Applied Ergonomics 60 (2017) 22e29

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Applied Ergonomics
journal homepage: www.elsevier.com/locate/apergo

Repositioning a passive patient in bed: Choosing an ergonomically

advantageous assistive device
Chava Weiner a, *, Leonid Kalichman b, Joseph Ribak c, Deborah Alperovitch-Najenson b, c
a
Zeide School of Nursing, Bnai-Zion Medical Center, Haifa, Israel
b
Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences at Ben-Gurion University of the Negev,
P.O.B. 653 Beer-Sheva, 84105, Israel
c
Department of Environmental and Occupational Health, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Repositioning of passive patients in bed creates health risks to the nursing personnel. Therefore,
Received 5 March 2016 appropriate assistive devices should be used. Our aim was to find the optimal assistive device for
Received in revised form reducing musculoskeletal load while moving a passive patient in bed. Torso kinematic inputs evaluated
3 October 2016
by the Lumbar Motion Monitor (LMM) and perceived load (Borg scale) were measured in female nurses
Accepted 8 October 2016
performing 27 patient transfers [represented by a mannequin weighing 55 (12 nurses), 65 (24 nurses)
and 75 kg (12 nurses) in bed] using a regular sheet, a sliding sheet and a carrier. The lowest rates of
perceived exertion were found when the sliding sheet and/or carrier were used, for all tasks (p
0.009).
Keywords:
Repositioning
According to the predicted risk for Low Back Disorder (LBD) based on the LMM inputs, negligible dif-
Work related musculoskeletal disorders ferences between assistive devices were found. In a 75 kg mannequin, the participants were able to
Sliding sheets perform all tasks only by using a sliding sheet. Utilizing sliding sheets is an advantageous technique in
Nursing comparison to traditional cotton sheets and even carriers.
Low back disorder risk model © 2016 Published by Elsevier Ltd.

1. Introduction
Work related musculoskeletal disorders (WMSD) are the lead-
ing factors affecting workers in industrialized countries (USDOL,
BLS, 2009a,b,c). Amongst nurses, these injuries are the source of
their main health problems (Goldman et al., 2000; Retsas and
Pinikahana, 2000; Alexopoulos et al., 2003; Nelson and Baptiste,
2006; Bohdana et al., 2004; Waters et al., 2006; Pompeìì et al.,
2009; Alexopoulos et al., 2011). Nursing assistants, orderlies and
attendants rank second while registered nurses rank sixth in a list
of at-risk occupations for strains and sprains (U.S. Department of
Labor (2012)). In Israel, a cross-sectional observational study
revealed a 43.9% 12-month prevalence of work-related low back
pain (LBP) among nurses in a rehabilitation hospital (Alperovitch-
Najenson et al., 2014).
Most studies reporting on WMSD in nurses have investigated
Abbreviations: EMG, electromyography; LBD, lower back disorders; LBP, lower
back pain; LMM, lumbar motion monitor; WMSD, work related musculoskeletal
disorders.
* Corresponding author.
E-mail address: chava.weiner@b-zion.org.il (C. Weiner).
patient lifts and transfers, even though these two activities
constitute only a small portion of all nursing tasks (Collins et al.,
2004; Nelson and Baptiste, 2006; Edlich et al., 2005; Hart, 2006;
Gonzalez et al., 2009; Hodder et al., 2010; Choi and Brings, 2016).
In contrast, repositioning patients in bed is a frequently performed
task (Nelson and Baptiste, 2006; Hodder et al., 2010; Fragala, 2011)
and one of the highest risk activities to health workers, causing
occupational injuries (Waters, 2008; Peterson et al., 2007; USDOL
BLS, 2012).
The term “repositioning” in healthcare refers to patient's body
re-positioning or re-posturing which includes manual handling,
transporting or supporting a load (i.e., lifting, lowering, pushing,
pulling, carrying or moving) by using hands or bodily force. When
repositioning patients in bed, assistance is needed to move patients
who have difficulty moving themselves (e.g., passive patients dur-
ing basic tasks such as moving or turning in bed, as well as health-
related treatments in bed). Repositioning reduces the risk of sec-
ondary complications from bed rest, such as pulmonary embolus,
deep vein thrombosis or respiratory infections. Repositioning pa-
tients can also maximize the benefit of other interventions such as
suctioning or providing hygiene (Potter and Perry, 2001; Taylor
et al., 2001; Dougherty and Lister, 2011). Repetitive repositioning

http://dx.doi.org/10.1016/j.apergo.2016.10.007
0003-6870/© 2016 Published by Elsevier Ltd.
 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29
tasks performed over the course of a workday comprise pulling
patients towards the head and side of the bed (Schibye et al., 2001;
McCoskey, 2007; Fragala, 2011; Fragala and Fragala, 2014).
Manual repositioning requires high physical demands and
awkward postures of the caregiver (e.g., leaning over the bed or
working in a confined space) due to the patient's excessive weight.
Studies have shown that these tasks are associated with increased
risk of pain and injury, particularly to the caregivers' backs (Nelson
et al., 2003; OSHA 3182, 2003; Fragala, 2011; Alperovitch-Najenson
et al., 2015). Marras et al. (1999) showed that the frequent “single
hook method” used by one worker standing beside the bed, holding
the patient under the shoulder by his elbow joint while moving the
patient upwards in bed, creates the highest risk for LBP and spinal
loads.
Because repositioning and pulling patients upwards or to the
side of the bed are frequent tasks creating significant risk for
WMSD in nurses and nursing aids (Screfer, 2001), caregivers should
use an appropriate mechanical device to assist in caring for the
patients while preventing potential injuries for both patients and
caregivers (Gonzalez et al., 2009; Koppelaar et al., 2012; Spratt
et al., 2012).
Various ergonomic devices have been developed over the past
few years to assist in reducing the mechanical load during patient
handling activities (Skotte and Fallentin, 2008; Drew et al., 2016).
For example, the use of friction-reducing sliding sheets has reduced
the risk of musculoskeletal injury among caregivers when
compared to traditional cotton sheets, due to lower spinal
compression (Bartnik and Rice, 2013). Several studies have sup-
ported the use of sliding sheets for repositioning patients in bed as
part of injury prevention programs (Fragala et al., 2005; Theou
et al., 2011; Bartnik and Rice, 2013). However, sliding sheets have
significant disadvantages including the inconvenience of additional
layers of bedding, the tendency to wrinkle while under the patient,
and their being too slippery for certain patients (Filek et al., 2010).
Despite the importance of assistive devices for safe reposition-
ing of patients in bed, their impact on the nurses’ body structure
has not been adequately studied (Peterson et al., 2007; Skotte and
Fallentin, 2008). Furthermore, Freiberg and his colleagues (Freiberg
et al., 2016), following a systematic literature search, claim that
there is no convincing evidence (from low-quality studies) for the
preventability of musculoskeletal complaints and diseases by the
use of small aids (bed ladders, anti-slide mats, slide boards/transfer,
boards, handling belts/gait, transfer mats, slide sheets, and slings).
Therefore there is a crucial need to investigate new techniques
and devices designed to reduce the mechanical load during patient
handling activities, thereby preventing back injury while main-
taining the patients’ safety and comfort (Zhuang et al., 1999;
Bartnik and Rice, 2013). The aim of this study was to investigate
measures of mechanical loading and low back risk from using three
devices during patient repositioning tasks, while moving a passive
patient towards the head or the side of the bed by one or two
nurses.
2. Methods
2.1. Participants
Participants in the study have been sampled from a general
hospital's departments. When the research protocol was presented
in routine staff meetings of seven departments, 48 (24 for
mannequin weighing 65 Kg, 12 others for mannequin weighing
55 Kg, and another 12 for mannequin weighing 75 Kg) healthy fe-
male nurses, volunteered to participate in the study. As a rule,
nurses who suffer from severe chronic pains and dysfunction do
not work in these departments.
23
Nurses signed an informed consent form and affirmed no back
pain on the trial day. The study was approved by the Ethical
Committees of Bnai-Zion Medical Center and Tel-Aviv University.
Data were collected from January through December 2014.
The sample size estimation was performed using Power and
Sample Size Calculation software. The main outcome measure was
the predicted risk for Low Back Disorder (LBD) based on the Lumbar
Motion Monitor (LMM) torso kinematic inputs. The pilot study
showed that the differences in results between measurements are
normally distributed with a standard deviation of 2.5. The differ-
ence in the predicted risk for LBD means was chosen as 5% (clini-
cally significant difference), effect size of 5%, a significance level of
5% (a ¼ 0.05) and statistical power of 80% (b ¼ 0.8). A sample of four
subjects was required. Since we performed three different trials
(three different devices for patient repositioning), the sample size
was multiplied by three. Therefore, the total number of subjects
needed was 12 for each portion of the study.
2.2. Evaluated assistive devices
The three assistive devices used in this study were: 1) a tradi-
tional cotton sheet, generally used by the nursing staff during
repositioning patients in bed; 2) a sliding sheet (a reusable tubular
slide sheet, 100  120 cm) made of synthetic nylon low-friction
materials, which enabled friction between the two nylon layers,
while moving the patient lying above. The sheet is cylindrical and
can be laundered at 70  C; and 3) a carrier (Molift® Multitrans,
102040-M) made of synthetic nylon low-friction materials, in an
inflexible structure, with ergonomic handles along each side, which
can be washed with 70% alcohol.
The passive patient was represented by a mannequin made of
canvas, filled with sand in an anatomic distribution of three sizes,
weighing 55, 65 and 75 kg. The mannequin was used to ensure the
standardization of a “patient's” weight and to prevent collaboration
of a patient or an actor while performing the repositioning tasks.
2.3. Outcome measures
2.3.1. LBD risk evaluation
The LMM, a commercial device, (marketed by the Chattanooga
Group) is an electro-goniometer worn as an exoskeleton of the
spine, capable of assessing the instantaneous position of the
thoraco-lumbar spine in a three-dimensional space, velocity and
acceleration. It is designed to evaluate torso kinematics that can be
used in the model of LBD risk prediction (Marras et al., 1999;
Ferguson et al., 2012; Davis and Ane s, 2014).
The probability of membership of the high-risk category of LBD
was developed and described in Marras et al. (1993, 1995), and this
model was validated in Marras et al. (2000). Marras et al. (1993),
asserts that by tracking five occupationally-related factors used in a
multiple logistic regression risk model (moment, lift rate, lateral
trunk velocity, sagittal trunk angle and trunk twisting velocity), it is
able to predict the probability of high-risk group membership. The
analysis identify the magnitude of each of the five model factors
that in combination, would result in incremental “benchmarks” for
probabilities of high-risk group membership that vary from 10% to
90% risk.
In order to calculate the probability of LBD risk by Marras’
model, some additional data were required:
1. Lift rate was set constant at one task per minute in all the trials.
2. Weight calculation: Since the participants were asked to drag
the mannequin on the surface of the bed and avoid lifting it, the
mannequin weight could not be taken in account as the correct
parameter for calculating the moment. Therefore, we calculated
24 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29
the real weight exerted on the participant's body in each mea-
surement individually: at each performance of each of the tasks,
the participant was standing on weighing scale (AD4406). The
weigh data were delivered simultaneously via electronic cable
to the receiving software (WinCT©, A&D Company, Limited)
installed on a laptop. The software recorded the participant's
weight every 10 s for the entire duration of the tasks, and
calculated the average weight measurements throughout the
task. The participant was weighed before performing the task. In
order to calculate the weight values incorporated in the model,
after each experimental task the participant's weight was
reduced from the average weight measurement that was
received throughout the task.
3. In order to measure the distance of the load from the person's
body, we stipulated beforehand certain conditions: (a) Before
each performance of a task, the mannequins were placed in an
invariable fixed place in bed, (b) The weighing scale, on which
the participant was standing was placed in a fixed place relative
to bed, (c) The vertical center of the participant's body was
marked on the bed side panel, in front of which the participant
was asked to stand with the center of his body. Given these
conditions, the measurements included the maximum moment
arms (horizontal distance between the approximate L5/S1 and
the hands during the exertion) at the beginning and ending of
the experimental task performance.
2.3.2. Estimation of the reliability and reproducibility of LBD risk
prediction
The reliability and the reproducibility of LBD risk prediction
were tested for two researchers. Each researcher positioned the
device twice on the back of each participant on two separate oc-
casions, in order to obtain reliable measurements according to the
manufacturer's instructions. Five subjects were asked to move a
basket filled with stones weighing 4.6 kg from the top shelf to the
bottom shelf of a hospital service cart, and then to the top. Each
subject performed four sets (each set three times, two sets per
examiner). All relevant data were entered into the LMM's software
program (based on Marras' model).
The Kappa inter-tester reliability was 0.81 and the Intra Class
Correlation (ICC) coefficient was 0.98. The mean load on the par-
ticipants' feet data needed to predict the probability of LBD risk by
Marras’ model was measured by CHINAWEIGH weighing scales,
which are able to measure weights up to 300 kg with accuracy of
0.5 kg. The weighing scales data (10 data per second) were trans-
mitted to a data reception and processing computer software
program (WinCT©; A&D Company, Limited), which calculated mean
and standard deviation weight during the task.
2.3.3. Physical exertion evaluation
The Borg Scale of Perceived Exertion (Borg, 1982) was used to
evaluate the participants’ subjective assessment of the physical
exertion required to complete the task of turning and positioning a
patient in bed. This instrument is a 10-point scale on which the
participants rated the exertion felt in the shoulder/upper back and
lower back while carrying out repositioning tasks from “nothing at
all” [1] to “maximal” [10]. It has been used for more than 40 years
and its validity and reliability was established by Chen et al. (2002),
among others. This tool was used because it is a validated psy-
chophysical measure of physical stress and has been widely
accepted in the ergonomics field.
2.4. Procedure
The study was conducted at the Zeida Nursing School of the Bnai
Zion Medical Center, Haifa, Israel. The researcher positioned the
LMM device to the participant's trunk. Each participant was then
asked to stand on the scale and perform a series of 27 transfers:
Three repositioning techniques: (1) transfer the mannequin to
the bedside by one participant, (2) transfer the mannequin to the
head of the bed by one participant and (3) transfer the mannequin
to the head of the bed by two participants. Each repositioning
technique was carried out using the three assistive devices: (1)
regular cotton sheet, (2) sliding sheet and (3) carrier. Each task was
performed three times, according to the LMM operating in-
structions in order to ensure reliability.
. When two nurses were required to move the mannequin to the
head of the bed, a researcher's assistant was the other participant
helping. The same assistant participated in all trials. While per-
forming the tasks, participants were instructed to lean on the side
of the bed, to prevent bending and torsion of the lower back and the
waist as much as possible and avoid lifting the mannequin. Each
participant was asked to grade his perceived exertion (Borg scale)
after performing each of the nine tasks (three transfer modes
through three transfer devices).
2.5. Statistical analysis
All statistical computations were performed using the SPSS 17.0
for Windows (SPSS, Chicago, IL, USA). Normal distribution of the
quantitative data was assessed by the Shapiro-Wilk test (because
our sample size was <50) and Q-Q plots. The Shapiro-Wilk test
showed that data significantly deviate from a normal distribution
(p < 0.05). Therefor we used non-parametric statistics for further
analysis. The Friedman test was used to compare LBD risk and
perceived exertion (Borg scale) between three assistive devices;
three “patient” weights (55 kg, 65 kg and 75 kg) and three repo-
sitioning techniques. A p-value of <0.05 was considered significant.
If the results of the Friedman tests were statistically significant,
post hoc comparisons with Bonferroni corrections was conducted
using the Wilcoxon matched pairs signed-rank test. Accordingly, a z
value was calculated with the SPSS and the p value was produced
by a T table. Significance was defined as p < 0.017.
2.6. Qualitative study
The Delphi procedure (Hasson et al., 2000) was conducted in a
focus group of six subjects who had participated in the study. The
aim was to discuss and choose the most favored assistive device for
repositioning a passive patient in bed. The subjects were divided
into pairs in which participants from different departments dis-
cussed the pros and cons of each assistive device. Subsequently, the
group was divided into two sub-groups where the differences be-
tween the devices were discussed. The preferred assistive device
was chosen at the concluding discussion of the group.
3. Results
In the group working with mannequins weighing 75 kg, all
participants were able to perform all tasks only using the sliding
sheets. Conversely, the task of repositioning the patient upwards in
bed by one participant was performed successfully only by two out
of the 12 participants using a regular cotton sheet; and five out of
the 12 participants successfully used a carrier. Further, the task of
repositioning the mannequin upwards in bed by two participants
was performed successfully by 10 out of the 12 participants who
used a regular sheet and by all participants who used a carrier. The
task of repositioning the mannequin to the side of the bed was
performed successfully by nine out of the 12 participants using a
regular sheet and by all 12 participants using a carrier (Table 1).
 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29 25

Table 1 exertion in the shoulder/upper back and lower back while carrying
The number of participants who failed in performing the tasks using a 75 kg out patient handling tasks. The results indicate significant differ-
mannequin.
ences between the three assistive devices while performing the
Assisting device Task Total number No. of subjects series of 27 “patient” transfers. A significant advantage was found
of subjects who failed in using the sliding sheet and/or carrier over regular cotton sheet in
Regular cotton sheet Upwards, one nurse 12 10 all tasks (p
0.009) (Fig. 2). Nonetheless, in comparing the assistive
Upwards, two nurses 12 2 devices, significant advantage for the sliding sheet over the carrier
Side, one nurse 12 3
was found only when moving a 65 kg mannequin to the side of the
Sliding sheet Upwards, one nurse 12 e
Upwards, two nurses 12 e bed by one participant (p ¼ 0.001) (Fig. 2).
Side, one nurse 12 e Results of the focus group discussions indicated a clear prefer-
Carrier Upwards, one nurse 12 7 ence for using sliding sheets when repositioning a passive patient
Upwards, two nurses 12 e
in bed (Table 4). The participants emphasized the advantages of a
Side, one nurse 12 e
sliding sheet over the carrier, i.e. a considerable reduction of exer-
tion and strain, high availability, easy extraction from the patient's
lower body and high suitability for use in heavy patients, in patients
Participants that did not succeed in performing the tasks of repo- where rolling would be dangerous as well as post-major surgery. In
sitioning the mannequin upwards in bed whether by one or by two addition, the participants indicated the effectiveness of the sliding
participants, and to the bed side by one participant, reported that sheet in preventing the transmission of infections and its reason-
they had not enough physical strength to perform the tasks. able financial costs, hence, increasing the feasibility of this device.
Table 2 and Fig. 1 compare the risk percentages among the three
assistive devices while performing the series of 27 “patient” 4. Discussion
transfers, estimated by the LMM. When moving a 65 kg and 75 kg
mannequin towards the head of the bed by two participants, a Low back disorder risk prediction and the perception of effort
significantly lower risk was found when a carrier was used as were examined using a regular cotton sheet during a repositioning
compared to the regular cotton sheet (p ¼ 0.004 and 0.011, maneuver compared to a carrier and a sliding sheet. The carrier was
respectively) (Fig. 1). All the other findings were statistically made of rigid material with a nylon bottom in order to reduce
insignificant (Table 2). friction, with handles on each of its four corners to assist in easing
Table 3 and Fig. 2 compare perceived exertion estimated by the the grip (coupling) of the caregiver. It is unrealistic to keep the
Borg scale (0 ¼ no exertion, 10 ¼ extremely heavy, maximal exer- carrier under the patient's body for an extended period of time. The
tion) (Borg, 1982). The scale was used to determine perceived sliding sheet is made of nylon to reduce friction, sewn into a cy-
lindrical shape, which slides “onto itself” while positioning a pa-
Table 2
tient in bed, thus reducing the friction.
Comparison of LBD risk prediction (%) between the three assistive devices while The main outcome of the current study was the rating of
performing the three tasks, on three mannequins weight: 55 Kg (N ¼ 12), 65 Kg perceived exertion estimated by the Borg scale (Borg, 1982), which
(N ¼ 24), and 75 Kg (N ¼ 12). determined the perceived exertion in the shoulder/upper and
Task; 55 Kg (N ¼ 12) Assisting device LBD risk percentage P value lower back while carrying out patient handling tasks. This rating
Median (Min, Max) indicated a significant difference between the three assistive de-
Upwards, one nurse Regular cotton sheet 32.50 (30,40) 0.300 vices and demonstrated a significant advantage for using sliding
Sliding sheet 40 (30,42) sheets and/or carrier in all tasks (p
0.009).
Carrier 40 (24,42) In other studies, where measurements were taken using the
Upwards, two nurses Regular cotton sheet 31.50 (22,46) 0.368 Borg scale, the results reaffirmed the advantage of a sliding sheet in
Sliding sheet 30 (18,44)
Carrier 30 (11,45)
reducing friction (Filek et al., 2010; Fragala and Fragala, 2014). In a
Side, one nurse Regular cotton sheet 35.50 (30,40) 0.150 study by Filek et al. (2010) of nursing staff working in a hospice, and
Sliding sheet 30 (24,41) rehabilitation, internal and surgical wards at the University of
Carrier 37 (22,40) British Colombia in Canada, the researchers used only sliding
Task; 65 Kg (N ¼ 24) sheets. After every positioning of the patients in bed, the partici-
Upwards, one nurse Regular cotton sheet 30 (20,49) 0.738 pants were asked to rank the subjective workload they experienced
Sliding sheet 37 (20,40) when using a sliding sheet compared to a regular cotton sheet.
Carrier 40 (20,59) Their findings suggest that a sliding sheet reduces the effort
Upwards, two nurses Regular cotton sheet 35 (18,50) 0.002 required to move the patient.
Sliding sheet 32 (20,55)
Similar findings were observed in Fragala & Fragala's study
Carrier 29 (6,48)
Side, one nurse Regular cotton sheet 30 (18,41) 0.068 (Fragala and Fragala, 2014) carried out under laboratory conditions
Sliding sheet 29 (19,40) among 12 experienced health workers. The participants were asked
Carrier 33 (17,59) to position a “patient” (volunteer's weight, 102 kg) in bed, 24 times
Task: 75 Kg (N ¼ 12) in order to compare friction reducing devises with a regular cotton
Upwards, one nurse Regular cotton sheet e
sheet. Their findings suggest that the use of friction reducing de-
Sliding sheet 32.50 (24,40) vices renders positioning of patients in bed easier and safer to the
Carrier _ worker. They also found a significant preference to the friction
Upwards, two nurses Regular cotton sheet 33.50 (25,45) 0.012 reducing sheet when comparing perceived shoulder, upper and
Sliding sheet 30 (20,45)
lower back and whole body exertion.
Carrier 30 (11,37)
Side, one nurse Regular cotton sheet 32 (21,40) 0.343 In a recent published study written by Drew and colleagues
Sliding sheet 30 (20,40) (Drew et al., 2016), the researchers compared using and non-using
Carrier 35.50 (11,41) of a sliding sheet, while pulling sand bags of varying weights. Their
P value obtained through Friedman test. The data in the table are median (minimum, findings in Borg Scale support the findings of the current study, and
maximum). Statistically significant differences at p
0.05. their EMG findings even strengthen the findings indicating a
26 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29

Fig. 1. Box Plots of LBD risk prediction (%) comparing between the three assistive devices while performing the upward two nurses tasks, on mannequins' weight: 65 Kg on the left
(N ¼ 24) and 75 Kg on the right (N ¼ 12).
Each box represents 50% of the observations in the center of the range. Vertical lines represent the range of upper and lower quarter. Abnormal observation is represented as a tiny
circle. The box center line represents median. Any significant change between the devices (Wilcoxon signed rank test with Bonferroni correction) is marked with “þ”. P
value < 0.017.

Table 3 revealed a longer duration muscle contraction in the EMG data and
Comparison of the perceived exertion (Borg scale) between the three assistive de- greater perceived exertion on the Borg scale during both reposi-
vices while performing the three mannequins weight: 55 Kg (N ¼ 12), 65 Kg
tioning movements with the traditional hospital bed sheet. When
(N ¼ 24), and 75 Kg (N ¼ 12).
compared with the traditional hospital bed sheet, the slider sheet
Task; 55 Kg (N ¼ 12) Assisting device Median (Min, Max) P value had the lowest coefficient of friction.
1
Upwards, one nurse Regular cotton sheet 6 (3,10) 0.000 Bartnik and Rice (2013) investigated the forces required for
2
Sliding sheet 3 (2,8) moving a patient upwards in bed using friction-reducing slide
3
Carrier 3.5 (2,8)
1 sheets and a traditional cotton sheet. They used a 3-D motion
Upwards, two nurses Regular cotton sheet 3 (2,5) 0.001
2
Sliding sheet 2 (1,3) capture system with four cameras to evaluate the shear force on the
3
Carrier 2 (1,3) lumbar region in addition to force gauges to estimate the hand
1
Side, one nurse Regular cotton sheet 5 (3,5) 0.000 force while moving a patient upwards in bed. The results suggested
2
Sliding sheet 2 (0,3) that the use of friction-reducing slide sheets reduces the potential
3
Carrier 3 (0,4)
for musculoskeletal injury among caregivers compared with
1
Task; 65 Kg (N ¼ 24) Assisting device Median (Min, Max) P value traditional cotton sheets due to lower spinal compression.
Upwards, one nurse 1
Regular cotton sheet 5 (3,10) 0.000 In our previously published repeated measurements experi-
2
Sliding sheet 3 (0,8) mental study (Weiner et al., 2015), the amount of force needed to
3
Carrier 3 (1,8) move a passive “patient” to the side or head of the bed by one or
1
Upwards, two nurses Regular cotton sheet 3 (2,7) 0.000
2
Sliding sheet 3 (0,5)
two participants, using the three devices (a regular cotton sheet, a
3
Carrier 2 (0,5) sliding sheet and a carrier), was measured using a hand-held
Side, one nurse 1
Regular cotton sheet 5 (1,10) 0.000 dynamometer (Baseline® Hydraulic Push/Pull Dynamometer). In
2
3
Sliding sheet 2 (0,4) this study, the “passive patient”, represented by a 61 year old
Carrier 2 (0,7)
healthy woman weighing 65 kg who asked to lie supine and to
1
Task; 75 Kg (N ¼ 12) Assisting device Median (Min, Max) P value avoid assisting the participants in performing the repositioning.
Upwards, one nurse 1
Regular cotton sheet 9.5 (6,10) 0.000 The results indicated that the amount of force needed to move a
2
Sliding sheet 4.5 (2,10) passive patient in bed (in all three tasks) was the lowest when using
3
Carrier 5 (1,10) a sliding sheet and/or carrier and the highest when using a tradi-
1
Upwards, two nurses Regular cotton sheet 5 (3,9) 0.001
2 tional cotton sheet (p
0.009). Repositioning a patient to the head
Sliding sheet 3 (0,7)
3
Carrier 3 (3,6) of the bed by one participant was the task requiring the highest
Side, one nurse 1
Regular cotton sheet 4 (3,10) 0.000 amount of force. According to our knowledge, the study described
2
Sliding sheet 2 (0,7) above is the only one comparing a sliding sheet to a carrier. This
3
Carrier 3 (2,6)
study found a significant advantage of a sliding sheet over a carrier
P value obtained through Friedman test. The data in the table are median (minimum, in all three tasks: repositioning a “passive patient” to the side of the
maximum). Statistically significant differences at p
0.05. bed by one participant or to the head of the bed by one or two
participants (Weiner et al, 2015).
significant preference for the sliding sheets. While using the LMM when various assistive devices were used,
Advantages of sliding sheets over regular cotton sheets have only moving the mannequin towards the head of the bed by two
been demonstrated in several studies. Theou et al. (Theou et al., participants showed a significant difference, with advantage to the
2011) used a portable surface electromyography (EMG), a Borg carrier. Lower risk was found when the carrier was used to move a
scale of perceived exertion and coefficient of friction to compare 65 and 75 kg mannequin, compared to the regular cotton sheet
the physical and physiological measures of muscle activity between (p ¼ 0.004 and 0.011, respectively). McGill & Kavaoc's study sup-
a slider sheet and a traditional hospital bed sheet, while performing ports our findings (McGill and Kavcic, 2005). The authors explained
boost and turn of a female volunteer weighing 51 kg. The findings the consequences of low back loads while performing patient
 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29 27

Fig. 2. Box Plots of perceived exertion (Borg scale) comparing between the three assistive devices: in each graph regular cotton sheet (left), sliding sheet (middle) and carrier
(right); while performing the three tasks: upwards one nurse (left column), upwards two nurses (middle column) and side one nurse (right column); on mannequins' weight: 55 Kg
(N ¼ 12) (upper row), 65 Kg (N ¼ 24) (middle row) and 75 Kg (N ¼ 12) (lower row).
Each box represents 50% of the observations in the center of the range. Vertical lines represent the range of upper and lower quarter. Abnormal observation is represented as a tiny
circle. The box center line represents median. Any significant change between the devices (Wilcoxon signed rank test with Bonferroni correction) is marked with “þ”. P
value < 0.017.

transfers using three different ‘sliding’ devices and by using an EMG
to measure muscle activation levels together with external forces
and kinematic positional data which were tested during push pull
and twist transfers. Spinal loads were estimated using a three-
dimensional biomechanical static link-segment model of the hu-
man body, demonstrating no consistent influences on trunk incli-
nation, low back compression or muscle activation profiles. These
findings also appear in other studies (Zhuang et al., 1999; Daynard
et al., 2001).
While predicting the probability of LBD risk using Marras model,
according to the torso kinematic inputs from the LMM, the general
absence of risk differences can be explained by the technique of
performing the task: while moving the patient upwards in bed by
one nurse, the participant leaned on the head panel of the bed
without moving his/her lower back. While moving the patient to
the side of the bed by one nurse and upwards in bed by two nurses,
the participant used counterforce with her own weight, thus pro-
ducing a lesser burden on the lower back.
In light of the fact that the force needed to perform the 27 tasks
differed between the three assistive devices, excluding the LMM,
28 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29

Table 4
Comparison between a sliding sheet and carrier (results of the Delphi procedure).

Domain Carrier Sliding Sheet

Exertion and strain on
musculoskeletal system
Availability for use
Extract from under the patient's body
Suitability to heavy patients
Suitability to patients to whom rolling
is dangerous
Suitability to patients after major
surgery.
Stability in bed
Danger of creating wrinkles in a sheet
and risk of bedsores
Increasing danger of falling from bed
Infection prevention
Financial cost
Some felt no contrast from a regular sheet.
The handles improving the grip, and enables a
better posture of the care giver.
Poor - no option to keep the carrier under the
patient's body
Difficult and cumbersome.- Need to turn the
patient while repositioning him.
Not suitable - Requires patient rotating in any
positioning and removal
Not suitable - Requires patient rotating in any
positioning and removal.
Not suitable - Requires patient rotating in any
positioning and removal
No sliding problem
Doesn't exist because of the removal after the
patient repositioning.
Doesn't exist because of the removal after the
patient repositioning.
Can only be disinfected
Very high cost (15 times the cost of a sliding sheet).
Significant reduction
Maximum - there is an option to keep the sliding sheet under the patient's
body
Easily - made of synthetic nylon low-friction materials, cylindrical, which
enable friction between the two nylon layers
Suitable - there is an option to keep the sliding sheet under the patient's body
Suitable e there is an option to keep the sliding sheet under the patient's body
Suitable e there is an option to keep the sliding sheet under the patient's body
A tendency to slide to the center of the bed
Requires attention, despite the lack of evidence in literature
Requires attention, despite the lack of evidence in literature
Washable (laundering).
Reasonable cost

might indicate that when repositioning a passive patient in bed,
most of the load is on the upper back, shoulders and arms.
Marras et al. (1999) found that specific techniques used by
healthcare workers to move patients in bed reduced the risk of LBP.
These researchers evaluated 17 healthcare workers for LBP risk
while repositioning patients. Spinal loading in this study was
evaluated by an EMG-assisted biomechanical model of the torso.
The results showed various repositioning techniques which created
significant risks for LBP.
The single hook method used by one worker standing beside the
bed holding the patient under the shoulder by the elbow joint
while moving the patient upwards in bed, created the highest risk
for LBP and spinal loads. The two-person draw sheet technique
showed the lowest risk.
A focus group, carried out by Filek (Filek et al., 2010) included 25
nurses from surgical, renal, hospice and rehabilitation units. The
nurses reported that using at least one component of the sliding
sheet system rather than traditional linens, made it “easier” and
“faster” to manually reposition patients. The participant's feedback
indicated that the slider bottom sheet is the most important
component in decreasing the friction and any other associated risk.
As described in our previous publication (Weiner et al., 2016),
similar conclusions were obtained in our focus group. Participants
indicated a clear preference for the sliding sheet, with significant
advantages compared to the carrier: reduction of exertion and
strain on musculoskeletal system, maximum availability for use,
suitability to heavy patients and for patients to whom rolling is
dangerous and for patients after major surgery, due to the option to
keep the sliding sheet under the patient's body. Additionally, the
sliding sheet had a benefit in preventing infections due to being
washable (laundering) and low financial cost compared to the
Carrier. Still, several issues still require special attention for the use
of sliding sheet: a tendency to slide to the center of the bed,
increasing danger of falling from bed and danger of creating
wrinkles in a sheet and risk of bedsores (despite the lack of evi-
dence in literature). However, the ability to reduce friction while
repositioning the patient in bed, and to reduce shear forces that are
applied to the patient's skin, help to reduce the risk of bedsores
(Grevelding and Bohannon, 2001).
5. Conclusions and recommendations
The findings of our laboratory study indicate a clear preference
for the sliding sheet over a traditional cotton sheet and even over a
carrier. It has been confirmed that the methods (e.g., technique/
assistive devices) used by nursing personnel have a significant in-
fluence on the back, upper limbs, shoulders and neck loading while
repositioning a passive patient in bed.
According the focus group, while using the sliding sheet, it can
be kept under the patient. Unlike the sliding sheet, using a carrier
requires extracting it out, after every repositioning of the patient.
We found no evidence in the literature to risk of bedsores using
sliding sheets. However, we believe that keeping the sliding sheet
under the patient for extended periods, requires strict surveillance
after the patients skin condition.
5.1. Limitations and future research
Several limitations in this study should be addressed: 1) at any
stage of the study, nurses were not required to perform tasks that
would endanger their health; 2) the research was conducted under
laboratory conditions (at a skills training class) where the “patient”
was represented by a mannequin and not under actual conditions in
a hospital ward; 3) the participants in our study were selected from
a convenience sample of volunteers, without representation of
those who refused to participate in the research; 4) the measure-
ments in the study were obtained from one nurse even when the
task was performed by two nurses; 5) Estimation of degree of the
research assistance aid in any separate testing has not been enabled.
Conflict of interest statement
There were no funding or financial benefits to the authors. This
paper has not been presented in the past in any form. No conflicts of
interest have been reported by the authors or by any individuals in
control of the content of this article.
Acknowledgements
This article is dedicated to the memory of Prof Theodore
Najenson, who died recently. Prof Najenson established Loewen-
stein Rehabilitation Hospital in its current form, and made a deci-
sive contribution to the development and progress of rehabilitation
medicine in Israel. May his memory be blessed.
The authors thank Mrs. Phyllis Curchack Kornspan for her
editorial services.
 C. Weiner et al. / Applied Ergonomics 60 (2017) 22e29 29

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