Gail Powell-Cope, PhD, ARNP, FAAN
Nancy L. Hughes, MS, RN
Carol Sedlak, PhD, RN, CNS, ONC, CNE
Audrey Nelson, PhD, RN, FAAN
Despite the well-documented evidence for preventing musculoskeletal injuries among nurses providing patient handling tasks using ergonomic principles, faculty in nursing schools continue to rely on the teaching of body mechanics which fails to reduce the risk of musculoskeletal injuries. In this article the authors report the qualitative data from a parent study designed to develop and test an evidence-based curriculum module in nursing schools. Focus groups were conducted with participating faculty to elicit their perceptions of facilitators and barriers for implementing a new, evidence-based, safe patient handling curriculum module at their nursing schools. Content analysis was used to analyze the data. Faculty, who were overwhelmingly positive about the curriculum module, related numerous implementation facilitators and recommendations for overcoming barriers. Findings from this study can be used to facilitate implementation of the curriculum module at other nursing schools and thus promote the use of safe patient handling throughout healthcare.
Citation: Powell-Cope, G., Hughes, N., Sedlak, C., Nelson, A., (August 18, 2008) "Faculty Perceptions of Implementing an Evidence-Based Safe Patient Handling Nursing Curriculum Module" OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 3.
Key words: back injury, devices, equipment, ergonomics, Handle With Care®, lifting techniques, musculoskeletal disorders, National Institute of Occupational Safety and Health (NIOSH), nurse safety, nursing, nursing education, nursing faculty, nursing schools, nursing students, occupational safety, Occupational Safety & Health Administration (OSHA), patient care ergonomics, safe patient handling, work-related musculoskeletal injuries
...the belief that “good” body mechanics will protect nurses from musculoskeletal injury is entrenched in the practices of many nurses and nursing faculty, despite strong evidence that body mechanics alone is not safe Despite the well-documented evidence to support “safe patient handling” practices (Collins, Wolf, Bell, & Evanoff, 2004; Nelson et al., 2006), manual patient handling techniques, are still being taught in nursing schools (Collins, & Menzel, 2006; Potter & Perry, 2006; Taylor, Lillis & LeMone, 2005, Owen, 2000). Manual patient handling is broadly defined as the transporting or supporting of loads by hand or bodily force and includes lifting, lowering, pushing, pulling, moving or carrying (Health and Safety Executive (2007). In contrast, safe patient handling is the application of evidence-based strategies to reduce the risk(s) associated with manual patient handling. Examples of evidence-based strategies include first assessing risk to identify the behaviors that put nurses at risk on a given unit, then identifying ways to avoid the task if possible, redesign the task, or use mechanical devices to reduce the manual forces required. For example, in nursing homes nurses are frequently required to move dependent residents from a bed to a chair. This type of manual transfer puts the nurse at risk for a musculoskeletal injury. In this case, the use of ceiling-mounted lifts with the correct slings and training on the proper use of the lift greatly reduces the risk of injury from transferring the resident. Technology solutions, which traditionally have been underused in patient handling, are often the preferred strategy for reducing the risks. However, the belief that “good” body mechanics will protect nurses from musculoskeletal injury is entrenched in the practices of many nurses and nursing faculty, despite strong evidence that body mechanics alone is not safe (Collins et al., 2004; Garg & Owen, 1992; Marras, Davis, Kirking, & Bertsche, 1999; Nelson & Baptiste, 2004; Nelson et al., 2006; Zhuang, Stogbe, Hsiao, Collings, & Hobbs, 1999).
Nurses have been identified in the top ten ranked occupations for work-related musculoskeletal disorders, with incidence rates higher in long-term care compared to hospitals (Bureau of Labor Statistics [BLS], 2002). High-risk patient handling tasks cause significant biomechanical and postural stressors on the spine and upper extremities resulting in acute musculoskeletal injury, or more commonly, cumulative injury over time. Lifting patients, awkward postures, and forceful movements likely contribute to the risk of low back pain in nurses (NIOSH, 1997).
High-risk patient handling tasks cause significant biomechanical and postural stressors on the spine and upper extremities resulting in acute musculoskeletal injury, or...cumulative injury over time. This article shares the findings of qualitative data from a parent study titled “Development and Evaluation of Safe Patient Handling and Movement Curriculum” (Nelson et al., 2007). The goal of the parent, 18-month quasi-experimental study, using a pre/post test design and a non-randomized control group, was to evaluate the translation of current research related to safe patient handling into the baccalaureate curricula taught at 26 nursing schools in the United States (US). The objective of this article is to describe the facilitators and barriers for implementing a new, evidence-based, safe patient handling curriculum module as perceived by nursing faculty at participating nursing schools. The curriculum module was described in a previous article (Menzel, Hughes, Waters, Shores, & Nelson, 2007) and is partially available online (National Institute for Occupational Safety and Health [NIOSH], 2007). The researchers were particularly interested in the implementation process, including factors that promoted or impeded the incorporation of the safe patient handling curriculum module into nursing school curricula; they sought recommendations to improve the curriculum module and implementation process. This article includes a review of the literature addressing safe patient handling in nursing education, a description of the evidence-based, safe patient handling curriculum module developed for this study, research methods (sampling, data collection procedure, data analysis), study findings, and a discussion of the research findings.
Background and Literature Review
The research base and evidence to support an ergonomic approach to moving dependent patients is strong, yet faculty in nursing schools are still teaching manual patient handling techniques. The literature review below focuses on the gap between the evidence for safe patient handling and the manner in which patient handling is still taught in nursing schools. The next section will describe the development of an innovative curriculum module to reduce these gaps.
Ergonomic-Based Safe Patient Handling
Nurses have been identified in the top ten ranked occupations for work-related musculoskeletal disorders...To date, interventions with the strongest level of evidence for safe patient handling that reduce the risk of musculoskeletal injury among nurses include: (a) patient care ergonomic assessment protocols, (b) use of patient handling equipment/devices, (c) clinical tools, such as algorithms and patient assessment protocols to aid in implementation, and (d) no manual lift policies once all other program components are in place (Nelson, 2006). Through ergonomic assessment, frequent and high-risk tasks are identified through workplace observations; and equipment is identified that can replace manually performed high-risk tasks. Once equipment is installed, initial and ongoing staff training is necessary to insure proper use. Clinical tools, such as algorithms, aid nurses in making decisions about which equipment to use and how many nurses are required to lift and/or move a patient, based on the patient’s degree of dependence and goals for moving the patient. Finally, after all of the components are in place, a no manual lift policy will help to insure program sustainability by identifying requirements and responsible parties.
The safe patient handling project described in this paper addresses a major attempt to change nursing curricula and the role of faculty in educating nursing students on safe patient handling by incorporating the evidence into the curriculum. This curriculum module supports the Handle With Care® campaign by the American Nurses Association (ANA) which focuses on the elimination of manual patient handling to prevent work-related musculoskeletal disorders and injuries (American Nurses Association, 2007).
Nursing Education and Safe Patient Handling
Traditionally new nursing students are taught patient handling skills, and techniques to move partially or completely dependent patients, during basic fundamental nursing courses in a laboratory setting. Patient-handling tasks vary across care settings, but common ones include transferring a patient between bed and chair or between bed and stretcher, repositioning a patient in bed, assisting a patient with toileting, and assisting a patient in standing from a seated position or during walking. Nursing faculty historically have emphasized the use of manual patient- handling techniques that have focused on use of good body mechanics and “proper” lifting techniques when moving, transferring, and positioning patients. However, performance of manual patient handling tasks is associated with significant risk for injury. Documentation of musculoskeletal hazards in nursing from moving and lifting patients was cited as early as 1898 in a textbook by Hampton, who stated that a nurse’s back injury during patient lifting was due to the female’s deficient strength and failure to do proper lifting. Early nursing arts textbooks emphasized the role of the nurse to assist patients with transfers to save the patient’s strength (Committee of the Connecticut Training-School for Nurses, 1906). During the post World War II era, early ambulation for postoperative patients became accepted practice, and nursing workload associated with patient handling tasks significantly increased since patients were often unstable, and easily lost their balance. As a result, publications about “aching backs” emerged (Svec, 1951).
The intent of body mechanics was to provide a program to protect nurses and patients while nurses repositioned patients by shifting their weight in certain ways thought to protect the back. The concept of “body mechanics” was introduced by Wright (1945), a physician, in an article in the American Journal of Nursing. The intent of body mechanics was to provide a program to protect nurses and patients while nurses repositioned patients by shifting their weight in certain ways thought to protect the back. In a curriculum training program on body mechanics implemented at Vanderbilt’s University, School of Nursing (Winters, 1950), a nurse and a physical therapist emphasized using one’s body to prevent strain and fatigue; but no scientific evidence existed to support or refute these practices designed to reduce injury and promote nurse safety.
Despite the lack of a scientific evidence base, throughout the 20th century and into the 21st century, nursing schools have continued to emphasize the use of body mechanics for preventing musculoskeletal injuries associated with manual patient handling. Current nursing-skills textbooks continue to emphasize body mechanics (Taylor, Lillis, & LeMone, 2005; Potter & Perry, 2006) despite the fact that numerous research studies have documented the relationship between the use of manual patient handling and musculoskeletal disorders in nursing (Edlich,Winters, Hudson, Britt, & Long, 2004; Nelson et al., 2006; Panel on Musculoskeletal Disorders Commission on Behavioral and Social Sciences and Education, National Research Council, & Institute of Medicine, 2001; Smedley, Egger, Cooper, & Coggon, 1995). The item writers for the National Council Licensure Examination-Registered Nurse (NCLEX-RN) test have persisted in including test questions focusing on the use of body mechanics for patient handling (National Council of State Boards of Nursing, 2003; Waters, Collins, Galinsky, & Caruso, 2006). Cronenwett et al. (2007) noted that to improve nurse safety, the nursing curriculum content needs to address human factors, recognizing interactions among nurses, patients, and other elements of a system, such as lifting equipment and the nursing practices used to move patients (International Ergonomics Association [IEA], 2000).
Safe Patient Handling Curriculum Module and the Faculty Training-the-Trainer Program
A consortium of experts in safe patient handling, from the American Nurses Association, the National Institute of Occupational Safety and Health, and the Veterans Integrated Service Network 8, developed the first draft of a curriculum module for use with nursing students and a train-the-trainer program for faculty (Menzel, Hughes, Waters, Shores, & Nelson, 2007). This draft curriculum module was revised based on feedback from the faculty of the 26 participating schools (described below) and an expert panel composed of a nurse educator, an ergonomist, a nursing health and safety specialist, and an authority on safe patient handling practices. The revised module materials included a narrated slide show on principles of safe patient handling (including the newest technologies), ergonomics, and use of algorithms based on patient assessment criteria to standardize decisions about what equipment should be used and how many nurses are needed to perform a patient handling task safely (www.cdc.gov/niosh/review/public/safe-patient). Supplemental materials included required readings, laboratory exercises, student assignments, a quiz, and background materials to enable faculty to strengthen their knowledge base and teach the module more effectively.
Faculty from 26 baccalaureate programs, whose administrators endorsed the project, were invited to a train-the-trainer program held at an annual, safe patient handling conference. The train-the-trainer program consisted of a preconference workshop to dispel commonly held myths about safe patient handling, a three-day conference of paper and poster presentations, an equipment vendor fair, and a one-day postconference workshop, which focused on implementing the new module. During these five days, faculty were immersed in safe patient handling content to build their knowledge and skills. Workshop content included the module material and strategies for teaching the content. Each nursing school was linked with an equipment vendor who arranged for the use of safe patient handling equipment in the schools’ teaching laboratories during implementation of the module.
The 30 faculty who volunteered to participate in the qualitative interviews were drawn from the 48 faculty who participated in the parent study (Development and Evaluation of Safe Patient Handling and Movement Curriculum) and represented 23 of the total 26 participating schools. All were women, most were Caucasian (90%), and the mean age was 48 years (SD=9). Faculty averaged 25 years of experience in nursing (SD=11) including 12 years in education (SD=9). Twenty-four percent had received previous training in patient handling. The majority of faculty were directly involved in teaching the content to students. Most interviewees taught both the didactic and laboratory content. Some were team leaders who had attended the train-the-trainer program, and who then assigned the curriculum module to other faculty. In teaching the content of the curriculum module, faculty reported means of 6.9 hours presenting didactic content, 3.1 hours in laboratory instruction, and 13.9 hours in clinical instruction (Nelson et al., 2007).
The 26 nursing schools were geographically distributed across the US. They included large and small programs in rural and urban settings, programs in two-year community colleges and programs in four-year university settings. The schools were generally large public institutions (65%), had a long history of undergraduate nursing education (mean=34 years, SD= 14.3), offered Bachelor of Science in Nursing (BSN) programs (93%), and graduated an average of 134 students per year.
Approval was obtained from each participating nursing school and each local Institutional Research Review Board. Documentation of written informed consent was waived due to the minimal risk of the study and belief that participating in the interview implied agreement to participate in the study. Confidentiality of participants was maintained through reporting data in aggregate summary without participants’ names.
Data Collection Procedures
The project manager contacted each faculty member after the faculty member had taught the curriculum module. Telephone interviews were scheduled with each faculty member and one of three co-investigators. All three interviewers were co-investigators in the parent study and had in-depth knowledge of safe patient handling based on either research, clinical, or policy experience. One had extensive experience in qualitative research methods, one represented the faculty perspective, and one represented a staff nurse perspective. After a brief introduction describing the purpose of the interview, interviewers asked the following six questions, using prompts as necessary to elicit information:
- What things made it easier for you to teach the safe patient handling curriculum module?
- What barriers got in the way of your teaching the safe patient handling curriculum module?
- Can you tell me about a time you were implementing the module that you felt you were very effective?
- Can you tell me about a time you were implementing the curriculum module that you felt you were not at all effective?
- What was the impact of this safe patient handling curriculum module on the clinical sites where students had clinical rotations?
- What recommendations do you have for implementing this curriculum module nation wide?
Interviewers took extensive notes during the phone interviews. Electronic files with participants’ responses were submitted to the lead interviewer for analysis.
Findings from qualitative questions were analyzed using content analysis (Weber, 1990) to determine common themes across respondents, focusing on barriers to implementation and recommendations for improving the curriculum module. One investigator developed a list of codes and definitions while coding the first 10 transcripts. These codes were reviewed by another co-investigator for logical consistency, coherence of the definitions of codes, and representativeness of what was reported in the transcripts. The lead investigator then recoded the initial 10 transcripts and the remaining 19 transcripts, noting no new codes. In general, there was relatively little variation in faculty responses regarding barriers and facilitators for implementation of the curriculum module. One co-investigator, who had also conducted interviews, reviewed study findings for content validity, verifying that the findings accurately represented content of the interview transcripts. All investigators were involved in preparing the final write-up of the findings.
From the analysis of the interview data, facilitators and barriers for implementing a safe patient handling curriculum module were grouped into four categories: (a) safe patient handling curriculum module, (b) nursing school resources and processes, (c) equipment vendor resources and support, and (d) clinical setting use of safe patient handling equipment. Findings for each of these categories are presented below along with recommendations for implementation.
The Safe Patient Handling Curriculum Module
The multi-media aspect of the module was helpful for reaching students with a variety of learning styles. The major facilitator that faculty identified for using the safe patient handling curriculum module was the structured and organized format that served as an exemplar of evidence-based practice, and helped students to understand the roles of professional organizations (e.g. American Nurses Association [ANA]) and regulation (Occupational Safety and Health Administration [OSHA] and National Institute for Occupational Safety and Health [NIOSH]). The module was deemed useful in easily presenting the material to students and to other faculty. One faculty commented: “I appreciated not having to reinvent the wheel.” Faculty identified the flexibility built into the safe patient handling curriculum module materials as a strength. The multi-media aspect of the module was helpful for reaching students with a variety of learning styles. The algorithms were useful in facilitating students’ critical thinking.
Faculty noted minor difficulties in technical aspects of using the curriculum module. Occasionally, the electronic format of materials was incompatible with in-house software and hardware. However, with technical assistance, faculty were able to use the module materials.
Faculty recommended continuing to improve the curriculum and to augment curriculum materials with more illustrations, improved sound quality of the video, and case studies and patient scenarios to facilitate use of algorithms. Faculty recommended dissemination of the curriculum module via national conferences that educators and clinical laboratory coordinators attend. Other recommendations included restructuring the ANA website, Handle with Care® to facilitate locating the site on the home page, offering a “hotline” to get just-in-time answers to questions that arise during implementation, and placing safe patient handling information on a listserv for nurse educators and clinical agencies. Faculty felt that authors of nursing textbooks should be encouraged to incorporate evidence-based safe patient handling into texts; and that NCLEX examination questions should be developed to reflect evidence-based practice for safe patient handling.
Nursing School Resources and Processes
Faculty felt that authors of nursing textbooks should be encouraged to incorporate evidence-based safe patient handling into texts... A major facilitator that faculty identified regarding nursing school resources and processes for implementing the safe patient handling curriculum module was the module flexibility, which allowed faculty to tailor the module by using in-house resources and various teaching-learning strategies. For example, one faculty described the development of case scenarios developed by her team that included varying the patient, setting of care, and context. The team used these cases interactively with students to stimulate problem solving and build critical thinking skills. Another faculty developed a skills checklist for students to complete. Although faculty varied in the specific teaching and learning strategies, the customization allowed by the module facilitated alignment with their overall curricula. Most schools used both didactic and laboratory-based learning, and required student preparation, such as reading evidence-based articles. Faculty who used didactic methods valued it for presentation of the background content (e.g. injury statistics) that helped students to understand the importance of the program and stimulate question and answer sessions. All schools used laboratory-based, hands-on training and valued it for its positive effects on students. One faculty said, “…the hands-on experiences provided the ah-ha moments for students that assured me that the students got it.”
Faculty identified administrators, other faculty, and students who were champions for the curriculum module as facilitators of successful implementation. One faculty stated, “My administration was very happy that we chose to participate. They said, ‘We back you 100%.’ ” Other stakeholders, whose support was perceived as important, included laboratory directors, other faculty, and faculty from other departments (in cases where faculty collaborated with physical therapy and other departments to implement the program). Nursing students were acknowledged as important facilitators who helped to ensure program implementation because they were enthusiastic about the curriculum module. Students appreciated the focus on nurse safety and the importance of protecting themselves from injury. In summing up students’ reactions to the program, one faculty commented:
Students were very excited about the program. They recognized this [safe patient handling] as the gold standard. Some students were stunned and shocked. They found it hard to understand that if safe patient handling techniques were so clearly documented, why was it not being used more? These champions facilitated acceptance and implementation of the module.
Faculty noted two nursing school barriers. One was the difficulty of “fitting one more thing into an already crowded curriculum.” Another noting this barrier said, “…I just had to fit this additional information in and carve out lab time.…” Overcoming the curriculum barriers was attributed to strong faculty dedication to implementing the module and the strong administrative support they had.
The other nursing school barrier that faculty identified for using the curriculum module was the challenge of working with faculty colleagues who did not attend the train-the-trainer program and insisted on keeping the old paradigm of relying on body mechanics as the primary means of preventing injury. Faculty reported resistance from colleagues at times. One frustrated faculty stated:
I had trouble with only one instructor...when I heard she went behind what we had done to teach safe patient handling....She taught her students how to do “hook and toss” [an outdated manual patient lifting technique] and I felt like I was banging my head against the wall.
Great pride was expressed in being involved in the safe patient handling initiative.This resistance from colleagues required persistence, creativity, and compromise.
A recommendation that faculty offered regarding nursing school resources and processes for using the safe patient handling curriculum module was the need for nationwide dissemination. Many faculty reported that through implementing the curriculum module they developed strategies to disseminate the new module beyond their own nursing schools. Dissemination activities that faculty used included: encouraging students to use the safe-movement algorithms in clinical settings; advising students to ask for and demand safe patient handling equipment when pursuing jobs; encouraging students, as new leaders for safe-movement initiative, to be proactive and share the information with nursing and administrative staff; organizing equipment fairs for community partners; presenting at state nursing associations; and distributing handouts to clinical sites about why students and faculty did not use manual lifting techniques. Great pride was expressed in being involved in the safe patient handling initiative.
Equipment Vendor Resources and Support
The major facilitator that faculty identified regarding equipment vendor resources was the technical assistance provided to facilitate successful implementation of the curriculum project. Most faculty noted the importance of having equipment in their labs that provided hands-on experience for students to develop necessary psychomotor skills. Faculty appreciated vendors who were responsive to their needs, communicated in a timely manner, made on-time deliveries of equipment, and worked with them as collaborators. They valued vendors who were flexible in bringing equipment when it was needed and removing it when no longer needed. This flexibility was important to faculty because it meant they did not have to worry about storing unused equipment in laboratories that often lacked storage space. Faculty appreciated not only the equipment, but also the support and training that vendors provided to insure proper use. Many faculty preferred working with equipment vendor staff who were also clinicians because they understood the clinical issues better than non-clinicians.
Faculty believed strongly that equipment vendor resources and support were critical for further implementation across all nursing schools in the US. The major barrier that faculty identified regarding equipment vendor resources and support was the challenge of working with vendors who did not provide good support. Not all vendor support was perceived as equal. Faculty felt frustrated in a few instances when equipment was delivered late, or when equipment malfunctioned and the vendor was not timely in making repairs.
Faculty believed strongly that equipment vendor resources and support were critical for further implementation across all nursing schools in the US. Faculty wanted to make sure that other faculty who implement the curriculum would work closely with equipment vendors to insure access to equipment when teaching the curriculum module. Faculty felt it would be essential to develop a nationwide collaborative effort with vendors and to have the equipment available on site. They stressed that all faculty teaching the curriculum module should learn about available equipment by attending the large vendor exhibit at the annual safe patient handling conference.
Clinical Setting Use of Safe Patient Handling
Faculty identified their own optimism for the future of safe patient handling as a major facilitator. They optimistically believed that the students they were now teaching would provide a significant impetus for helping to change the patient lifting and moving paradigm in clinical settings in the future. One faculty related an incident during a clinical experience:
It happened that we were on a unit and we had to move a morbidly obese patient and there was no equipment to be found. That’s when I contacted the educator to tell her that we could not provide the care we needed to unless we had the equipment. I also mentioned it to the staff nurses and the charge unit, and they agreed that we needed to have the equipment available. I gave the card from the equipment company to one of the educators and encouraged her to contact that person to come and talk. I don’t know if that happened. I should follow up to see if they have anything in the plan to obtain the equipment.
Faculty encouraged students to ask questions about safe patient handling equipment when seeking employment and to make job decisions based on the availability of equipment. Faculty viewed themselves as role models for how students could bring about change in clinical settings.
Faculty encouraged students to ask questions about safe patient handling equipment when seeking employment and to make job decisions based on the availability of equipment. Many faculty noted a perception that change was underway. Clinical sites were in varying stages of implementing safe patient handling, ranging from a vague awareness of alternatives to manual lifting, evaluating equipment for purchase, purchasing equipment, and implementing policies to eliminate manual lifting.
The major barrier that faculty identified for applying the content in the safe patient handling curriculum module in the clinical setting was the gap between the content of the curriculum and the manual lifting that commonly occurred in clinical areas where students had clinical experiences. This gap resulted in both student and faculty frustration, and sometimes faculty colleagues used this as a reason for resisting the use of the safe patient handling curricula. One faculty shared this clinical experience with students:
...I had a group of students in clinical. We had an obese man in the bathroom and he could not get up. He was weak and could not get up. We had no mechanical device to get him up and help him walk back to the bed. I had no choice…I got manpower, got his walker, stabilized the walker and had him hold onto that as we assisted him.
This experience left her feeling disappointed and frustrated.
Recommendations that faculty identified for applying the safe patient handling curriculum module content in the clinical setting were: including guidelines for influencing state and local policy about safe patient handling, providing a nationwide list of faculty consultants to clinical agencies, hosting a listserv to facilitate communication among nursing schools and clinical agencies, hosting an open house and equipment fair for local clinical agencies, and developing a speaker’s bureau.
The enthusiasm for the curriculum module expressed by faculty in the current study supports findings of the parent study which demonstrated the positive effect of the curriculum module on both faculty and student knowledge and attitudes about safe patient handling (Nelson et al., 2007). Additionally, 95% of faculty rated the curriculum module as good or very good, and eighty percent of faculty intended to continue to teach safe patient handling after completion of the study (Nelson et al., 2007).
Study findings provide important information for successful integration of this new, evidence-based, safe patient handling curriculum module into nursing education. The findings offer guidance to faculty as they support the ANA’s Handle With Care® campaign. Prior research has shown that tailoring interventions to overcome known barriers can facilitate the implementation of clinical practice guidelines and improve care provided and patient outcomes (Shaw et al., 2005). Study findings can be used by faculty to identify potential barriers and proactively diffuse them. For example, the reluctance of some of their colleagues was a disappointment; but it was overcome by administrative support and student enthusiasm for the program. Almost all faculty reported an overwhelmingly enthusiastic response from students to the curriculum materials and the hands-on practice with the equipment and transfer devices. Despite some clinical areas that were not using patient-lifting equipment, students took their new knowledge into the clinical settings and taught others. Both faculty and students rapidly became change agents, role models, and early adopters (Rogers, 1884) to facilitate implementation of safe patient handling into clinical practice at their local institutions.
...students took their new knowledge into the clinical settings and taught others.Findings of this study confirm that faculty implementing the safe patient handling module need to be partnered with equipment vendors and negotiate services with them. The availability of equipment was perceived by faculty as a key component to the success of the project. The message for equipment vendors is that the quality and consistency of vendor support and, in some cases, donations of equipment will greatly facilitate curriculum implementation. In Child’s (2002) survey of 276 clinical resource center faculty, no faculty member reported the presence of safe patient handling equipment, and most reported budgetary constraints. This survey finding emphasizes the need to partner with vendors in implementing the safe patient handling curriculum.
While the safe patient handling curriculum module contained scripted content, it was designed so that implementation could be customized based on the procedures, policies, and operations of the local clinical teaching laboratory and nursing program. Emerging research is beginning to demonstrate the effectiveness of several specific approaches to teaching skills to nursing students. For example, Salyers (2007) compared a traditional skills teaching format to a web-enhanced approach. Although the web-enhanced group performed better on examination, the traditional group was more satisfied with the course. The safe patient handling curriculum module is flexible enough to be used with traditional teaching modes, computer-assisted instruction, or web-based teaching approaches. Additionally, the clinical demonstrator role in which a staff nurses partnered with faculty to provide skills training was found to greatly increase student’s perceptions that both groups were “singing from the same song sheet” (Hilton & Pollard, 2005). Perhaps closer collaboration between academia and the practice setting than we used in our project would facilitate implementation of the safe patient handling module.
Findings from this qualitative analysis can provide faculty with a road map for implementation and specific suggestions for facilitating curriculum change. Curriculum change will benefit nursing students in the short term by reducing their risk of musculoskeletal injuries. In the long run, it will significantly shorten the research translation time for adoption of safe patient handling in all healthcare settings thus decreasing the risk of musculoskeletal injuries for all nurses. Faculty play an important role in promoting evidence-based practice for safe patient handling by linking curriculum change to improvements in the clinical agencies affiliated with their nursing programs.
The study was supported by the National Institute for Occupational Safety and Health, American Nurses Association, and the Department of Veterans Affairs, Veterans Health Administration, Patient Safety Center of Inquiry (Tampa, FL). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the National Institute of Occupational Safety and Health.
Gail Powell-Cope, PhD, ARNP, FAAN
Dr. Powell-Cope has almost 30 of experience in nursing and currently serves as the Associate Chief of Nursing Service for Research at the Tampa, Florida VA. She is the Assistant Director for hazardous wandering at the Veterans Integrated Service Network 8 Patient Safety Center of Inquiry, “Preventing Adverse Events Associated with Mobility.” Dr. Powell-Cope has been involved in patient safety since 1999 and has worked in the areas of hospital bed safety, patient falls, fall-related injuries, safe patient handling, and implementation of evidence-based practice. Dr. Powell-Cope is the Assistant Director of Clinical Research at the University of South Florida College of Nursing, and holds an adjunct faculty appointment in the College of Public Health. She is also the Co-Director of the “Interprofessional Fellowship Program in Patient Safety” at the Tampa VA which is funded by the VA Office of Academic Affiliations.
Nancy L. Hughes, MS, RN
Nancy L. Hughes is the Director of the Center for Occupational and Environmental Health of the American Nurses Association. She has held numerous positions in nursing and healthcare prior to joining ANA including those of obstetrical staff nurse, emergency department staff nurse, inpatient nurse manager, internal medical auditor, and employee health nurse. She has also served as a director of occupational health responsible for employee health and safety/industrial hygiene in a major health system with 10,000 employees.
Carol Sedlak, PhD, RN, CNS, ONC, CNE
Dr. Sedlak is a Professor at Kent State University, College of Nursing. She is certified in orthopaedic nursing and serves on the Editorial Board of Orthopaedic Nursing, the journal for the National Association of Orthopaedic Nurses. Dr. Sedlak is a certified nurse educator and is the author of over 50 publications in peer-reviewed nursing and interdisciplinary journals on topics of orthopaedic nursing, osteoporosis prevention, and nursing education including critical thinking. The focus of her nursing research is bone health, specifically osteoporosis prevention. She has been funded from the National Institute of Nursing Research and the National Institute of Aging for research on osteoporosis prevention in postmenopausal women, and in men 50 years of age and older. She serves as a community advocate with clinical agencies in the prevention of musculoskeletal injuries of healthcare workers
Audrey Nelson, PhD, RN, FAAN
Dr. Nelson has over 27 years of experience in nursing and is currently the Associate Chief of Nursing Service for Research at the James A. Haley Veterans Hospital in Tampa, Florida. She serves as the director of the Patient Safety Center of Inquiry. She is also the Associate Director of Clinical Research at the University of South Florida, College of Nursing. Dr. Nelson is a national leader in patient and nurse safety, with a program of research on safe patient handling. She was appointed by the United States Secretary of Labor to the National Advisory Committee on Ergonomics and collaborates with the American Nurses Association to promote safe working environments for nurses.
American Nurses Association. (2007). Handle with Care®. Retrieved August 21, 2007 from www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/handlewithcare.aspx
Bureau of Labor Statistics (BLS). (2002). Survey of occupational inquiries and illnesses, 2001. US Department of Labor. USDL December 19, 2002.
Child, J. C. (2002). Clinical resource centers in nursing programs. Nurse Educator, 27(5), 232-235.
Collins, J., Wolf, I., Bell, J., & Evanoff, B. (2004). An evaluation of a “best practices” musculoskeletal injury prevention program in nursing homes. Injury Prevention, 19, 206–211.
Collins, J. W., & Menzel, N. N. (2006). Scope of the problem. In A.L. Nelson (Ed.), Safe Patient Handling and Movement: A Guide for Nurses and Other Health Care Providers (pp 3–26). New York, New York: Springer Publishing.
Committee of the Connecticut Training-School for Nurses (1906). A Hand-Book of Nursing, Revised Edition: For Hospital and General Use. Philadelphia, PA: J.B. Lippincott.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D. T., & Warren, J. (2007). Quality and Safety Education for Nurses. Nursing Outlook, 55, 122–131.
Edlich, R. F., Winters, K. L., Hudson, M. A., Britt, L. D., & Long, W. B. (2004). Prevention of disabling back injuries in nurses by the use of mechanical patient lift systems. Journal of Long Term Effects of Medical Implants, 14(6), 521–533.
Garg, A. & Owen, B. (2002). Reducing back stress to nursing personnel: an ergonomic intervention in a nursing home. Ergonomics, 35, 1353–1375.
Hampton, I.A. (1898). Nursing: Its Principles and Practice. Cleveland, OH: J.B. Savage.
Health and Safety Executive (2007). The Manual Handling Operations Regulations 1992 (as amended) (MHOR). Accessed 1/30/08 www.hse.gov.uk/foi/internalops/fod/oc/300‑399/313_5.pdf
Hinton, P.A., & Pollard, C.L. (2005). Enhancing the effectiveness of the teaching and learning of core clinical skills. Nurse Education in Practice, 5, 289-295.
International Ergonomics Association [IEA] (2000). What is Ergonomics? Retrieved May 18, 2007 from www.iea.cc/browse.php?contID=what_is_ergonomics.
Marras, W. S., Davis, K. G., Kirking, B. C., & Bertsche, P. K. (1999). A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Ergonomics, 42, 904–926.
Menzel, N. N., Hughes, N. L., Waters, T., Shores, L. S., & Nelson, A. (2007). Preventing musculoskeletal disorders in nurses: A safe patient handling curriculum module for nursing schools. Nurse Educator, 32(3), 130–135.
National Council of State Boards of Nursing (2003). Detailed test plan for the NCLEX-RN® Examination. Chicago, IL: Author.
National Institute of Occupational Safety and Health [NIOSH] (1997). Musculoskeletal Disorders and Workplace Factors A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. NIOSH Publication No. 97-141. Retrieved January 12, 2008 www.cdc.gov/niosh/docs/97-141/ergotxt6.html
National Institute for Occupational Safety and Health (NIOSH). (2007). Draft Document for Public Review and Comment: Safe Patient Handling and Movement Principles (NIOSH Docket #072. Retrieved January 7, 2008, from www.cdc.gov/niosh/review/public/safe-patient .
Nelson, A., Waters, T. R., Menzel, N., Hughes, N., Hagan , P. C., Powell-Cope, G., Sedlak, C., & Thompson, V. (2007). Effectiveness of an evidence-based curriculum module in nursing schools targeting safe patient handling. International Journal of Nursing Education Scholarship, 4(1). Retrieved January 7, 2008 from www.bepress.com/ijnes/vol4/iss1/art26/.
Nelson, A. (2006). Evidence-based practices for safe patient handling and movement (updated reprint from The Online Journal of Issues in Nursing, September 2004). Orthopaedic Nursing, 25(6), 366–379.
Nelson, A., Matz, M., Chjen, F., Siddharthan, K., Lloyd, J., & Fragala, G. (2006). Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. International Journal of Nursing Studies, 43, 717–733.
Nelson, A. & Baptiste, A. (2004). Evidence-based practices for safe patient handling and movement. Online Journal of Issues in Nursing, 9, 3, Manuscript 3. Retrieved January 7, 2008 from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/EvidenceBasedPractices.aspx
Owen, B. (2000). Preventing injuries using an ergonomic approach. Association of Operating Room Nurses Journal, 72, 1031–1036.
Panel on Musculoskeletal Disorders and the Workplace, Commission on Behavioral and Social Sciences and Education, National Research Council, & Institute of Medicine. (2001) Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: National Academy Press.
Potter, P.A., & Perry, A.G. (2006). Fundamentals of Nursing, 6th ed. St Louis, MO: Elsevier Mosby.
Rogers, E.M. (1983). Diffusion of Innovation, Fourth edition. New York: Free Press.
Salyers, V.L. (2007). Teaching psychomotor skills to beginning nursing students using a web-enhanced approach: A quasi-experimental study. International Journal of Nursing Education Scholarship, 4(1), 1-12.
Shaw, B., Cheater, F., Baker, R., Gillies, C., Hernshaw, H., Flottorp, S., & Robertson, N. (2005). Tailoring interventions to overcome identified to change: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 3(CD005470).
Smedley, J., Egger, P., Cooper, C., & Coggon, D. (1995). Manual handling activities and risk of low back pain in nurses. Occupational and Environmental Medicine, 42, 160–163.
Svec, L. (1951). Oh, that aching back! RN, 14(7), 30–32.
Taylor, C., Lillis, C., LeMone, P. (2005). Fundamentals of nursing: The art and science of nursing care. Philadelphia, PA: Lippincott Williams & Wilkins.
Waters, T., Collins, J., Galinsky, T., & Caruso, C. (2006). NIOSH research efforts to prevent musculoskeletal disorders in the healthcare industry. Orthopaedic Nursing, 25(6), 380–389.
Weber, R.P. (1990). Basic Content analysis. (Sage University Paper Series on Qualitative Applications in the Social Sciences, series no. 07-004). Newbury Park, CA: Sage.
Winters, M. C. (1950). Nursing education: Integration of body mechanics and posture in nursing. American Journal of Nursing, 50(11), 745–747.
Wright, J. (1945). Protective body mechanics in convalescence. American Journal of Nursing, 45(9), 699–703.
Zhuang, Z., Stogbe, T. J., Hsiao, H., Collings, J. W., Hobbs, G. R. (1999). Biomechanical evaluation of assistive devices for transferring residents. Applied Ergonomics, 30, 285–294.
© 2008 OJIN: The Online Journal of Issues in Nursing
Article published August 18, 2008
- Evidence-Based Practices for Safe Patient Handling and Movement
Audrey Nelson, PhD, RN, FAAN; Andrea S. Baptiste, MA, CIE (September 30, 2004)
- Handle With Care®: The American Nurses Association’s Campaign to Address Work-Related Musculoskeletal Disorders
A.B. de Castro, PhD, MSN, MPH, RN (September 30, 2004)
- Workplace Violence in Health Care: Recognized but not Regulated
Kathleen M. McPhaul, PhD(c), RN, MPH; Jane A. Lipscomb, PhD, RN (September 30, 2004)
- Safe Handling of Hazardous Drugs
Martha Polovich, MN, RN, AOCN (September 30, 2004)
- Needlestick and Sharps Injury Prevention
Susan Q. Wilburn, MPH, RN (September 30, 2004)
- Caring for Those Who Care: A Tribute to Nurses and Their Safety
Mary Foley, MS, RN (September 30, 2004)