2024 Volume 24 Issue 1 Pages 1-11
The purpose of this study was to identify factors that promote or inhibit the introduction and utilization of no-lifting care in social welfare facilities in Japan. No-lifting care prevents back pain among caregivers by avoiding manual lifting of patients.
Back pain among caregivers is a growing issue in Japan and other countries, often caused by manual lifting. While other countries recommend using equipment that eliminates manual lifting to prevent back pain, in Japan, the Ministry of Health, Labor, and Welfare also endorses no-lifting care. However, nationwide adoption of no-lifting care is limited, and even where implemented, it is often underutilized. A lack of caregiver knowledge is a noted barrier to no-lifting care adoption in social welfare facilities, but the factors that either promote or hinder no-lifting care use are not sufficiently understood. To address this, we conducted semi-structured interviews with caregivers leading no-lifting care efforts (no-lifting care instructional staff) in facilities that have adopted no-lifting care. Through qualitative analysis, we identified the factors that facilitate and inhibit the introduction and utilization of no-lifting care.
The results show that the initial inhibiting factor was the resistance from caregivers who opposed changes in their work methods, while the facilitating factor was the involvement of rehabilitation specialists. During utilization, the facilitating factor was the acquisition of experience using the welfare equipment. In contrast, the inhibiting factor was the lack of opportunities for no-lifting care guidance committee members to gain sufficient knowledge and skills in physical function assessments. Furthermore, it became clear that the no-lifting care instructional staff are structured in a way that puts them in a position where they are forced to assume the leadership role of to the rest of the staff.
Future research should explore broader facility types and include diverse caregiver perspectives to further validate these findings.
As of 2024, back pain among nursing care workers in Japan’s nursing facilities is a growing concern, affecting 85-89% of workers [1, 2]. Additionally, a Ministry of Health, Labour and Welfare survey reported a rising trend in health and hygiene industry workers, including those in nursing care facilities, applying for compensation for work absences of over four days due to back pain [3]. Spengler et al. and Pransky et al. found that lower back pain also increases medical costs and makes it harder for nursing care workers to return to work [4, 5]. Therefore, back pain arguably leads to labour shortages due toabsenteeism, higher job turnover, and fewer job applicants due to the deteriorating image of caregiving [6].
Back pain among nursing care workers is becoming increasingly severe due to numerous risk factors in their work environment [7]. These factors include heavy physical labour, repetitive tasks, staffing shortages, and irregular working hours, particularly on night shifts. Among these, repetitive lifting movements are particularly problematic [8, 9]. Other countries, such as the United Kingdom, the United States, and Australia, recognize the problems related to human-powered lifting movements in the welfare and medical fields and have implemented measures to prevent back pain.
The United Kingdom enacted the Health and Safety Act in 1974. Under this law, the Manual Handling Operations Regulations of 1992 raised awareness among workers of measures to prevent back pain. In 1996, the Royal British Nursing Association’s Code of Practice for Patient Transfer prohibited manual lifting of patients in all situations [10].
In 2003, the U.S. Occupational Safety and Health Administration developed the Guidelines for Nursing Homes to encourage the use of nursing home equipment, educate the public on preventing back pain in nursing care, and improve working environments [11]. In 2013, the American Nurses Association enacted Safe Patient Handling and Mobility laws in 10 states, banning manual patient lifting and encouraging safe transfer practices [12].
In Australia, job turnover and industrial accident claims due to back pain among caregivers and nursing staff increased around 1996. In 1998, the Victoria Branch of the Australian Nursing Federation announced the “No Lifting Policy.” This policy prohibits the sole use of human power for transfers, which can be dangerous and painful. Instead, it mandates the use of equipment that considers the patient’s dignity to assist with transfers, effectively eliminating back pain among caregivers and nursing staff [13]. Consequently, other countries recommend using such equipment in the welfare and medical fields to prevent back pain.
In 2013, Japan’s Ministry of Health, Labour and Welfare revised the Guidelines for Prevention of Back Pain in the Workplace, extending their scope to include nursing care in social welfare facilities where back pain is a common issue [14]. The guidelines advocate using lifts and other equipment for patients who require total assistance, minimizing the need for human-powered lifting for patients who can sit, the guidelines prescribe appropriate transfer assistance, such as the use of a sliding board or similar device. However, despite these guideline revisions, back pain incidents have continued to rise, indicating a lack of significant reforms [9].
We then focused on the no-lifting policy, which has been successful in Australia as a back pain prevention measure. Implementing no-lift care in nursing and the establishment of occupational health laws significantly reduced work-related accidents, injury-related absences, and workers’ compensation claims among nursing and caregiving workers Australia [15]. No-lift care was introduced in the 2000s by Yasuda of the Japan No-Lift Association and has since spread throughout Japan [16]. The term “no-lift care” became commonly used but was often confused with not using a lift device care. Therefore, the term no-lifting care has come into common use. Will be used in this study no-lifting care (NLC).
In this study, NLC refers to prohibiting transfers using only human power and utilizing welfare equipment in consideration of the patient’s level of independence. This is in accordance with the definition of the Japan No-Lift Association.
The number of nursing care facilities in Japan using NLC is growing, leading to reduced back pain among nursing care workers and lower turnover rates [17]. Moreover, patients have experienced fewer epidermal lacerations, avulsions, internal bleeding, and fractures [18]. In the April 2021 revision of the Long-Term Care Insurance Law’s long-term care reimbursement system, support for the acquisition of nursing care techniques to reduce the physical burden on caregivers, introduction of nursing care equipment such as nursing care robots and lifts, and implementation of measures to prevent back pain through training and other measures were included in the additional incentive program for caregivers. NLC is included in this category, indicating that NLC is expected to be a measure for preventing back pain.
However, the percentage of NLCs in nursing care facilities is expected to remain low. As of March 2024, the penetration rate of NLCs in nursing homes nationwide is unknown; furthermore, the penetration rate of mobile lifts, which are essential for NLCs, is 4.9% [19]. Moreover, other welfare equipment, such as sliding boards, had a 9.2% introduction rate, suggesting that the NLC introduction rate was approximately the same as that of nursing care welfare equipment. Additionally, only 27.6% of caregivers used sliding boards and sheets, even when they were available [20], suggesting that even if NLCs are introduced caregivers may not utilize.
In 2015 and 2016, Kochi Prefecture implemented an initiative to create a comfortable work environment by preventing back pain through the introduction of NLCs (a Welfare and Nursing Care Work Environment Improvement Promotion Project). The 12 facilities involved are referred to as “model facilities.” Kochi Prefecture collaborated with an incorporated association to promote NLC, providing eight months of practical skills and management support training to these model facilities. Additionally, managers and supervisors of social welfare facilities received NLC training based on their roles and posts. During training, caregivers learned about NLC introduction measures identified workplace issues, and devised solutions to address them.
The introduction and use of NLC by Kochi Prefecture effectively reduced the number of back pain complaint incidences and workplace attrition rates [21]. However, as of July 2023, only 120 of the 939 social welfare facilities and hospitals in Kochi Prefecture (428 daycare facilities, 329 residential care facilities, 39 specified facilities, 120 hospitals, and 23 support facilities for the disabled) implemented NLC [22-24]. That is, only about 12.7% of facilities in Kochi Prefecture adopted NLC.
Factors contributing to the low adoption rate of NLC include caregivers being too busy with work to spend time on welfare equipment and their insufficient knowledge of NLC [25, 26]. Thus, the busy work environment and lack of knowledge among caregivers may hinder the adoption of NLC. Even in Kochi Prefecture, where training and workplace management addressed these issues, NLC has not become widespread. This may be due to other disincentivizing factors beyond the work environment and caregiver knowledge when introducing NLC. Furthermore, even when a facility adopts NLC policies, the decision to utilize NLC is left to the caregivers, but few of them do [27, 28].
Therefore, this study aimed to identify the factors that promote or inhibit the adoption of NLC, which have not been fully clarified in previous research. To achieve this, we surveyed social welfare facilities in Kochi Prefecture, which serve as model facilities for the project to promote improvements in the nursing care work environment.
1. Research Design
This qualitative, descriptive study effectively identifies patterns and trends in behavior and other phenomena. It is particularly effective for defining and describing complex events, processes, and human experiences related to research questions [29, 30]. This study aimed to understand the innovations and efforts involved in the introduction and use of NLC, as well as the changes in caregivers’ attitudes and the work environment from the time of introduction to the time of use. Therefore, a qualitative descriptive was deemed appropriate, capturing detailed descriptions of participants’ experiences.
2. Participants
Eight of the 12 social welfare facilities in Kochi Prefecture that introduced NLC as part of the welfare and nursing care work environment improvement project agreed to participate in the survey. One central nursing care worker (NLC instructional staff) from each facility was selected for the survey, totaling eight individuals.
3. Data collection
Individual semi-structured interviews were conducted using an interview guide. The interviews were recorded on an IC recorder and transcribed verbatim with the consent of the participants. Data were collected from December 18, 2019, to October 22, 2020. The interview content included (1) demographics (age, years of experience, and post); (2) background before the introduction of NLC; and (3) changes in leadership, caregivers, assistance methods, and welfare equipment from the introduction of NLC. Questions were asked to clarify any unclear areas in the interview content.
4. Data Analysis
Voice data from the survey were compiled into verbatim records and categorized. We created codes based on the transcripts and analyzed them using MAXQDA10 qualitative data analysis software. We examined the relationships between codes to form subcategories and categories. Repeated data, subcategories, and categories were reviewed based on their relevance to the research questions, and the most appropriate terms were chosen. Finally, we organized and diagrammed the relationships between the categories.
5. Analysis validity and reliability
The validity of the analysis was ensured through member checking of the survey participants. For this process, the results of the analysis were sent in writing to eight participants, and their feedback was solicited. Additionally, the entire analytical process was iteratively reviewed by four co-researchers and supervised by two qualitative research specialists, university professors specializing in social work.
Table 1 shows the demographics of the survey participants, including the two chief caregivers, one deputy chief caregiver, two-unit leaders, two floor leaders, and one NLC promotion committee member. The group comprised three males and five females, aged 30-50, with 9 to 20 years of work experience. The average level of care at each facility ranged from 3.83 to 4.03, and the average disability support category was 4.62.
Each interview lasted 48-84 minutes, averaging 66.5 minutes. Sixteen categories were generated from 77 codes and 34 subcategories based on a survey of NLC implementation efforts, innovations, and challenges. Table 2 summarizes these categories and subcategories.
In the following text, categories are denoted by [ ] and subcategories by « ». The analysis of the 16 categories, their characteristics, and relationships led us to classify them into challenges, innovations, and initiatives during the NLC introduction. During the NLC utilization, they were classified into innovations, changes, and ongoing challenges. The data analysis clarified the relationships between these categories, as shown in Figure 1.
1. Challenges during NLC introduction, efforts, and innovation
Issues identified at the time of introduction included a [conservative attitude that does not favor work reform] and a [biased image of transfer assistance]. However, no attempt was made to address these issues. Additionally, the following issues were noted: [customarily fixed facility operations], [an environment lacking sufficient time and mental flexibility], [irregular work hours preventing effective communication and handover], and [challenging placement of welfare equipment]. No interventions were found to manage [customarily fixed facility operations] and [an environment lacking sufficient time and mental flexibility], while [efforts to convey information even during irregular work hours] were made to deal with [irregular work hours preventing effective communication and handover]. [Efforts to encourage the use of welfare equipment] were made to deal with [challenging placement of welfare equipment].
2. Measures encouraging NLC adoption
By [devising ways to shorten work hours], [devising ways to reduce physical burden], and [devising ways to let people experience welfare equipment], which stemmed from [efforts to create a suitable environment for using welfare equipment], «the physical burden on caregivers is reduced» and «work is adjusted to ensure sufficient space», [reducing the burden on caregivers] is improved.
3. Changes from introduction to utilization of the NLC
The [biased image of transfer assistance] when NLC was introducedchanged as [awareness of transfer assistance grew]. Moreover, [the rehabilitation profession is critical to introducing NLC]. However, the role was transferred to [caregivers who are proficient in technology are critical to NLC practice].
4. Issues using NLC
When using the NLC, the NLC instructional staff provide guidance in situations such as «being unable to explain the rationale for assistance to the caregiver» and «not knowing how to utilize welfare equipment when the user’s condition changes». NLC’s instructional staff faces challenges. The challenge is [caregivers who are skeptical of NLC and continue to lift patients].
1. Disincentive at the time of NLC introduction
One of the challenges in implementing the NLC was the caregivers’ reluctance to change their work methods. They were accustomed to lifting assistance, which a [biased image of transfer assistance]. Additionally, the understaffed environment and heavy individual workload left little room to adopt new practices, contributing to [a conservative attitude resistant to changes in business operations]. Although this study targeted welfare institutions, the most common reason for resistance to organizational change is “because change entails pain and people do not want to go through it,” as noted in a previous study [31]. This reluctance to change likely exists in other fields beyond nursing care. Therefore, the caregivers’ reluctance to change their work routines was believed to be the main disincentive during the introduction of the NLC.
2. Facilitating factors during NLC introduction
We believe that the category [the rehabilitation profession is critical to introducing NLC] influences the introduction of NLC. According to the No-Lift Care Management Manual and the No-Lift Care Practice Manual [32] which were prepared for the introduction and use of NLCs, effective implementation of NLC requires an (i) understanding of the purpose of NLC and (ii) knowing how to care for patients without lifting as well as how to use welfare equipment. Previous studies highlight the importance of assessing the physical function of users when using welfare equipment such as slide boards [33]. Therefore, the ability to evaluate users’ physical functions may also be necessary for implementing NLC.
Conditions (i) and (ii) could have been managed by attending the training provided by Kochi Prefecture during NLC introduction. Knee extension [34] lower limb loading [35], 3-meter chair-to-chair walking [36], and the Berg Balance Scale [37] have all been reported as useful assessments of physical functions necessary for transfer assistance. However, these methods require tools and time-consuming preparation, making them difficult to implement in clinical settings [38]. Although the specific physical function assessments needed for the NLC are not fully clarified, it has been shown that experienced physical and occupational therapists, among others, can perform more accurate assessments [39]. It was suggested that rehabilitation professionals, such as physical therapists and occupational therapists, meet the requirements for the introduction of NLC. Therefore, we believe the involvement of expert rehabilitation professionals was a key facilitating factor in introducing the NLC.
3. Facilitating factors when using NLC
Despite the innovations introduced with the NLC, some caregivers continued lifting manually. The NLC instructional staff [devised ways for caregivers to experience welfare equipment], reducing their physical burden and changing their [biased image of transfer assistance]. Previous studies have shown that caregivers do not recognize the benefits of NLC until after they have used it [40]. Therefore, caregivers who persist in lifting manually may change their behavior if they first experience the equipment. We consider the key factor in utilizing NLC to be providing devices that enable caregivers to accumulate experience with welfare equipment.
4. Disincentives to using NLC
When using NLC, we noted caregivers skeptical of NLC continuing to lift patients. We attributed this issue to the change in instructors for caregivers, from rehab staff who initially provided guidance to NLC instructional staff. The present study results indicated that [the key to implementing the NLC was the rehabilitation profession]; this role was transferred to [caregivers who are proficient in technology are critical to NLC practice]. This falls under the subcategory of «when I gained experience in NLC, I became caregiver-centered». This represents a role shift as the NLC instructional staff accumulate experience.
To introduce NLC effectively, it is necessary to assess users’ physical function. However, NLC instructional staff are not rehabilitation professionals and lack the specialized skills for such assessments. Additionally, due to «decreased consultation with rehabilitation professionals», NLC instructional staff often face situations of caregivers «not knowing how to utilize welfare equipment when the user’s condition changes». This lack of knowledge leads to [caregivers who are skeptical of NLC and continue to lift patients], causing potential issues. The purpose of NLC is to prevent back pain among caregivers. Therefore, the training in Kochi Prefecture may not have covered the need for patient physical function assessments.
Ultimately, a disincentive to utilizing NLC is the lack of opportunities for NLC instructional staff to acquire sufficient knowledge and skills to conduct a physical function assessment. Furthermore, we believe the training program’s structure compelled NLC instructional staff to assume leadership roles over other staff members.
5. Limitations of the Study
This study focused on a limited number of social welfare facilities in eight locations in Kochi Prefecture, with only eight participants. Therefore, the results may not reflect the situation in other regions or facilities with different operating environments. Also, since there were only eight participants, it is difficult to say that the results are representative of other social welfare facilities. Furthermore, it may be difficult to obtain diverse perspectives in terms of age, experience, job description, and other backgrounds. There is a risk of overemphasizing certain views or trends because the views of people with different occupations and backgrounds are not reflected.
6. Future issues
Future studies should not only expand the number of surveys and geographic areas covered, but also reflect the views of people with different occupations and backgrounds. Examples include workers with negative views of NLC, those involved in management such as facility directors, disabled and elderly persons receiving NLC, and other occupations such as rehabilitation professionals and nurses. Furthermore, for a more comprehensive survey, it would be possible to conduct a multifaceted analysis by investigating differences by type of facility (e.g., elderly care welfare facilities, medical facilities, support facilities for the disabled, etc.) and by prefecture.
This study examined a social welfare facility in Kochi Prefecture that introduced NLC by addressing caregivers’ lack of NLC knowledge a barrier identified in previous studies and improving the workplace environment through management. The present study identifies the facilitating and inhibiting factors involved in the introduction and adoption of NLC. The results show that the main inhibiting factor was caregivers’ resistance to changes in work methods, while the key facilitating factor was the involvement of expert rehabilitation professional.
The facilitating factor in the use of NLC was the accumulation of experience in using the welfare equipment. In contrast, the inhibiting factor was the lack of opportunities for the NLC instructional staff to acquire the necessary knowledge and skills to evaluate physical function. Furthermore, it was found that NLC instructional staff were compelled to assume a leadership role over other staff members. These findings highlight the importance of having individuals with specialized knowledge and skills in assessing patients’ physical functions to guide caregivers and support the introduction and use of NLCs.
Rehabilitation specialists are expected to have expertise in physical function assessments. However, some facilities, such as the long-term care welfare facilities for older adults, are not mandated to employ these specialists under the Long-Term Care Insurance Law. Therefore, it falls to the NLC instructional staff to acquire these knowledge and skills. Offering training on NLC and physical function assessments to these members could facilitate the introduction and adoption of NLC. Various physical function assessments, such as knee extension muscle strength, lower limb loading, 3-meter chair-to-chair walking, and the Berg Balance Scale, are useful for patient transfers. This indicates a need to develop a physical function assessment tailored for NLC. We aim to address this in future studies.
I would like to express my sincere gratitude to Dr. Toyoharu Yokoyama for his invaluable guidance in writing this paper.
The authors declare no conflict of interest. This study was reviewed and approved by the Research Ethics Committee of the Kochi Prefectural University (approval no. SHAKEN RIN 19-54). Approval was also obtained from the Ethics Review Committee of the Niigata University of Health and Welfare (Approval No. 18940-221110).
