs 172-2 136-4 vs 179·6

chair us toilet chair vs repositioning

337·6 vs 311·0 336·6 vs 288·6 314·8 vs 290·7

5·89 -2,25 -5,46

274 310 266

I' < 0·001

105 102 102

P < 0·005 P < 0·005 n.s,

p < 0·05 "_< 0·001

. Great' ward category

toilet us repositioning

3-40 3-34 1·84 (b) Ranking

Moderate ward category

Slight ward category I. Chair, bed, bath, repositioning 2. Toilet

1. 2, 3. 4.

Repositioning Chair Bed, toilet Bath

Great ward category I. Chair 2. Toilet, repositioning

3. Bed 4. Bath

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Hospital ward patient-lifting tasks

1271

staff on average because there are a small number of wards (5 %) where three members of staff were indicated as required and relatively less wards (14 %) indicated that one member of staff was required as opposed to the hoist users (19 %). It is interesting that where hoists are used for bathing, the frequency of this task is less than for those wards where manual lifting is used (Figure 7). This probably reflects the fact that hoists are generally available in wards where fairly large numbers of patients require lifting (Table 4) and should not be interpreted in terms of cause and effect. The finding does, however, raise the probability that the actual frequency of bathing is not necessarily the desired frequency, a point which will have to be pursued in further studies. In comparing manual lifting and hoists for bathing it is quite clear that respondents have judged the physical effort involved to be less when a hoist is used. Less than 15 %of respondents who use a hoist rated the physical effort as greater than 'moderate' (point 3 on the rating scale) as compared to about 50 %of those who use manual lifting (Figure 8). In fact, identical mean ratings were calculated for hoist users in the two ward categories of' moderate' and' great' (Table 8). One of the most striking features in the analysis of the' nurse's load' is the considerable variation which exists for any given task between wards. The grouping of wards into one of three categories, 'slight', 'moderate', and' great', was based on a combination of medical specialities and the number of patients requiring lifting and this classification helps to highlight the differences between wards. It is particularly interesting that the mean ratings of physical effort increase from the' slight' to the . great' ward categories for each task, with the exception of the two groups where hoists are used for bathing (Table 8). This suggests that there is a qualitative difference in the lifting' load' between ward types as well as a quantitative difference in terms of patient numbers and frequency for each task. An in-depth study of groups of patients within each ward category will be necessary to confirm this finding. One of the primary objectives of the survey reported here was to provide. a description of current patient-lifting tasks in numerate terms to guide more specific studies on the suitability of lifting equipment from both the patient's and staff point of view. There is no doubt. however, that currently there is considerable concern with the specific problem of back injury to nurses. The limited objective information which is available does support the view that patient-lifting tasks, as currently practised, do cause back injuries to nursing staff. In a survey 01'911 nurses in the Dundee General Hospitals and 949 teachers in Dundee, occupational low back pain was found to be significantly more frequent among nurses (19'9 %compared with 12·8 %). In nurses, patient-lifting was the most common task associated with attacks of back pain and the highest incidence occurred in geriatric specialities (Cust 1972). Dehlin and Lindberg (1975) used a force plate to determine the load imposed on a nursing aide during three lifting tasks in a geriatric ward. One task, repositioning in bed, was performed by one aide and the other two tasks, bed to chair, and chair to bed transfers were performed by two aides. The load during lifting often equalled or exceeded the recommendations of various authorities concerning permissable maximum weight loads during lifting. The lifts were often performed under unfavourable conditions and seldom with an 'ideal' lifting technique. No conclusions were drawn on the relative loads imposed by each task but the published results suggest that each of the three tasks were comparable in terms of the vertical load. It is not unreasonable to suggest that the probability of injury to nursing staff increases where the rating of physical effort is high, the number of patients requiring lifting is high and the frequency of undertaking a task is high. All of the tasks are

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F. Bell, M. E. Dalqity; 1'.1.-1. Fennell, and R C. B., Aitken

rated by over 40 % of the respondents as involving greater than' moderate' physical

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effort when manual lifting is used (Figure 8). The first step in comparing tasks was to

select this sample where physical effort ratings were high and compare the relative "load' imposed by each task in terms of' patient-frequency', i.e. the product of number of patients and frequency of the task. From the analysis the ranking of the bed and bath tasks was achieved but no statistically significant differences were determined for the chair, toilet, and repositioning tasks. The second step in the ranking was to examine the entire population of respondents regardless of physical effort rating, again using the . patient-frequency' variable. For this population, the same relative ranking of the bed and bath tasks resulted but, in addition, a separate ranking for the toilet task was achieved. No statistically significant difference could be determined for the chair and repositioning tasks. The third and final step in ranking was to examine each task within the three ward categories, . slight', . moderate', and' great '. In this final step the variable' patientfrequency' was modified by multiplying it by the rating of' importance', because at this stage we were, in fact, attempting to make a fine judgment on the relative importance of the chair and repositioning tasks and inclusion ofactual ratings of importance seemed to be appropriate. For the' great' ward category, the chair task was ranked as first and for the' moderate' ward category the repositioning task was ranked as first. The final decision is essentially one of personal judgment because on the one hand the' moderate' category represents a larger number of nursing staff than the . great' category (by a factor of about three), but on the other hand the staff within the' great' category deal with the greatest patient load. Our decision was to rank the chair task as of first priority.

A partir dunc cnquete par questionnaire aupres du personnel infirmier de 362 salles d'h6pital en Ecossc ct 363 sallcs cn Angleterrc, rcgroupant les categories pathologiques essentiellcs, on a rente de definir les cinq uctivites principalcs impliquant Ie soulevernent des malades. Pour chaquc activite, on a cstime fidelite de six parametres, tels que la technique pour soulever Ie malade. Ie nombre de rnaldes qui neccssitent d'etre soulcves, lc nombre de personncs necessaires par personnc et par soulevernent, l'irnportance de la tache, 1a frequcncc et l'cffort physique requis. Ces parametres, etant juges pertinents, ont ensuite etc utilises pour etablir un c1asscment des cinq activites it I'intcrieur et entre les salles de garde. II est apparu que lcs techniques de souleverncnt manuel c1assiques n'etaient pas satisfaisantes et qu'une priorite devait etre donncc :l une etude detaillee des methodes pour deplaccr ou soulever les malades dans au hors des chaises, los rcpositionner dans leurs chaises ou dans leur lit, les mcttre et les en lever des sieges de toilettes, Ics moure ou les descendre de leur lit, les rncttre ou les sortir du bain (enumeration dans I'ordre d'importancc.dccroissantc du probleme),

Mil Hilfc ciner Fragbogenaktion wurden Informationen tiber die funf wichtigsten auf verschiedenen Krakcnhausstationcn vorkommcnden Belreuungsaufgaben der Schwestern gcsammclt, bei welchen das Hebert von Patienten crforderlich ist (unter Heben verstcht sich auch das Absetzen). Die erfallten Krankenhuusstationcn (362 in Schottland und 363 in England) deckten die wichtigsten medizinischen Bcreiche abo Die Rcliabilitttt von scchs Parametcrn, narnentlich der Hebcmethode, dcr Anzahl der zu hebenden Paticnten. dcr Anzahl dcr zurn Heben von Patienten erforderlichen Personen, der Wichtigkeit der Betreuungsaufgabe, der Htiufigkeit sowie der erforderlichen physischen Anstrengung wurde fur jede der funf Betrcuungsaufgabcn ermittclt und als akzeptabel eingestuft. Die erwahnten Parameter wurden anschlieliend zur Bildung cincr Rangordnung der filnf Betreuungsaufgaben innerhalb sowie zwischen einze1nen Stationen verwcndct. Es konnte fcstgestellt werden, daO derzeitige Methoden des Hebens von Patienten nieht zufricdenstellend und dctaillierte Untersuchungen dieses Problems fur die 8etreuungsaufgaben in folgcndcr Ecihcnfolgc (entsprechend der Bedeutung der festgestellten Mangel) erforderlich sind: Heben von Patientcn von St ilhlcn, Positioniercn von Patienten in Stiihlen und Betten, Heben von Patienten auf Toilcucn, Heben von Patientcn von Betten und Badern.

Hospital ward patient-lifting tasks

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References BELL, F., DALGITY, M. E., OSBORNE, S. J. P.. and AITKEN, R. C. B., 1979, The use of patient hoists in hospital wards. International Journal of Rehabilitation Research. 2. 312-313. CUST, G., PEARSON, J. C., and MAIR, A., 1972, The prevalence of low back pain in nurses. International

Nursing Review, 19, 169-179. DEHLlN, 0., and LINDBERG, B., 1975, Lifting burden for a nursing aide during patient care in a geriatric ward. Scandinavian Journal of Rehabilitation Medicine, 7, 65-72.

LANCET, 1965, Leading Article. The nurses load. Lancet, li, 422-423. LLOYD, P., 1979, Avoiding low back injury among nurses. Report of an RCN working party. (London: THE ROYAL COLLEGE OF NURSING). NIE, N. H., HULL, C. H., JENKtNS, J., STEINBRENNER, K., and BENT, D. H., 1975, Statisticat Packagefor the Social Sciences. 1I,'(New York: MCGRAW-HILL).

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Manuscript received t 9 February 1979. Revised manuscript received 22 May 1979.

Hospital ward patient-lifting tasks.

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