Protecting Backs in Patient Lifting and Transfer

Why is patient lifting technique alone not enough?

When patient lifting technique is mentioned, the rule "bend your knees and keep your back straight" usually comes to mind. This rule works when lifting a box; but a patient is not a box. Their weight is usually far above what one person can safely lift, there are no handles, the weight is unevenly distributed, and during a transfer they may move unexpectedly, go limp or start to fall. The distance between bed and stretcher, IV lines and cramped rooms also force staff to work bending and twisting. Back pain among nurses and the back problems of care staff are the natural result of these conditions.

So in healthcare facilities, the foundation of protecting back health is, besides technique, equipment, teamwork and planning. When patient transfer is approached from an ergonomic point of view, the question is not "how do we lift?" but "how do we move them without lifting?". The legislation follows the same order.

Choosing the method according to the patient's mobility

The first question to ask before every transfer is how much the patient can do themselves. The method and equipment are chosen accordingly:

Patient's condition	Type of transfer	Assistive equipment	Note
Independent, good balance	Bed to chair, standing	Supervision; walking frame if needed	Staff only guide and stand alongside
Partially weight-bearing	Sit to stand and turning	Transfer belt, stand aid or standing hoist	If the patient can use their arms, they hold a grab rail, not the staff member
Can sit but cannot stand	Bed to chair, chair to toilet	Transfer board or standing hoist	Surfaces should be at the same height
Fully dependent	Bed to chair, lifting from the floor	Mobile or ceiling-track patient hoist with a suitable sling	No manual lifting
Lying in bed	Moving up the bed, turning on the side	Slide sheet	At least two people; sliding, not lifting
Lying in bed	Bed to stretcher, stretcher to imaging table	Transfer board and slide sheet	Team and a single leader; surfaces level

A patient's condition may change during the day. A patient who was independent in the morning may be fully dependent after returning from surgery; the assessment should be updated at shift handover.

Bed-to-stretcher transfer step by step

Bed-to-stretcher transfer is one of the most frequent heavy transfers on wards and in A&E. A safe transfer using a slide sheet and transfer board follows this sequence:

Plan. The patient's condition, lines and drains, and how many people are needed are established. One of the team is chosen as leader; only they give the count.
Explain to the patient. A conscious patient who knows what will happen resists less and can help.
Level the surfaces. The bed and stretcher are brought to the same height, close to the staff's waist level; the wheels of both surfaces are braked.
Close the gap. The transfer board is placed over the gap between the two surfaces.
Position the slide sheet. The patient is turned on their side by two people and the sheet is placed underneath.
Slide, don't lift. On the leader's count, the patient is slid across by pulling, in a single movement. Staff keep their feet apart, use their arms close to the body and shift their weight from the front foot to the back foot instead of twisting the trunk.
Remove the equipment. The slide sheet and board are removed from under the patient; the slide sheet is not left under the patient for long.

This transfer is not a job one person can do alone. How the transfer will be done when staff numbers fall on the night shift should be planned in advance, with support requested from another ward if necessary.

Teamwork: one leader, one count

In transfers carried out by more than one person, a significant share of injuries come from the team not moving at the same time. One pulls early, another is late, and the whole load suddenly falls on one person's back. A few simple rules are enough to prevent this:

One leader: The transfer is directed by the person standing at the patient's head who can see the patient best. The others move only on their command.
A command agreed in advance: Is it "after three" or "on three"? The command word and the moment the movement starts are stated before the transfer.
Similar height, right position: Where possible, staff of similar height stand opposite each other; the strongest person takes the position at the trunk, the heaviest part of the patient.
Owning the lines: It is clear who will hold IV, catheter and drain lines during the transfer; nobody lunges suddenly to save a line.
Right to stop: If anyone in the team sees a problem, they say "stop" and the transfer stops.

If these rules are briefly repeated at the start of the shift in fast-paced units such as A&E and intensive care, they become habit.

Slide sheets and positioning in bed

Moving a patient up the bed is the most frequent but most underestimated task. Dragging the patient up by holding them under the armpits harms both the staff member's back and shoulders and the patient's shoulder joint and skin; this method should not be used.

The correct method is the slide sheet. When this two-layer, low-friction sheet is placed under the patient, two staff members can slide the patient towards the head of the bed with almost no lifting. These rules also reduce the load on the back when positioning:

The bed height is adjusted to the staff member's height before every task.
The head of the bed is lowered flat if possible; the patient is not slid uphill.
The patient is asked to bend their knees and push with their feet; they do as much as they can themselves.
The staff member stands beside the bed, close to the patient; they do not pull while reaching.

Patient hoists: selection, slings and use

For fully dependent patients, a patient hoist is used instead of manual lifting. A mobile hoist is flexible but needs space; a ceiling-track hoist is easier to use in small rooms and intensive care. Room width, access to bathrooms and toilets and the weight range of patients are the deciding factors in selection.

The safety of a hoist depends largely on the sling. The sling is chosen to suit the patient's size and the task (sitting, bathing, lifting from the floor); its stitching, straps and label are checked, and the safe working load on the label is not exceeded. A worn sling is not used.

The Work Equipment Regulation requires work equipment to be maintained as specified by the manufacturer and checked before each use. A short pre-use check for a hoist includes: battery charge, the emergency lowering mechanism working, wheel brakes, sling attachment points and the condition of the sling. The problem seen most often on site, however, is that the hoist is not used at all: staff choose to lift by hand rather than use a hoist whose battery is flat, which is locked in a store or which is at the other end of the ward. The hoist should be where it is needed and ready for use.

Risk assessment for patient handling

In a healthcare facility, patient handling should not appear as a single line in the risk assessment. The assessment is done ward by ward, and the four headings in Annex 1 of the Manual Handling Regulation are adapted to the site as follows:

Characteristics of the load: The dependency level and weight range of patients on the ward, risk of sudden movement, lines and devices.
Physical effort required: How many transfers are made a day, and how many of them require bending and twisting.
Working environment: Room and bathroom width, whether bed height can be adjusted, flooring, turning space for a hoist.
Requirements of the activity: Emergency transfers, staff numbers on the night shift, time taken to access equipment.

Intensive care, orthopaedics, neurology, A&E and imaging units are often treated as priorities because of the number of dependent patients and table transfers. The result of the assessment should be concrete: how many hoists, slide sheets and boards are needed on which ward, and the minimum number of people for which transfers. Groups requiring special policies, such as pregnant employees, are assessed separately; for details see our article on pregnant and breastfeeding employees. Our article on manual handling and lifting technique is also useful for general lifting rules.

Training and health surveillance

Training is as important as having the equipment. A staff member who has never used a slide sheet or a hoist will go back to lifting by hand in a moment of haste. So training should be done not in the classroom but in the ward environment, with real equipment and with practical exercises in which staff take turns playing the patient. For newly started nurses and care staff, induction training showing the ward's equipment is the most effective route.

The workplace physician monitors back and neck complaints through health surveillance and assesses the employee's fitness for work on recruitment, on a change of job and on returning to work after a long illness. Cases where a complaint began during a transfer should be recorded and the cause investigated. The same approach applies to incidents that count as near misses; see the near miss reporting system.

Bursa Sistemer provides risk assessment and workplace physician services to healthcare facilities in Bursa and the surrounding provinces. For other sector-specific risks see our healthcare facilities page, and for sharps injuries our article on sharps and needlestick injuries. You can see your minimum obligations with the OHS obligations calculator.

Frequently Asked Questions

Up to how many kilos can a patient be lifted by hand?

The Manual Handling Regulation does not set a kilogram limit. The risk is determined as much by the patient's dependency level, posture, environment and the requirements of the task as by their weight. If the patient needs to be lifted completely, a hoist should be used.

Can a slide sheet be left under the patient?

The slide sheet is for transfers. It should be removed after the task is finished; because it has low friction, if it is left underneath the patient may slip unintentionally in bed.

Using a hoist takes too long; isn't lifting by hand more practical?

It may seem so in the short term, but back injuries mean long periods of incapacity and loss of staff. If the hoist is kept where it is needed, charged and with its sling ready, the time it takes to use falls markedly.

What should a staff member do if a patient starts to fall?

Trying to hold a falling patient up exposes the staff member to serious back injury. The staff member aims to lower the patient to the floor in a controlled way, keeping them close to their body; the patient is then assessed and lifted from the floor with a hoist.