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Safe patient handling: Is your facility ready for a culture change?

Cadmus, Edna PhD, RN, NEA-BC; Brigley, Patricia BSN, RN, COHN-S; Pearson, Madelyn MA, RN, NEA-BC

Nursing Management (Springhouse): November 2011 - Volume 42 - Issue 11 - p 12–15
doi: 10.1097/01.NUMA.0000406571.96461.53
Department: Evidence-Based Nursing

Edna Cadmus is a clinical professor and the specialty director of the DNP-Leadership Track at Rutgers University in Newark, N.J. At Englewood Hospital and Medical Center in Englewood, N.J., Patricia Brigley is the director of Occupational Health Services and Madelyn Pearson is the senior vice president/CNO.

The authors have disclosed that they have no significant relationship with or financial interest in any commercial companies that pertain to this article.

Creating a safe patient-handling environment for patients and staff requires a strategic plan, leadership support, and staff engagement. The benefits of creating such an environment far outweigh the financial outlay; yet very few institutions have committed to this change nationally. We present one facility's experience with developing, implementing, and evaluating a safe patient-handling program.

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Pathway to change

In 2005, an interdisciplinary facility-wide ergonomics committee was formed, comprised of staff nurses, patient-care associates, physical and occupational therapists, directors of occupational health nursing units, rehabilitation medicine, biomedical engineering, and the CNO. Over 50% of the committee was comprised of direct patient-care providers. This was important to gain staff buy-in early in the process. The aim of this team was to identify a strategic plan for safe patient handling. The occupational health director chaired the committee. It was important to the success of this program that a senior leader be involved from the beginning to ensure that she could translate the need for the program to the board of trustees and show the staff that leadership was serious about implementing a program of this nature. Union leadership was in support of this program and encouraged staff participation in the process.

The first step in creating a safe patient-handling program was to become educated on the scientific evidence that was behind the use of ergonomic equipment. A literature search was conducted to identify best practices and to support the need for ergonomic equipment.1–9 The team found that the Tampa Veterans Administration had received funding to implement and evaluate a comprehensive safe patient-handling program. This program's materials were available online and could be utilized to assist in the planning process. Additionally, various vendors were asked to present their equipment so that the team could learn and evaluate the pros and cons of each device.

A facility-wide assessment of current equipment, injury data, staff perception, and knowledge regarding assistive devices was completed. Based on the assessment, the team recognized early on that there was minimal equipment available, the current equipment was limited and didn't meet the expansive needs of our patient population, staff perceived the equipment as difficult to use, and injuries were most likely underestimated because staff members frequently didn't report musculoskeletal injuries until they became debilitating.

Based on the available products, two vendors were selected to present the equipment to staff across the institution. Staff members were asked to evaluate the equipment for their departments using an evaluation tool that aggregated results. Additionally, site visits were made to other institutions that had utilized the vendors to determine the effectiveness of their equipment. A request for proposal was developed based on key items that the committee felt were important to achieve success. These areas included the variety of equipment available for the types of patients served in the institution, educational programs offered by the vendor, and the sustainability of a program of this magnitude through a partnership approach. The committee recognized early on that this would require a change in culture and, therefore, consistent staff reinforcement.

Preimplementation measures were established to help determine success factors for this program, including an expected return on investment based on a 60% reduction in the number of patient-handling incidents to employees each year, employee satisfaction, and adherence to the program. Before the purchase of the equipment, a needs assessment was conducted on each unit by the vendor and the staff representatives. Recognizing that the cost of this program was approximately $600,000, the CNO prepared a presentation for the board of trustees. This program would be a major investment and had to be measured against the other competing needs of the institution. Recognizing the return on investment, the board approved the purchase.

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A reassessment of the type of equipment was conducted with the vendor and staff unit by unit. This was done to ensure that the equipment requirements didn't change and no items were missing. Equipment needs varied by unit. For example, in the ICU, selected rooms in the ED, and on the bariatric unit, ceiling lifts were installed. In the OR, orange tubes were identified to help move the patient from the stretcher to the OR table. Equipment was also identified for the morgue to assist in moving patients. On the medical-surgical units, there were different needs on each unit based on the population they served.

A safe patient-handling plan was developed by the occupational health director, with feedback provided from the ergonomics committee. The purpose of the plan was to ensure that all patient transfer/lifting was done safely and appropriately to protect the patient and the employee. The plan included the following components: (1) committee roles and responsibilities, (2) patient rights, (3) procedures for each type of equipment, (4) storage of equipment requirements, (5) infection control recommendations, (6) laundering procedures, (7) compliance expectations, (8) remediation procedures, (9) documentation requirements, and (10) reporting mechanisms of injuries/incidents.

Changing the culture required setting clear expectations of leaders and staff. It was expected that employees would be responsible for their health and safety, as well as that of their patients. A remediation procedure was incorporated into the plan if an employee sustained an injury resulting from a lift or moving task and didn't use the equipment during transfers. Educational materials were provided to patients and their families on admission to help orient them to the safe patient-handling program.

Before implementation, the occupational health director met with various departments that would be involved in this plan, including infection control, to determine the types of slings purchased (disposable or nondisposable) and the cleaning process. The director met with the laundry department regarding the cleaning and return process of the maxislides, patient-care directors for location and storage of the equipment and the slings, and the biomedical department for repair procedures.

Each unit identified transfer mobility coaches, as well as RN staff super users. Education was provided to them along with the responsibility of maintaining the inventory and ensuring competence of their staff. The educational program for the transfer mobility coaches and RN super users was a 4-hour session.

Rollout of the program began in September 2007 and was completed by December 2007. Staff members and managers were provided with around-the-clock training on the equipment for their unit to ensure competence. The 2-hour educational programs included didactic and hands-on experience with the equipment. Staff members were required to demonstrate competency in all techniques and practices presented. Training was provided during orientation and annually thereafter. Videos were placed on the intranet for staff members who needed a quick refresher. Additionally, each piece of equipment was tagged with a quick reference guide.

A schedule was developed for rounding with the occupational health director and the vendor representative to work with staff members on the use of the equipment on their units and identify any areas where there needed to be intervention. For example, on one unit there wasn't enough equipment purchased to meet their needs. Monitoring of equipment usage occurred through the meters on the equipment. If a piece of equipment had minimal usage, that unit was targeted for an intervention by the team.

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Hand-off requirements

The nurses utilized a patient mobility assessment tool, which was modified from the templates provided by the vendor. This tool helps determine what level of assistance the patient requires. All patients are assessed on admission and whenever a change in the patient's functional status occurs, but they're evaluated at least once per shift. The assessment of the level of equipment needed is entered on the nursing assessment flow sheet by the day-shift nurse. It's also entered on the rounding form so that anyone entering the room is aware of the patient's level of assistance needed.

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The program's effectiveness was measured by collecting workplace injury data, reduction in lost days, employee satisfaction, and use of equipment over time. A summary of the outcomes can be found in Table 1. Using 2007 as our baseline year, we saw an 80.5% reduction in lost days and a 57.1% reduction in workplace injuries over a 2-year period. As a result of the significant reductions in workplace injuries and lost days, the workers' compensation insurance module was reduced significantly and was identified by the carrier as the lowest in the state of New Jersey. The return on investment was set at 155% in a 3-year period. This was met and exceeded in 29.5 months.

Table 1

Table 1

RN satisfaction was measured using the National Database of Nursing Quality Indicators® (NDNQI) RN satisfaction tool and rounding feedback. Unit results were compared with the national database, including questions on lifting equipment availability and the percentage of "yes" responses. Our NDNQI results showed an increased percentage of RN staff members who felt they had enough help to move patients. In 2007, during the preimplementation phase, the percentage of "yes" results was 71%, compared with postimplementation results 1 year later of 77%. This showed an improvement of 6%. RN satisfaction will continue to be assessed in future surveys to measure the culture shift.

Usage of the equipment is measured using the meters on the equipment. The full-body lift equipment has seen the most increase in usage, followed by the standing and raising aid, and the standing and raising aid for those patients with less upper-body strength. The ceiling lifts, maxislides, and the steady device don't have measurement devices on them and were, therefore, difficult to evaluate except through anecdotal information. Because the measurements on the equipment are cumulative over time, it's difficult to determine the exact differences from year to year. For the future, the equipment will be zeroed each year to provide a more accurate assessment of usage changes.

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Lessons learned

Safe patient handling isn't about the purchasing of equipment; it requires a comprehensive plan to change the culture. Creating a culture change of this magnitude requires ongoing vigilance and patience. Staff and leaders need to be engaged in the process to achieve success. If leaders don't value the program, staff members won't value the program. If sufficient and appropriate equipment isn't in close proximity to the patient, staff members will revert to old behaviors without using available equipment. Measurements of success must be set from the beginning of this journey. We've learned that implementing a program of this size requires ongoing dialogue with the users, monitoring of indicators to determine any changes in the results, and the commitment of leaders that safe patient handling is an important part of providing care for patients and caregivers.

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© 2011 by Lippincott Williams & Wilkins, Inc.