Nurses have the highest rates of work-related back pain. Educational interventions can help prevent injury and promote understanding of safe patient handling.
Why safe patient handling is important to prevent injury
The principles of safe patient handling
Birmingham City University’s approach to patient handling education
Stephen Wanless is senior lecturer and patient handling lead, Faculty of Health, Birmingham City University; Steve G Wanless (Snr) is moving and handling coordinator, Tameside Hospital Foundation Trust, Manchester.
Wanless S, Wanless SG(2011) Improving training and education in patient handling.Nursing Times; 107: 23, early online publication.
Injuries associated with patient handling activities are common in healthcare and cost the NHS more than £80m a year. Improving education and training can help prevent injury, and better communication between education and clinical areas will improve monitoring of poor patient handling practice. This article discusses Birmingham City University’s approach to patient handling education for pre-registration student nurses.
Keywords: Patient handling, Musculoskeletal injuries, Risk assessment
This article has been double-blind peer reviewed
Patient handling is a skilled activity combining theoretical knowledge with practical experience. Poor technique can cause musculoskeletal injuries
Healthcare education for safe patient handling is shared between the university and clinical practice. Universities have a legal duty to prepare healthcare students for patient handling activities in practice (HSC, 2004)
Safe patient handling starts with a personal risk assessment. Every time you assist or transfer a patient you are at risk of injury so a handling procedure should only be carried out if it really necessary
Poor posture can be corrected by maintaining a neutral spine, using your legs, never twisting your back and keeping the load close
Promoting good posture and positioning in nurse education will only be beneficial if patient handling is taken seriously in clinical settings
Injuries associated with patient handling have been a problem in healthcare for decades, particularly for nurses, who have the highest rates of work-related back pain among health professionals (Edlich et al, 2004). Patient handling is a skilled activity combining theoretical knowledge with practical experience, and poor technique can lead to herniated discs and other musculoskeletal injuries. However, efforts to reduce injuries associated with patient handling are often based on tradition and personal experience rather than sound educational theory. Weaknesses have been identified in the educational approaches to improving patient handling practices (Wanless and Page, 2009), and there is a growing body of evidence supporting newer interventions for reducing musculoskeletal injuries to healthcare workers (Wanless and Page, 2009).
This article discusses the methods for educational interventions in patient handling at Birmingham City University and describes how simulation exercises can help prevent injury and promote an understanding of the principles associated with patient handling tasks.
Despite strong evidence on its importance, the most commonly used strategy of teaching moving and handling – showing healthcare workers prescriptive techniques required to handle patients – has proved to be ineffective. Healthcare education for safe patient handling is shared between the university and clinical practice. Universities have a legal duty to prepare students for clinical placements and patient handling activities (Health and Safety Commission, 2004). The process begins during pre-registration education with the initial patient and inanimate load training, followed by annual updates; students are then expected to gain further practical experience on clinical placements (Royal College of Nursing, 2000).
As initial teaching is carried out by training and academic, rather than clinical, staff, there is the potential for a gap to develop between taught theory and practice. Felstead and Angave (2005) said teaching patient handling is not always seen as the “true work” of higher education institutions and may not be valued by academics. Health faculties have also failed to take advantage of the opportunities and benefits of interprofessional learning (Kneafsey et al, 2003). Inconsistencies over taught content, mode of delivery and assessment strategies in patient handling also exist (Smith, 2005), as do discrepancies about which set of principles should guide education and training, such as neuromuscular, ergonomic, biomechanical or kinetic (Hignett, 2005). The way patient handling training is designed and delivered has the potential to improve greatly.
The joint responsibility for training in patient handling led to a lack of clarity over the responsibilities between Birmingham City University and the local NHS trusts. One of the primary aims of the patient handling programme at the university was to make it evolutionary rather than revolutionary. Working with other disciplines within the health faculty and being responsive to their needs, rather than imposing a system of work on them, is vital to establishing ownership of the programme and gaining commitment from other disciplines to teach the subject.
The majority of students who undertake patient handling training at Birmingham City University are pre-registration student nurses. Students are vulnerable to injury because they lack both the technical skills and muscular conditioning developed through patient handling activities (Kier and Macdonell, 2004).
Students at the university are encouraged to be active learners, working towards a set of clear learning outcomes relating to evidence-based patient handling, posture, and positioning. Teaching and learning activities are tailored to the needs of students with different levels of experience.
During patient handling sessions, students often say the practices and techniques promoted bear little resemblance to those undertaken in clinical settings. This raises questions about the relevance of the university’s patient handling training and suggests students are not being adequately supervised or assessed to develop safe patient handling skills. However, the anecdotal nature of students’ comments makes it difficult to determine how widespread these views are.
Students’ experiences are discussed in the training sessions; those who are reluctant to change unsafe practices are encouraged to reflect on their methods and explore the rationale for adopting safe handling postures and an ergonomic approach to risk management. A system is now in place to address the learning needs of students who have difficulty grasping the main principles of safe patient handling, which are:
Use your legs;
Keep the load close to your body.
The principles of patient handling start with a personal risk assessment. Patient handling requires a mix of common sense and adaptability to any situation that may arise, and because the load to be moved is unpredictable every patient handling task is unique. Circumstances can change quickly, so a personal risk assessment must be done before each procedure.
The first consideration is always the aim and objective of the patient handling task. It is vital to remember that every time you assist or transfer a patient you are at risk of injury; a handling procedure should only be carried out if there is no other way to achieve the objective. This helps ensure the handler will not be caught unprepared, or put at risk. The following areas should be considered to ensure the patient handling procedure is carried out safely:
Environment (Wanless and Page, 2010; Smith, 2005).
On completing the assessment, handlers should ask themselves: “Do I need to perform this procedure?” Once the risk assessment has been completed, handlers must concentrate on position and posture to reduce the risk of personal injury.
Keeping the spine naturally straight allows it to act like a spring and absorb body weight, assisting the main shock absorbers and the smaller spinal muscles to work to their full potential. Using an anatomical skeleton, students are shown what a neutral spine is (Fig 1) and the facilitator highlights the sloppy “S” shape.
Students are asked to sit in what they consider a neutral spine position; the session facilitator then helps them to achieve the correct position. Students complain how uncomfortable and unnatural this feels but are reminded this is how they were born and that socialisation, as they have grown older, has affected their posture. Students are then asked to adopt the position in which they watch television or sit at a computer; this highlights how they have adopted a “C” position in the way they sit and stand.
The position of the feet is the secret to safe handling. The handler’s feet should be comfortably apart with one foot slightly in front of the other, giving a wider base of support and stability in all directions. Relaxing knees and hips with an offset base can improve balance. The offset feet position also creates a greater surface area as feet are kept in contact with the floor when knees and hips are relaxed.
To demonstrate the importance of this principle, students are paired up and asked to stand toe to toe with their partner. They must then stand on tiptoe, rocking backwards and forwards to see if they are in a stable position. They are then asked how they should position their feet to feel more stable. They are advised to bend their knees and use the quadriceps to aid stability, then practise the same movement but with feet flat on the ground, shoulder-width apart. This position shows stability in a side-to-side rock, but less stability with a forward and backward movement (Fig 2).
Students then perform the same procedure with their feet shoulder-width apart, and with one foot in front of the other. This shows the importance of using the legs when performing a patient or inanimate load handling task.
Twisting, or rotating the spine, reduces the effectiveness of the joints and muscles and decreases the body’s capacity to do work; this increases the likelihood of injury (Fig 3). If the spine has to be rotated, handlers need to reposition their feet – not doing so can cause the pelvis and shoulders not to be level.
The facilitator demonstrates this by holding their arms out straight in front and asking one of the students to push their arms from the side, highlighting the twist of the spine. Students are asked how they can stop this from happening. The facilitator then demonstrates two techniques to prevent the spine from twisting – namely, stepping in the direction of the force and swivelling feet and legs on the spot.
The distance of the person or load from the spine, at waist height, is an important factor in the overall load on the spine and back muscles. Reducing the effect of excessive leverage is best achieved by being as close to the patient as possible. Students are asked to grab a handful of air from in front of them and hold it shoulder’s length distance from their bodies in a cupped hand. The facilitator looks for signs of students starting to tire, such as shoulders rising, and tells them this is how it feels to physically lift during a patient handling exercise.
Students then bring their hands in front of them at their waist and the facilitator asks if this is releasing the strain on their back and shoulder muscles, highlighting the importance of keeping the load close.
After being shown and practising the principles, students are asked to lift a 5kg box. Their peers watch to ensure they maintain posture and positioning using the four main principles. All students must participate in the task.
When applying the principles of practical patient handling, students are asked to choose a leader for the task. It is the leader’s role to communicate with the team. Once the patient is prepared, the handlers prepare the equipment and environment, carefully removing all hazards from the handling area and route if transferring a patient.
Students are told movement should commence on a predetermined signal, such as “ready, steady, stand”.
Two patient handling coordinators were appointed to lead the team of trainers at Birmingham City University, providing a central point of contact for staff and students. The coordinators are members of the National Back Exchange, an organisation that supports health professionals in reducing occupational back pain in healthcare (www.nationalbackexchange.org). One of the aims of the National Back Exchange is to develop and promote common standards of training in safer handling (Williams et al, 2002). All trainers attend yearly updates to share their knowledge and experience with the training team. This helps ensure all trainers are kept up to date with any developments in moving and handling.
Communication between education and clinical placement areas, and monitoring of poor patient handling practice has improved in the West Midlands. Patient handling training has also improved corporate commitment, and the faculty has ensured compliance with legislation and best practice. This will help improve student and patient experiences in this important area of practice.
University education, using the promotion of good posture and positioning, will only be beneficial if students learn to take patient handling seriously in clinical settings, and where a culture of safety exists throughout the organisation.
Box 1. Back injuries: the facts
Work-related musculoskeletal disorders, including manual handling injuries, are the most common type of occupational ill health in the UK (Health and Safety Executive, 2007)
NHS sickness absence due to musculoskeletal disorders accounts for 40% of all sickness absence (NHS Employers, 2009)
Work-related back pain has an annual prevalence of 40-50% for nurses, and a lifetime prevalence of 35-80% (Edlich et al, 2004)
Unison has estimated that around 3,600 nurses are forced to retire every year due to back injuries (NHS Employers, 2009)
Sickness absence related to patient handling injuries costs the NHS over £80m a year (HSE, 2007)
Mangar Health is a member of the Winncare Group