Part 1 Student Demographics
Twenty-four students completed both parts of the survey. There were 21 female and 3 male students (Table 2). All students were in the third year of the DPT program. A majority of the students (67%) had completed an outpatient orthopedic clinical experience, with 12.5% completing an outpatient neurologic experience. Twenty percent of students had experiences in either a skilled nursing facility, inpatient rehabilitation, or acute care clinical experience. According to the survey, none of the students went through a formal training program with SPHM equipment while on their clinical experiences, but 21% did indicate that they used SPHM equipment for gait or transfer training. Students who had used SPHM equipment reported using ceiling lifts (4%), floor-based lifts (8%), walking harness systems (8%), and sit-to-stand lifts (8%).
Part 2 Safe Patient Handling and Mobility Pre–post Intervention Survey Results
Pretest results showed strong levels of previous knowledge in several areas. All the students reported that they could state the harmful effects of immobility, and most students (71%) could identify 1–2 limitations of using manual assistance in patients who were challenging to move. Most of the students (75%) agreed or strongly agreed that there is sufficient evidence to support the use of SPHM equipment and practices, and all students agreed that these practices are feasible during physical therapy sessions. In addition, 96% students reported that the quality of physical therapy is not diminished by the use of SPHM equipment.
In contrast, only 21% of students were confident in their ability to use SPHM equipment on the pretest. After the intervention, 87% of students either agreed or strongly agreed that they were confident in their ability to use SPHM equipment. Similarly, before the class, only 4% of students were familiar with the research related to therapist injury during manual handling. This improved to 83% posttest. Before the class, none of the students reported being aware of the legislation related to SPHM or the APTA position statement. After the intervention, these improved to 71% and 67%, respectively.
Laboratory Worksheet Results
Table 3 summarizes students' average rate of perceived exertion in their role as the treating therapist on a 0–10 scale, (0 = no exertion and 10 = maximal exertion), quantity of task performance (repetitions, minutes, or steps), and the quality of the intervention (good, fair, or poor), during assigned manual and SPHM equipment-assisted activities.
Repeated Sit-to-Stand Task
Using SPHM equipment, students were able to achieve greater repetitions of sit to stand with dramatically lower rates of perceived exertion. This was consistent across all 8 students performing this task (Figures 3A, B). Seven of 8 students rated the quality of their intervention as good with SPHM equipment versus all 8 students reporting quality as poor with manual assistance.
Walking to the Bathroom Task
All 3 students completing this task reported lower RPE and greater number of steps when using the SPHM equipment when compared with manually performing the task (Figures 4A, B) None of the students reported treatment intervention quality as “good” when using manual assistance. When using the equipment, all 3 rated the quality as “good.”
Repeated Reaching in Sitting Task
Attempting to complete 30 repetitions of reaching in the sitting position using manual assistance, the 3 students assigned to this task achieved 5, 15, and 5 repetitions with an RPE of 7/10, 6/10, and 6/10, respectively. All rated the quality of intervention as “fair.” With SPHM equipment, all 3 students achieved 30 repetitions, with RPE of 1/10, 2/10, and 1/10, respectively (Figures 5A, B). All rated the quality of intervention with SPHM as “good.”
Standing Balance Task
During manually assisted standing balance, 3 of the 4 students performing the task achieved all 5 minutes. One student was unable to complete even 1 minute of standing balance because of difficulty holding the patient up. Rate of perceived exertion ratings by student during manual assistance were 9/10, 8/10, 9/10, and 6/10, and quality of intervention was rated as “fair” by 3 students and “good” by 1 student. With use of the equipment, all 4 students achieved the 5-minute goal in standing with RPE at 1–2/10 (Figures 6A, B).
The need for SPHM education in physical therapy curriculum has been clearly identified.10,35 Previous studies have recommended integration of SPHM content into physical therapy education33; however, this is the first case report to describe an example of such a learning module in detail. Similar to acute care therapists' responses in the study by Olkowski and Stolfi,33 students were aware that SPHM equipment was available in some practice settings. They had some baseline knowledge about the evidence to support the use of SPHM and agreed that it was feasible to use and did not diminish the quality of care. However, students were not confident in their abilities to integrate SPHM principles into their treatment interventions. This may provide an explanation for the findings of Stevenson et al10 that identified a knowledge–practice gap between what students know and how comfortable they are applying the knowledge in a variety of clinical situations.
Laboratory activities were designed to promote knowledge transfer from cognitive to psychomotor domain through physical experience with and without SPHM equipment (mastery experiences). Students were asked to critically appraise the SPHM equipment by comparing and contrasting their experiences (verbal persuasion). When students compared their laboratory worksheets, it was clear that their “patients” were able to achieve more steps, more repetitions, and longer activity times in the equipment than when manual assistance was provided. They also documented higher quality interventions when using the SPHM equipment. Students also remarked on the noticeable difference in their perceived exertion, with little to no bodily stress while using the equipment. Students did report that in some cases, the equipment itself was challenging to manage, and it took some time to learn how to apply slings and set their “patients” up in the equipment.
During informal discussion, students reported that the additional time allotted to develop, implement, and document their own plan of care using the SPHM equipment helped them to further consolidate their skills and integrate knowledge taught in this class with previous classes. They reported that group presentations helped them defend their clinical reasoning in designing a plan of care that was safe for both the patient and themselves (emotional state and vicarious experiences).
PTs are expected to be advocates and leaders in education for SPHM. In order for students to be better prepared for this role, improving student self-efficacy regarding SPHM content is paramount. This module improved DPT students' knowledge, awareness, and self-reported confidence with SPHM equipment in neurorehabilitation, meeting the overarching goals of the educational intervention.
Recommendations for Improvements to the Current Model
Recommendations for improvements to this module are grounded in concepts from social learning theory, in particular, the development of perceived self-efficacy and modeling in student populations.46 The activities developed for this module allowed students to observe how SPHM principles are used by experienced therapists (modeling) and experience success (and failures) with the equipment through hands-on opportunities (mastery experiences). Students presented their activities with rationale to the class (regulation of physiologic states) and verbally defended/received feedback about the activities presented by other students and instructors (verbal persuasion).
In learning new content, hands-on practice and observation, critical thinking, feedback from experts, and collaboration with others help with transfer of knowledge and skills into clinical practice. Students must be given sufficient opportunities to develop context-specific self-efficacy to translate SPHM skills from academia into practice. Three recommendations to further improve successful integration of SPHM content into physical therapist professional education are proposed.
Recommendations for Safe Patient Handling and Mobility Principles to be Threaded Throughout the Curriculum
According to Bandura,39 mastery of content requires repeated exposures through a variety of active learning strategies. Safe patient handling and mobility content should be included in foundational patient care courses and embedded throughout the curriculum. Ideally, SPHM should be an integral component of any patient care scenario where lifting patients is required to promote recovery, but safe lifting levels are exceeded.47 Repeated observational learning and mastery experiences will improve student self-efficacy to merge legal and professional obligations and clinical decision making across the care continuum.
Research also suggests that PT educational programs need both didactic support of SPHM content and partnerships with clinical sites to reinforce skills developed in the curriculum and improve competency during clinical education experiences.25 Clinical educators are influential in shaping student attitudes, and students who actively participate in SPHM behaviors in the clinic are more likely to advocate for SPHM in the profession.10
Recommendations for Entry-Level Doctor of Physical Therapy Programs to Have Continuous Access to Safe Patient Handling and Mobility Equipment
Bandura39 advocates multiple context-specific hands-on experiences to achieve self-efficacy, which increase the odds of translating skills to clinical practice. Continuous access to SPHM equipment (as with other equipment such as goniometers, walkers, and wheelchairs) allows students and faculty to easily access and integrate use of the equipment during case scenarios at any time. Ultimately, SPHM principles should be an automatic consideration for both faculty and students during clinical decision making. The authors recommend that schools invest in having continuous access to (through equipment purchase or contract with vendors) a variety of SPHM equipment (Table 4) to ensure availability of these types of experiences throughout the curriculum.
Recommendations for Outcomes Research
Stevenson et al10 reported on student attitudes regarding SPHM use after graduation. At present, there are no reported measures of SPHM knowledge transfer from the classroom into clinical practice in the physical therapy literature. Future research should help determine optimal amount of time and placement of SPHM content within the curriculum to achieve entry-level competency and translation to clinical practice. Documenting changes in student self-efficacy should be included for this content. Future research should also assess the impact of SPHM content within the DPT curriculum on new graduate therapists' injuries.
The SPHM module only applies to the experience of a small group of students in 1 course embedded in 1 DPT program. The learner survey did not assess achievement of higher-order learning objectives, students' ability to apply their learning in a clinical situation, or their self-efficacy. The authors also acknowledge that observing and measuring classroom behavior is not the same as ensuring that the behavior will carry over into clinical practice.
The APTA calls on PTs to be leaders and advocates of SPHM and to lead the education of others. Perlow, et al states “physical therapist educators can influence future attitudes and practice by preparing student PTs to make sound clinical decisions about the use of both manual and mechanically assisted patient mobility.”35 We have provided 1 model, with recommendations for improvement, that embeds SPHM content into entry-level physical therapist education. In doing so, educators are advancing skills associated with SPHM to apply evidenced-based recovery principles for patients who are difficult to move while reducing risk of injury to students and new PT graduates.
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Curriculum; Safety; Safe patient and handling mobility; DPT education
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