Learning to handle patients safely: safe patient handling policies and procedures have been adopted throughout most health care facilities. But challenges still remain.

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Lifting patients is the most significant cause of injuries to nurses and health care workers. It costs the health sector and the Accident Compensation Corporation (ACC) many millions of dollars each year and causes a great dear of suffering. (1)

Handling or moving a person is more complex and unpredictable than handling or moving an object. Manual handling of patients involves moving or supporting them, including carrying, putting, pushing, lifting and lowering. The aim of safe patient handling training is to equip staff to avoid manual handling-related injuries, to themselves and others.

Safe patient handling has evolved over the last decade to improve working conditions, keeping both staff and patients safe. It involves encouraging patient independence or using the right equipment for the job and staff working together. Another driver for improving manual handling practices is to reduce the cost of injury to industry and the ACC.

Under the Health and Safety in Employment Act (1992), all industries and organisations must ensure all hazards in the workplace are identified and managed appropriately to ensure all staff work in a safe environment. Employees are also bound under this Act to ensure they work within the safety controls the organisation has implemented. These are legal requirements. The Code of Practice for Manual Handling was introduced in 2001 by the Department of Labour and ACC to help employers and employees meet the requirements of the Act. The code is a statement of preferred practice.

In 2003, ACC released the New Zealand Patient Handling Guidelines: the Liten Up Approach. (1) These are voluntary standards that propose that nurses and other health workers do not lift patients. The guidelines state that any toad over 16kgs represents a risk of harm to nurses and health workers. Though the costs to ACC have not reduced significantly since the release of the guidelines, the severity of the injuries has.

Safe manual handling is an evolving journey. Observing practice in various clinical settings, both within and outside district health boards (DHBs), it is clear we still have further improvements to make. As we fix one problem with the aid of modern technology or clever techniques, we sometimes create others. It's how we manage these handling problems to further reduce the risk to both ourselves and patients that make us safe practitioners.

I have been teaching manual handling theory and techniques at Capital and Coast DHB for the last four years. During this time I have seen a huge change in attitude among health care workers. The majority of staff I have taught have been registered nurses, though I have been involved in running courses across the multi-disciplinary care team.

Challenges as a co-ordinator

The three main challenges for me as a manual handling co-ordinator have been:

* finding appropriate training to qualify myself as a trainer;

* transferring techniques and concepts to the clinical work environment; and

* ongoing support from the organisation to support the safe patient handling programme.

Anyone involved in training staff in safe patient handling needs to know s/he is competent, and is either working towards or has the necessary skills/qualifications to teach the topic. No formal training for this rote exists in New Zealand. When I first started, it was understood that ACC, having developed the guidelines, were also working on a "train-the-trainer" programme. When the guidelines were revised in 2005, the tack of a recognised training programme and certified providers or experts in patient handling training was identified. ACC has not developed a training programme and has latterly moved toward a preventing and managing discomfort, pain and injury programme instead (see www.acc.co.nz). The patient handling guidelines, however, have been a great resource for manual handling trainers/coordinators and advisors, and are available via the ACC website.

My first major challenge was finding appropriate training to help build my own skills and understanding of safe patient and manual handling. An established patient handling programme consisted of just a presentation and some training by a colleague in the occupational health and safety team. But I felt I needed more depth and application, so set about identifying key staff experienced in manual handling practice.

Long before ACC published its patient handling guidelines, associate charge nurse manager at Capital and Coast DHB's intensive care unit (ICU), Cheryl Davidson, had identified concerns around staff manual handling practices and the occurrence of back strain among staff. This had prompted her to undertake a research project where she questioned ICU staff about the incidence of back discomfort and pain. The results were so alarming, she stopped the research and sought more proactive methods to address the issue.

In 1999, she introduced the use of the "sliding sheet", also known as "slippery sam". This was quite revolutionary in an organisation that had not yet embraced safe handling practices. I attended the ICU monthly core competency training, delivering some of the theory behind safe patient handling. Both assisting with, and observing manual handling demonstrations helped build my skills.

I approached the DHB physiotherapy team for some guidance around safe patient handling but found its focus was on therapeutic handling. This is concerned with patient rehabilitation and mobilisation. I assisted the team with training around the patient handling concepts.

I Learned to facilitate discussion and en courage the sharing of information within the training sessions. Participants had a range of experience and training, both within New Zealand and overseas. Sharing stories and reflecting on how situations had been managed, and exploring other ideas proved essential learning.

It was difficult to find any other recognised training programmes outside the DHB. I did attend a two-day workshop run by Smoothmovers Ltd. This was useful to consolidate the theory behind manual handling, which I was already teaching. The concepts taught followed the French physiotherapist Paul Dotte and his manutention programme. The manutention philosophy, based around physiotherapy techniques, was not something I felt comfortable teaching. However, it was good to know about manutention techniques and concepts.

Another reason for my reluctance to explore these techniques further was the limited timeframe allowed for manual handling training within the DHB. I felt these techniques required solid support in the clinical areas and, at this stage, I was not able to offer this.

Learning from manual handling colleagues

Networking with manual handling experts from other DHBs proved the most valuable source of information and guidance. Together, we set up quarterly regional meetings where we shared ideas and frustrations around implementing training programmes. The issues were similar--consistent training for the trainers and coordinators, getting clinical areas to release staff to attend training and access to equipment. We also had the opportunity to meet at national DHB health and safety conferences. This enabled me to observe progress and find out about new initiatives. It was apparent we all had different ways and techniques of teaching the same thing. Although numerous facilities had no-lifting policies, they varied across institutions, with no standardised approach. Having agreed competences across DHBs, so manual handling skills are interchangeable, would certainly be very helpful.

ACC finally recognised the need for support with training and funded a Safe Patient Handling/ Liten Up (SPH) pilot in 2006, using a core group of trainers at Waitemata DHB. This project involved an eight-day training course, co-ordinated by Waitemata DHB manual handling trainer Anne McMahon. The results were positive, with the project now a tool used to assist other DHBs or organisations with their manual handling programmes. An evaluation of this project can be found on the ACC website.

MidCentral DHB purchased the Australian O'Shea patient handling programme in 2004. Under the O'Shea No-Lift System, health care managers must sign a commitment to support the programme, including providing appropriate and adequate handling devices, supported with regular staff training. The programme is rolled out to the various clinical areas stage by stage, starting with a week of "train the trainers", involving four to six nominated trainers from each area. These trainers are then responsible for staff training in their areas.

Physiotherapist and nurse Louise O'Shea does not mince words around the true impact on health care workers' lives, should they injure their backs at work. "Would your workplace step in and take your children to sports events when you are unable to do so?" she asks. It's a sobering question.

I recently attended a two-day manual handling workshop by certified ergonomist and nurse Louise Whitby who has worked with WorkCover NSW, Australia's equivalent of ACC. Her comprehensive training guideline, with a strong focus on nurses, is available free from her website www.workedwell.com.au.

International, evidence-based research shows the most successful patient handling programmes use an integrated systems approach.

Characteristics include:

* having a dear patient policy statement;

* defining and communicating everyone's roles and responsibilities;

* being based on safe legal responsibilities and safe biomechanical principles;

* using data collection tools for ongoing evaluation and a risk assessment methodology;

* using handling equipment and safe techniques;

* describing and eliminating unsafe techniques;

* differentiating between patient care and therapeutic handling;

* putting theory into practice; and

* having support from all organisational levels. (1)

There are pros and cons to teaching manual handling techniques in a simulation suite. The positive side is that participants have the opportunity to explore and practise techniques. There is no rush or pressure, and there is the opportunity for discussion and sharing ideas. The downside is that when staff return to their work areas, a number of factors can influence how or whether they implement new skills:

* they can't remember exactly how the technique went;

* the culture of the ward is unsympathetic;

* strong negative personalities prove obstacles;

* due to work pressure, there is no time to apply the new techniques;

* participants try a new technique and, for whatever reason, it doesn't work, so they slip back to how they practised previously; and

* human nature--participants start off with good intentions but old habits die hard, even if they are not good for you.

Changing ingrained habits

It takes several attempts to change a habit. Manual handling is no exception. Changing the culture of the ward and dealing with negative personalities can be difficult. But if management has introduced and fully supports the manual handling programme, this should then become a performance management issue. The ACC patient handling guidelines have been around long enough now for staff to know the new methods and implement them.

Staff must also be responsible for informing management about the lack of equipment or resources. This can be done verbally or through reportable event forms. These forms enable good data on manual handling incidences to be collected. Actions or outcomes are then required.

Awareness of the importance of safe patient handling continues to grow across the health sector. All nurses must continue their efforts to keep themselves safe, to work with colleagues to maintain a safe work environment, and to encourage student nurses and new graduates to work within safe patient handling principles. The cost of not doing so is just too high.

Reference

(1) http://www.acc.co.nz/injury-prevention/safer-industries/ health/patient-handling-guidelines/WCM001675. Retrieved 15/04/09.

Angela Stevenson, RN, BN, co-ordinated the manual handling training programme at Capital and Coast District Health Board (CCDHB) for four years. She now works at Whitireia Community Polytechnic, co-ordinating student nurse placements, and assists with staff training at CCDHB.