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Low back injuries as well as other injuries related to patient handling are prevalent in health care (Barnes, 2007; D'Arcy, Sasai, & Stearns, 2011; Ogg, 2011; Pompeii, Lipscomb, Schoenfisch, & Dement, 2009; Sikiru & Shmaila, 2009; Trossman, 2009). Staff injury rates as well as costs related to lost work and restricted work days have supported the growth of safe patient handling programs with specific lifting policies and increased use of equipment (Edlich, Winters, Hudson, Britt & Long, 2004; Barnes, 2007; American Nurses Association, 2008; Tullar et al., 2010). Although there have been several studies reporting the incidence of injuries through manual lifting, rehabilitation professionals have resisted successful implementation of safe handling policies due to the supposition that rehabilitation is meant to foster increased independence and use of lifting equipment may limit or decrease functional gains (Durham, 2007; Nelson, Harwood, Tracey & Dunn, 2008). Additionally, there is a belief that knowledge and practice of proper body mechanics will prevent injuries; however, studies have demonstrated that repetitive lifting even with proper body dynamics results in injury.
The acute inpatient rehabilitation unit at our facility admits people with stroke, spinal cord injury, brain injury, as well as those requiring comprehensive, intensive therapy post surgery such as hip replacements and spinal fusions. In response to a high level of staff injuries related to patient transfers, our facility implemented a safe patient handling policy that included a hands-on training class called, Safe Transfers Every Person Succeeds (STEPS). Both nursing and therapy staff participated in a research study from October 2004 through June 2005. During the study period, staff participated in education about the safe patient handling policy and was evaluated on knowledge and performance of patient transfers. Staff scoring below 80% on the competency pretest was identified as benefiting from further training and attended the STEPS training class. Trained staff did not receive refresher courses on safe patient handling.
The objectives of the study, to evaluate our facility's STEPS program, were to identify whether (1) reduction in staff injuries due to patient transfers was realized during the 1.5-year period post training and implementation of the safe patient handling policy and (2) reduction in staff injuries due to patient transfers was sustained during a 2.5-year period following the post training period. We chose to focus on injury due to transfers rather than on all aspects of patient handling (e.g., boosting, turning, gait training) for two reasons: (1) our facility had experienced a large number of injuries due to patient transfers, which motivated the creation of the STEPS program, and (2) we could better control the effects of our intervention on a single dependent variable by focusing on transfers versus all aspects of patient handling. Garg & Kapellusch (2012) described long-term success of a multisite safe patient handling program supported by a comprehensive ergonomics program over a 3- to 5-year period. To our knowledge, there are no other studies that evaluate long-term effects of implementation of a safe patient handling program on injury in the absence of a comprehensive program for retraining, monitoring, and reinforcement (Black, Shah, Busch, Metcalfe, & Lim, 2011).
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We have shown that training in safe patient handling and establishment of a safe patient handling policy was effective in reducing staff injuries at our facility by more than 50% during the 1.5-year post training period, from an expected number of 17 injuries to only 8. Our results are similar to those of Sedlak, Doheny, Jones, & Lavelle (2009) who reported that training in conjunction with a safe handling policy and procedures does have a positive impact on reduction in staff injuries. Our results further support other studies that report and propose significant reduction in staff injuries through hands-on training incorporating a multifactorial intervention/program (Krill, Raven, & Staffileno, 2012; Morgan & Chow, 2007; Nelson et al., 2008). During the 1.5-year post training period, it is possible that staff injuries at our institution were reduced compared with the baseline period pre training due to the training as well as an ongoing emphasis on safe patient handling and reinforcement of the safe patient handling policy.
In the absence of retraining in safe patient handling, the number of injuries due to patient handling long term was not different from that at baseline. To our knowledge, there are few studies that evaluate long-term outcomes in the absence of retraining (Black et al., 2011; Garg & Kapellusch, 2012; Wardell, 2007). Garg & Kapellusch (2012) demonstrated significant reductions in injury rates at seven institutions where data were collected post intervention for 36–60 months. In this study, the observation period was not divided into post intervention and long term, and therefore we cannot compare the impact of time from date of implementation on incidence of injury. We considered other factors that may have impacted the long-term outcome: (1) FIM measures for bed, toilet, and tub transfers as well as total motor score (including other aspects of burden of care measures such as toileting, bathing, lower body dressing) were shown to be similar between time periods; (2) training of newly hired care providers using STEPS continued, demonstrating management's commitment to safe patient handling; (3) staffing ratios remained constant over the study period; (4) equipment and supplies for safe patient handling at our institution were strictly maintained and available; and (5) consequences of violating safe patient handling policy remained constant where management discussed the incident and may have suggested additional training. The factor that most likely impacted long-term outcome was adherence to safe handling policy (Garg & Kapellusch, 2012; Schoenfisch, Pompeii, Myers, Yeung, Frickas, et al. 2011). Staff was more frequently reminded about following procedures through spot checks and communication of findings during the post time period. In addition to our program not including ongoing retraining, we did not include formal peer coaching and mentoring, which have been shown to improve support of safe patient handling practices (Alamgir et al., 2011).We know from observation and discussions with staff that they do not always use the equipment provided in large part due to the amount of additional time required as well as wanting to provide opportunities for patients to progress toward increased physical independence. We hypothesize that retraining can directly affect behavior in adhering to safe patient handling policy and positive culture. We further hypothesize that monitoring accompanied by significant consequences of not adhering to this policy will help increase adherence and reduce staff injuries. Garg & Kapellusch (2012) provided evidence of decreased injury at seven nursing facilities over a 3- to 5-year period when training in safe patient handling was supported through positive safe patient handling culture including the following: a comprehensive ergonomic program that included management commitment and participation; empowerment of nursing personnel in equipment selection and program implementation; evaluation of patients' transferring needs by nursing personnel; laminated cards to specify patient handling devices and technique in patients' rooms; additional patient handling devices to limit downtime or inaccessibility of equipment; hands-on training of all personnel; monitoring of use of patient handling devices supported with monthly meetings to address and resolve problems or concerns; feedback by key nursing personnel to those staff who needed help; and team approach to address patient/family concerns regarding patient handling devices.
We have shown that retraining in safe patient handling, assuming that the outcome, maintenance of injury reduction as demonstrated in the post training period, is attributable in large part to further training, would result in a positive cost benefit of $3.71 for every dollar invested in retraining. This finding is supported by Pelczarski (2012); however, further studies are needed to test this assumption and to identify the most efficient timing for retraining. These studies should include evaluation of competencies as well as quantification of adherence to policy over the long term.
Our study found that injury rates were higher in nursing staff compared with therapy staff. This may be due to the fact that (1) nursing staff is larger than the therapy staff, and therefore in a typical 24-hour day, nurses perform more transfers than therapy staff; (2) therapy staff may have greater opportunity to control the environment for transferring patients than nursing staff. For example, therapy staff can modify and control conditions for a transfer by raising or lowering a surface such as a firm therapy mat, while nursing staff may not be able to do this because they are dealing with conditions that are less modifiable like toilets and hospital beds; and (3) therapy staff are typically involved with only one patient from their case load at a time, while nursing staff are responsible for several patients which limits the time they can spend in using safe transfer methods resulting in increased risk of injury.
In response to having learned that injury rates returned to baseline rates during the long-term training period, our facility is planning a refresher course addressing safe handling during transfers. The safe handling literature suggests that one of the biggest barriers to implementing and adhering to a safe patient handling policy is the absence of a safe patient handling culture (Cadmus, Brigley, & Pearson, 2011; Durham, 2007; Johnson & Hall, 2005; Tideiksaar, 2008). Facilities with a high safety culture as well as strong adherence to safe handling have the lowest incidence of injuries (Cornish & Jones, 2010; Hignett & Crumpton, 2007; Schoenfisch, Myers, et al., 2011). It is possible that although our intervention addressed how to select the safest option for transferring a patient as well as providing a variety of transfer methods, we also needed to address and improve the safety culture at our facility (Cornish & Jones, 2010; Schoenfisch, Pompeii et al., 2011). Our staff have used both portable lifts and ceiling lifts more frequently, but they rarely use lifting equipment for tasks such as boosting, turning, or even facilitating standing and walking. When asked why staff is not using positioning slings, a frequent response is that it is time consuming and disruptive to patients' sleep and skin integrity. It is also possible that staff has not been integrated sufficiently into the selection process for these devices and therefore does not have full appreciation of their benefits in avoiding injury (Garg & Kapellusch, 2012; Kim & Lee, 2010; Mutch, 2004). Furthermore, staff may need to be trained to incorporate patients and family members in selection and use of these devices to create a culture that is more accepting of safe handling equipment (Cadmus et al., 2011; Garg & Kapellusch, 2012; Pellatt, 2005).
STEPS training focused on safe patient transfers and therefore we included only injuries due to transfers in analyzing our results. Boosting and turning patients are another source of injury we are addressing with a new initiative.
There was natural turnover of staff during the baseline, post, and long-term periods. Although new hires receive STEPS training at orientation, they practice with staff who have not been retrained and who may have adopted poor patient handling practices. This environment can negate safe practices learned during training. This situation supports the need for ongoing training.
The novelty of new equipment installed for safe patient handling may have impacted adherence in the post training period. As the novelty wore off, attitudes with regard to using it may have changed (Cadmus et al., 2011). If this is true, then ongoing training to strengthen the culture of safe patient handling may be necessary.
Key Practice Points
- Safe patient handling continues to be affected by several factors including the importance of continued retraining as well as ongoing efforts to maintain positive cultural support of staff and administration regarding safe patient handling in a rehabilitation setting.
- Although many studies support reduction in staff injuries with safe patient handling programs, this study highlights the challenges with maintaining the reduction long-term (i.e. greater than 1.5 years)
- Although ongoing retraining of staff involves a cost, the cost benefit of retraining leading to potential long term positive effects of sustained reduction in staff injuries across disciplines outweighs the costs of staff injuries and ongoing use of safe patient handling equipment.
- Hands on training of safe patient handling through multiple strategies including training and competency assessment across nurses and therapists can reduce staff injuries.