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Safe patient handling and movement in a pediatric setting.

According to the American Nurses Association (ANA) (2006), up to 38% of all nurses experience back injuries. Musculoskeletal disorders (MSDs), more than any other work-related injury or illness, are responsible for lost work time, the need for protracted medical care, and permanent disability among health care workers. It is estimated that 12% of nurses leave the profession annually due to back injuries, and 52% complain of chronic back pain (ANA, 2009a).

In September 2003, ANA (2008) developed the American Nurses Association Ergonomics Handle with Care Campaign to mount a profession-wide effort to prevent back and other musculoskeletal injuries in health care facilities. The campaign addressed issues that included greater education and training, the use of equipment technology when moving and transferring patients, and a need for a paradigm shift in the schools of nursing curriculum.

ANA called for a collaboration of nursing organizations, the Occupational Safety and Health Administration (OSHA), and the National Institute for Occupational Safety and Health (NIOSH) to work together to develop a plan to promote these new strategies. The VISN 8 Patient Safety Center of Inquiry (PSCI), located at the James A. Haley Veterans' Hospital in Tampa, FL, in collaboration with these other organizations, performed a school of nursing study with nursing schools throughout the United States (Nelson et al., 2007). NIOSH, the American Nurses Association, and the Veterans Health Administration developed and evaluated an evidence-based training program on safe patient handling for educators at schools of nursing. Because the outcome of the study was positive, the Patient Safety Center developed a school of nursing curriculum under the direction of Dr. Audrey Nelson, which can be found on the center's Web site (U.S. Department of Veterans Affairs, 2009). The study found that when using the curriculum, nurse educator and student knowledge improved significantly, as did the intention to use mechanical lifting devices in the near future (Menzel, 2007; Nelson et al., 2007). The curriculum module won the 2008 National Occupational Research Agenda (NORA) Partnership Award and can be accessed on the Internet for use by all nursing schools to reduce the risk of musculoskeletal disorders among nurses (U.S. Department of Veterans Affairs, 2009).

The VISN Patient Safety Center also developed evidence-based practice algorithms for safe patient handling and movement. Prior to the use of the generic algorithms, a patient assessment is conducted; based on the assessment, an algorithm is used for a specific patient handling task. Because the patient's health needs change as the patient's condition changes, new assessments must be performed at the different states of a patient's health status. For example, patients' needs will differ pre-operatively and post-operatively. The patient assessment tool is used whenever there is a change in the patient status or health condition.

The Use of Lifting Technology in Pediatric Settings

The development of assistive patient handling equipment and devices has rendered the act of strict manual patient handling an unnecessary function of nursing care. Further, the use of mechanical lifts can substantially reduce patient skin tears and the frequency of patients being dropped.

The NIOSH equation for safe lifting demonstrates that when a patient or patient limb is greater than 35 pounds, lifting equipment should be used (Waters, 2007). Thus, any child weighing over 35 pounds should be lifted using technology. The health care workers could use a ceiling-mounted lift with a pediatric patient sling for lifting and moving the child. A variety of vendors supply pediatric slings as well as tools for measuring the slings.

Technology can also be used in pediatric home care. Children with special needs are often discharged home with their parents and have resources, such as a visiting nurse or a home health aide. The same safe lifting protocols and techniques should be used for safe lifting in the home setting to benefit the health care worker as well as family members who care for the child. For example, an 18-year-old boy requiring total care was discharged home after many years of hospitalization in a Pediatric Rehabilitation Unit. He is ventilator dependent and uses a wheelchair. Prior to his discharge home, his family had a ceiling-mounted lift installed in his home. The boy has a ceiling track from his bed directly into his bathroom. He is transferred to and from his bed to the tub and shower, and to and from his bed to his motorized wheelchair with one caregiver using the ceiling-mounted lift and patient sling.

Today, there is a great need for safe lifting equipment in the school setting. Many children with special needs attend public schools as well as special education school settings. Children may require lifting and moving several times during the day so that their medical needs can be met. For example, a 13-year-old girl with spina bifida needs to be straight catheterized twice during the school day. The nurse's office could be equipped with a floor-based lift to transfer the child to and from her wheelchair and table or stretcher for her nursing care. The floor-based lift can be moved to different classrooms, to the nurse's office, or to other areas of the building as needed.

Safe patient handling equipment should be used on all pediatric units. The same safe lifting principles used with the nursing care of patients on a medical/surgical unit would apply. The Patient Assessment Tool and the Generic Algorithms should also be used.

There are several "cross-overs" in SPHM. For example, a pediatric patient can also be a bariatric patient. A limb-lifter sling with ceiling-mounted lift can be used on the bariatric patient for insertion of a catheter, as well as for the female patient in labor and delivery who is ready to push.


Several states have either initiated or enacted safe patient handling and movement laws (see Table 1) (ANA, 2009b). As state laws pass, each health care facility is required to develop and implement institution-wide SPHM plans. Movement is also taking place at the federal level. In June 2009, "The Nurse and Health Care Worker Protection Act of 2009" was introduced in the U.S. Congress (H.R. 2381) to reduce musculoskeletal injuries resulting from manually lifting, repositioning, and moving patients (U.S. Congress, 2009). For the proposed legislation, see Table 2.

Health care institutions can begin the process of selecting members for the committee, evaluating and purchasing equipment, and developing the plan. This will allow institutions to become proactive in the protection of one of the institution's most valued employees--the nursing staff.

Patient Assessment and Algorithms

The VISN Patient Safety Center developed a patient assessment tool and algorithms to assist the nursing staff to safely lift and transfer patients. An overview of the patient assessment tool follows (Nelson, 2006, p. 61):

* Patient's level of assistance.

* Weight-bearing capacity.

* Upper extremity strength of the patient.

* Level of cooperation and comprehension.

* Patient height and weight.

* Patient conditions.

* Specific physician order.

Once the patient assessment is completed, the algorithms are used. There are six generic algorithms (VISN 8 Patient Safety Center, n.d.):

* Transfer to and from bed to chair, chair to toilet, chair to chair, or car to chair.

* Lateral transfer to and from bed to stretcher, trolley.

* Transfer to and from chair to stretcher, chair to chair, or chair to examination table.

* Reposition in bed: side to side, up in bed.

* Reposition in chair: wheelchair or dependency chair.

* Transfer a patient up from the floor.

Facility Culture of Safety

The health care facility must be committed to make a change at every level. As schools of nursing begin to teach evidence-based safe lifting protocols and legislation is passed, institutions will be challenged to develop and implement the SPHM policies and procedures in their facilities. A paradigm shift must occur within the institution at different levels for the SPHM plan to be successful.

The institution needs to create a culture of safety in the workplace regarding SPHM. The five rights of the program include 1) a patient assessment, 2) proper lifting equipment, 3) correct approach, 4) appropriate number of caregivers based on the algorithms, and 5) correctly measured sling size and type of sling. Three levels of support are required for an SPHM program to be effective: administrative, engineering, and behavioral (Nelson & Baptiste, 2004).

Administrative Controls

At this level, top administration must provide hospital personnel with the financial backing required for the program to be effective. The vice president of nursing must clearly be the nursing administrative representation needed, and the vice president of human resources must also play a key role in the recruitment and retention of the hospital's nurses. Administrative controls include financial support for capital budget equipment and the purchase of slings. Time needed for education support staff to provide instruction at all levels and to all shifts is essential.

The hospital can hire an ergonomist to evaluate each unit and shift for needs for engineering controls in the workplace. Leaders include the nurse manager and nursing supervisors, along with the Education Department and the clinical nurse educators, to ensure the program is successful. Specific policies and procedures must be defined and incorporated into the daily nursing care plans of the patients. The Education Department should work closely with vendors of safe lifting equipment to supply the means necessary to educate all units and all shifts.

Educating patients and families is key for this hospital-wide effort to be successful. Some hospitals have developed a patient/family teaching pamphlet explaining that the institution uses engineering controls to safely transfer patients. This information can include facts, such as a decrease in patient falls as well as decreased skin shearing injuries, when using the technologic solutions to transfer patients.

Engineering Controls

Front-line patient care employees should be allowed the opportunity to evaluate the different types of equipment, keeping their specific patient population in mind. Disposable and non-disposable slings are available. Each equipment vendor has measurement criteria that must be followed when choosing the proper sling for each patient. For example, there are pediatric-size slings for use in the pediatric setting and mesh slings that can be used in the therapy pool. Once the equipment is purchased and education has taken place, the proper chain of command must be followed with the maintenance of all equipment that will be used. Just as a department will be responsible for equipment maintenance, a department and specific personnel will be responsible for maintaining both disposable and non-disposable slings.

Behavioral Controls

Each specific clinical area will be charged with development and implementation of the specific policies for the units. For example, the medical-surgical unit's education plan will differ from the pediatric unit's plan. Education plays a key role in the implementation of change, from the old ways to the new evidence-based practice ways. Clear responsibilities for the use of equipment must be defined. There should be initial employee orientation upon hire followed by annual competencies for the safe use of the equipment.


Schools of nursing have incorporated SPHM into their fundamental nursing curricula and are teaching safe patient handling as opposed to body mechanics. The National Council Licensure Examination (NCLEX[TM]) is removing "body mechanics" from the examination and adding SPHM concepts. Laws are being passed requiring health care facilities to develop and implement SPHM policies and procedures. Health care facilities should be proactive in the development of these plans.

There is a nursing shortage, one that will become increasingly worse as nurses retire and people live longer. Hospitals that already have SPHM plans in place can use their plans in recruitment and retention strategies. During initial interviews, the interviewer can briefly discuss that a plan exists in the facility for SPHM. The new nurse can be informed that the hospital values its nurses and that the SPHM plan is one aspect of their caring attitude toward their nursing personnel. Retention strategies will be in place, and as a result, nurses will be required to use safe lifting equipment, safe lifting policies and procedures, the patient assessment, and the correct algorithm in daily patient care. The retention of nurses will follow suit as nurses continuously believe the facility holds their best interest at the forefront.

ANA supports the efforts of the VISN Patient Safety Center and NIOSH in the effort to prevent musculoskeletal injuries in the nursing workplace. The SPHM curriculum should be taught in every school of nursing in the United States as well as in other countries. SPHM concepts should be used in every institution, in every unit, and by all nursing personnel. Pediatric patients often weigh more than 35 pounds. It is therefore imperative that these policies, procedures, and programs be implemented for the benefit of the health care worker as well as for the patient.

Appendix A

A teenager with spinal cord injury who is ventilator dependent is able to be at home with friends due to safe lifting equipment for transfers.


A teenager is transferred to a wheelchair by a nurse using a floor-based lift and sling in a pediatric rehabilitation center.


A teenager transfers to a wheelchair using a floor-based lift and sling by the nurse and nursing assistant in a pediatric rehabilitation hospital.


A teenager transfers into the shower using a ceiling-mounted lift and stretcher by a home care nurse.


A patient at home in bed as his friend uses a ceiling-mounted lift and sling for transfers from bed to shower stretcher, bed to wheelchair.


Additional Readings (2009). Safe patient handling law updates. Retrieved July 24, 2009, from safe-patient-handling-224129.html

American Nurses Association. (2009). ANA supports safe patient handling measures in Congress. Retrieved July 24, 2009, from Nursing-News-Events/more-news/ ANA-Supports-Safe-Patient-Handling-Measures-in-Congress_30060.aspx

Centers for Disease Control and Prevention (CDC). (2009). Preventing back injuries in healthcare settings. Retrieved July 24, 2009, from niosh/blog/nsb092208_lifting.html

Menzel, N., Motacki, K., & Nelson, A., (2008). The illustrated guide to safe patient handling and movement. New York: Springer Publishing Company.

Senate and General Assembly of the State of New Jersey. (2008). P.L. Chapter 225. Retrieved July 16, 2009, from http:// 225_.PDF


American Nurses Association (ANA). (2006). Preventing back injuries: Safe patient handling and movement. Retrieved June 21, 2009, from http://nursing ationalandEnvironmental/occupational health/handlewithcare/PreventingBack Injuries.aspx

American Nurses Association (ANA). (2008). Ergonomics/handle with care. Retrieved July 16, 2009, from http://nursing pationalandEnvironmental/occupational health/handlewithcare.aspx

American Nurses Association (ANA). (2009a). ANA supports safe patient handling measures in Congress to improve safety of nurses and patients. Retrieved June 21, 2009, from Categories/OccupationalandEnvironmental/occupationalhealth/handlewithcare/ Safe-Patient-Handling-Measures--PR.aspx

American Nurses Association (ANA). (2009b). Safe patient handling and movement. Retrieved July 24, 2009, from State/StateLegislativeAgenda/SPHM. aspx

Menzel, N. (2007). Preventing musculoskeletal disorders in nurses: A safe patient handling curriculum module for nursing schools. Nurse Educator, 32(3), 130-135.

Nelson, A. (Ed.). (2006). Safe patient handling and movement: A practical guide for health care professionals. New York: Springer Publishing Company.

Nelson, A., & Baptiste, A.S. (2004). Evidence-based practices for safe patient handling and movement. Online Journal of Issues in Nursing, g(3). Retrieved July 16, 2009, from MenuCategories/ANAMarketplace/ANA Periodicals/OJIN/TableofContents/ Volume92004/No3Sept04/Evidence BasedPractices.aspx

Nelson, A., Waters, T., Menzel, N., Hughes, N., Hagan, P., PowelI-Cope, G., et al. (2007). Effectiveness of an evidence-based curriculum module in nursing schools targeting safe patient handling and movement. International Journal of Nursing Education Scholarship, 4(1), Article 26.

U.S. Congress. (2009). H.R. 2381. Retrieved June 21, 2009, from congress/bill.xpd?bill=h111-2381

U.S. Department of Veterans Affairs. (2009). Safe patient handling and movement. Retrieved July 24, 2009, from http:// center/safePtHandling/default.asp

VISN 8 Patient Safety Center. (n.d.). Safe patient handling and movement algorithms. Retrieved July 24, 2009, from http://www.washingtonsafepatient for_Safe_Patient_Handling_Movement. pdf

Waters, T. (2007). When is it safe to manually lift a patient? The revised NIOSH Lifting Equation provides support for recommended weight limits. American Journal of Nursing, 107(8), 53-58.

Kathleen Motacki, MSN, RN, BC, is a Clinical Assistant Professor, Saint Peter's College, Jersey City, NJ.

Lisa Marie Motacki, BA, is a Master's Student, Caldwell College, Caldwell, NJ.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education series.
Table 1.
State Legislation Regarding Safe
Patient Handling and Movement

States Where     States Where
SPHM Has Been    SPHM Has Been
Initiated        Enacted

Florida          Connecticut
Hawaii           California
Minnesota        Illinois
Maryland         Iowa
New Jersey       Massachusetts
Ohio             Michigan
Rhode Island     Missouri
Texas            Nevada
Washington       New York

Source: Adapted from ANA, 2009b.

Table 2.
Safe Patient Handling and Injury Prevention Standard

The safe patient handling and injury prevention standard shall
require the use of engineering controls to perform lifting,
transferring, and repositioning of patients and the elimination of
manual lifting of patients by direct-care registered nurses and all
other health care workers, through the use of mechanical devices to
the greatest degree feasible except where the use of safe patient
handling practices can be demonstrated to compromise patient care.
The standard shall apply to all health care employers and shall
require at least the following:

1. Each health care employer to develop and implement a safe
patient handling and injury prevention plan within 6 months of the
date of promulgation of the final standard, which plan shall
include hazard identification, risk assessments, and control
measures in relation to patient care duties and patient handling.

2. Each health care employer to purchase, use, maintain, and have
accessible an adequate number of safe lift mechanical devices not
later than 2 years after the date of issuance of a final regulation
establishing such standard.

3. Each health care employer to obtain input from direct-care
registered nurses, health care workers, and employee
representatives of direct-care registered nurses and health care
workers in developing and implementing the safe patient handling
and injury prevention plan, including the purchase of equipment.

4. Each health care employer to establish and maintain a data
system that tracks and analyzes trends in injuries relating to the
application of the safe patient handling and injury prevention
standard, and to make such data and analyses available to employees
and employee representatives.

5. Each health care employer to establish a system to document in
each instance when safe patient handling equipment was not utilized
due to legitimate concerns about patient care and to generate a
written report in each such instance. The report shall list the

a. The work task being performed.

b. The reason why safe patient handling equipment was not used.

c. The nature of the risk posed to the worker from manual lifting.

d. The steps taken by management to reduce the likelihood of manual
lifting and transferring when performing similar work tasks in the

Such reports shall be made available to OSHA compliance officers,
workers, and their representatives upon request within one business

6. Each health care employer to train nurses and other health care
workers on safe patient handling and injury prevention policies,
equipment, and devices at least on an annual basis. Such training
shall include providing information on hazard identification,
assessment, and control of musculoskeletal hazards in patient care
areas and shall be conducted by an individual with knowledge in the
subject matter, and delivered, at least in part, in an interactive
classroom-based and hands-on format.

7. Each health care employer to post a uniform notice in a form
specified by the secretary that:

a. Explains the safe patient handling and injury prevention

b. Includes information regarding safe patient handling and injury
prevention policies and training.

c. Explains procedures to report patient handling-related injuries.

8. Each health care employer to conduct an annual written
evaluation of the implementation of the safe patient handling and
injury prevention plan, including handling procedures, selection of
equipment and engineering controls, assessment of injuries, and new
safe patient handling and injury prevention technology and devices
that have been developed. The evaluation shall be conducted with
the involvement of nurses, other health care workers, and their
representatives, and shall be documented in writing. Health care
employers shall take corrective action as recommended in the
written evaluation.

Source: U.S. Congress, 2009.
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Title Annotation:Continuing Nursing Education Series
Author:Motacki, Kathleen; Motacki, Lisa Marie
Publication:Pediatric Nursing
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2009
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