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The effectiveness of a patient handling education program for nursing assistants as taught by physical therapy and nursing educators.

Musculoskeletal injuries are among the most prevalent injuries in the healthcare workplace and back pain is the second most common occupational injury responsible for days away from work. The importance of educating and training employees in safe lifting techniques and patient handling to avoid both days away from work and worker's compensation claims is cited in the literature. (2) A high correlation has been reported between direct patient care and injuries sustained in hospitals. (3)

Nursing assistants and aides (NAs) are the most commonly injured health care workers during patient care activities. (4) One aspect contributing to musculoskeletal injuries is the minimal training provided to nursing assistants on proper lifting techniques and patient handling. (2) Limited training or education can expose the nursing assistant to an increased risk of injury considering part of the job description includes transferring and lifting patients. Although registered nurses receive patient handling training as part of entry level education, (5) tasks such assisting a patient in personal hygiene and everyday mobility needs are frequently delegated to nursing assistants. Nursing assistants generally receive 50 hours of theory and 100 hours of supervised clinical training during training and may not feel prepared when entering the work force; (3) many nursing assistants are trained on the job and many receive no formal external schooling or certification. (6) Other factors contributing to musculoskeletal injuries are improper equipment, staffing limitations and long work hours. (2) These conditions may cause fatigue and create an unsafe environment for the nursing assistant and the patient.

Despite receiving limited training on patient handling, newly trained healthcare workers are exposed often to poor patient-handling techniques and are encouraged to participate in incorrect practice. (7) Work factors significantly associated with reports of patient-handling injury include "low decision latitude, high job insecurity, low social support, high job demands (physical and psychological), perceived hazardous working conditions and high job dissatisfaction." (8) Literature review failed to identify any accepted or standardized training beyond the definition of a Certified Nursing Assistant (CNA) established in 1987 by the United States Government, which requires 75 hours of training and 16 hours of "supervised practical training" to work in a nursing home environment. The requirement of any type of formal training or certification to be employed as a nursing assistant is highly variable from state to state, and in most states previous certification or training is not required to be able to secure employment at a hospital. (6) According to the Bureau of Labor Statistics, "Some employers provide classroom instruction for newly hired aides, while others rely exclusively on informal on-the-job instruction by a licensed nurse or an experienced aide," indicating the high level of variability in the training of these individuals. As of 2010, nine states have enacted some form of Safe Patient Handling Legislation, which includes guidelines for appropriate equipment and training, but each state has varying levels of detail and requirements. (9)

According to the Bureau of Labor Statistics for 2006, nursing assistants, orderlies, and attendants had 49,480 days away from work at a rate of 526 per 10,000 workers. (1) Manual lifting and transfer activities rank among the job tasks most frequently associated with back injuries in hospital personnel.l This is a concern because of the rising costs of healthcare and the increased number of back injuries, which has been shown to be one of the most prevalent conditions seen by physical therapists. (2,10-12) In addition to the risk of injury to the healthcare worker, improper patient handling can expose the patient to an increased risk of injuries from falls and unsafe transfers. Safe patient handling is defined as a process that provides an alternative to manual patient lifting, transferring and repositioning. (13)

Back injury prevention programs may decrease the rate of back injuries to health care personnel and biomechanical evaluation of patient handling as well as education and research are suggested to be keys to improving the quality of work and decreasing the risks of injury to nursing staff. (14,15) Having knowledge and education in lifting techniques may be a contributing factor in reducing the load on the spine and reducing the risk of injury. (16)

The purpose of this article is to describe the implementation and development of an interdisciplinary educational session developed by physical therapists and nurses to educate nursing assistants on patient handling and injury prevention skills. A retrospective analysis of the participants' tests and surveys was performed to determine whether completion of the patient handling educational program.was associated with a change in knowledge and confidence in patient-handling skills. Nelson and Baptiste note that evidence-based patient handling "solutions must be specifically applied to address each high-risk task identified. For this reason, there is no standard approach to improving nurse safety that can be generalized to diverse clinical practice settings." (17) No knowledge tests or confidence surveys could be located in the literature that adequately applied to the unique training session and practice environment described in this article, prompting the investigators to develop the outcome tools internally.

METHODS

In 2008, the physical therapy and nursing departments at Beaumont Hospital in Troy, Michigan developed a quality improvement program entitled "Start from the Heart" utilizing evidence-based teaching tools and patient-handling training techniques. This program was a multidisciplinary, hands-on educational course for nursing assistants developed with the intent to increase the knowledge, confidence, and comfort level regarding patient handling procedures in the acute care setting. Beaumont Hospital, Troy is a 394-bed acute care suburban-Detroit teaching hospital that ranks among the nation's highest-volume community hospitals for admissions and surgeries.

Gap analysis for Program Development

The eight-hour mandatory educational program emphasized body mechanics, safe patient handling and prevention of injuries. It was developed as a result of a gap analysis of commonly cited requests by nursing personnel. This gap analysis consisted of interviews of nursing personnel, review of fall incidents and injury statistics, current nursing assistant training and orientation, turnover rates and staff satisfaction. The results of the gap analysis revealed that: 1. NAs understood the basic need for patient mobility but did not feel that they understood how to mitigate the risks associated with patient mobility such as falls and proper body mechanics, 2. NAs did not have a deep enough medical understanding to be able to determine the appropriate amount of mobility without causing increased risk to the patient, 3. NAs did not have a strong understanding of the assistive devices and medical equipment related to mobility, 4. NAs tended to be younger with limited patient care experience and a high rate of turnover was noted. In addition, the NAs cited concerns regarding mobilizing obese patients and those with multiple medical problems. Some nursing assistants also noted that they did not have sufficient time in their days to assist patients with mobility. Nurse manager interviews and observational workflow analysis demonstrated, however, that this was likely not a prevalent issue. Nonetheless, organizational recommendations would be included into the program to assist with fitting patient mobility into the workday. As a result of this gap analysis, the educational program content was developed collaboratively between nursing, physical therapy, and the department of education to address all of the key concepts identified in the gap analysis. Of special note in this development was the finding that nursing and therapy terminology and descriptions of mobility were different and needed to be reconciled. For example, therapy uses the term "gait" to describe walking, some nursing staff were not aware of this term; similarly, nursing frequently uses the term "dangling" when sitting a patient at the edge of a bed, which is not commonly utilized in therapy literature or education.

Subjects

Subjects included nursing assistants employed at Beaumont Hospital, Troy between the dates of January 1, 2008 to December 31, 2008. Although participation in the quality improvement program was mandatory for the NAs, the participants were provided with a waiver of consent to utilize the data for retrospective analysis. At the beginning of the program, each nursing assistant was assigned a number to be used on the tests and surveys to protect participants' identities. This study was approved by the Beaumont Hospitals' (Royal Oak, MI) Human Investigation Committee and an Exemption from Review from Oakland University's (Rochester, MI) Institutional Review Board.

Research Protocol

Prior to the educational program, each nursing assistant completed a five-question demographic survey as well as a ten-question survey regarding confidence level and comfort in handling patient mobility and transfers (Appendix 1). During design of the educational program, no survey to assess caregiver confidence with patient handling skills could be located. Therefore, a survey was developed internally; these questions were not validated beforehand due to the retrospective nature of this study. In the survey, subjects rated comfort level or confidence with specific aspects of patient handling on a 1-5 scale (1-Strongly Disagree, 5-Strongly Agree).

Didactic knowledge was assessed using a ten-item multiple-choice content test with one correct answer per item (Appendix 2). Although the questions for the content tests had been used previously in the entry-level physical therapy educational curriculum at Oakland University in Rochester, Michigan for many years, these were not tested for validity in this particular educational program prior to data analysis. Both the content test and confidence survey were believed to have face validity by subjective review of institutional experts at Oakland University and Beaumont Hospital, Troy.

Educational Program

In 2008, a total of 23 classes were held with an average attendance of 12 participants per class. Nineteen eight-hour classes were held during the day and four night classes were divided into 2 four-hour parts and held from 7-11 pm (Table 1). This program was taught by two of four health care professionals who were considered to be institutional clinical experts on this topic. The instructors included the authors CMW and MMB as well as a physical therapist with over 25 years of experience and a physical therapist assistant with over 8 years of experience. One physical therapist professional and one nurse educator alternated speaking at each class. Generally, the therapy professional would speak to the technical aspects of mobility (body mechanics, technique, hand placement, adjusting assistive devices) and the nurse educator would speak about the medical issues related to mobility and the practical aspects (job expectations, nursing policies, teamwork, time management, accountability and documentation). The educational seminar was supported by a financial grant from the Beaumont Foundation to offset instructor salary costs and to supply each participant with an embroidered transfer belt.

Introductory topics included safety precautions, the effects of bed rest, red flags, fall prevention, proper use of a gait or transfer belt, as well as ergonomics and body mechanics during patient handling, transfers and lifting. Education was also provided on the unique and complimentary roles that nursing, physical therapy, and occupational therapy disciplines play in patient mobility during a hospital stay and the importance of interdisciplinary communication and collaboration. Special focus was placed on identifying when utilizing manual lifting techniques would be inappropriate, when assistance of additional team members was appropriate, and when mechanical lifts or assistive technology should be applied. At this point, the students received instruction in the hospital's Golvo Mechanical Lift System, including practicing lifting a person up from a sitting and lying position.

Bed mobility, transfers, and ambulation techniques were demonstrated and practiced in a lab setting with modifications for various conditions commonly seen in the hospital. This portion also included instructing and ambulating patients with canes, crutches and walkers with case studies that required different gait patterns and weight bearing statuses, including determining whether an assistive device was an appropriate fit for that patient. The subjects also received instruction in appropriate performance of joint range of motion to prevent loss of mobility and prevention of contractures, including demonstration and practice. The next portion of the class involved the instructors discussing and demonstrating various types of braces and prostheses that a nursing assistant would encounter, including ankle-foot orthoses (AFOs), thoracolumbosacral orthoses (TLSOs), lumbosacral orthoses (LSOs), cervical collars, immobilizers and halo vests. The last portion of the educational program included unique patient care situations based on patient diagnoses or surgical procedures and their precautions, including knee and hip arthroplasty, cervical and lumbar spine surgery, fractures, and cerebrovascular accidents.

After completion of the educational program, the participants were administered the same confidence survey and knowledge test to reassess comfort level and basic knowledge performing patient handling tasks.

Blinded data collection was completed in conjunction with the educational seminar by the instructors who taught that particular class session. To avoid data interpretation error, investigators decided upon how to interpret potentially ambiguous answers. The SAS System for Windows, version 9.2 was used to interpret and analyze inferential statistics.

Data analysis

An overall score was created to serve as a summary score for the survey. Although the total score has no real numeric interpretation, we feel that a higher score indicates more confidence so we have included the total survey score along with the change in the total survey score.

The changes for each of the continuous scores from pre to post were examined using paired t-tests for patients overall and within groups. When comparing male to female or injured to non-injured the continuous scores pre, post and the changes from pre to post were examined using Wilcoxon rank tests. The effect of age and experience on confidence levels was explored using the Spearman correlation for the changes in both total scores.

RESULTS

Demographic data

Two hundred and seventy-five NAs participated in the educational program. Twenty-one elected not to have their data analyzed, resulting in data for 254 subjects (220 female, 21 male, and 13 missing responses). The ages reported ranged from 18 to 61 years. The most frequently reported age range was 18-25 with 101 responses. (Table 2) The least reported age ranges were 56-60 and 61+ with four responses each. The participants worked in various units. One hundred and sixty-four participants reported no injuries and 77 reported having a history of one or more injuries. Thirteen responses regarding injury were missing.

The level of experience ranged from less than one year to over 15 years. The most frequently reported level of experience was one to five years with 106 participants responding. The least reported level of experience was 10-15 years with 13 responses.

Table 3 details the results of the confidence survey. The overall confidence score increased from 39 [+ or -] 6% to 46 [+ or -] 4% (p <0.0001), indicating a statistically significant change in confidence levels immediately following the implementation of the educational program. The difference in the confidence survey before and after the educational session was calculated for each of the ten questions separately. Figure l depicts the percentage breakdown of responses for the pre-test confidence survey. Figure 2 depicts the percentage breakdown of the responses after the educational program, illustrating that between 92 and 99 percent of responses for each question were "Strongly Agree" or "Agree."

Confidence increased in both men and women, but no difference was found between them. No statistically significant difference could be found in confidence levels related to age or experience of the nursing assistant. No statistically significant difference was found in participant confidence levels between those who have reported injury versus no injury, but within each group the scores increased significantly.

For the multiple choice content test, a positive value indicated an increase in score and a negative value indicated a decrease in score. Scores increased significantly from 4.0 [+ or -] 2.2 to 7.0 + 2.2 (p <0.0001) immediately following the educational program (Figure 3). Table 4 depicts the statistical examination of the content tests. Both men and women improved, but no difference was found between male and female subjects. The only statistically significant correlation was for age and the total post-knowledge score. As age increased, the knowledge posttest score decreased; however, the correlation coefficient was very small (-0.15) and the p-value (0.02) is not very strong. No statistically significant difference was found between those who reported injury and those who reported no injury. Table 5 depicts the within group and between group data analysis results.

DISCUSSION

The purpose of this retrospective analysis was to determine whether staff confidence levels and comfort regarding mobility procedures changed and to determine whether knowledge of the content taught in the class improved after the educational program was completed. Overall, the test results provide statistically significant data to support the research purpose that nursing assistants' knowledge of patient transferring techniques improved and that confidence and comfort in the acute care setting increased immediately after the educational program.

Potential implications of this study

The results of this study suggest several implications that may positively impact patients/clients, nurses and nursing assistants, and physical therapy professionals. After the implementation of the safe patient-handling program, a significant increase in nursing assistants' confidence in performing this aspect of their job duties and an increase in understanding of the concepts used when performing their job occurred. An onsite safe patient handling educational program can provide a hospital with the opportunity to train a nursing assistant on policies and procedures for patient handling in a consistent manner.

The clinical implications of this research may affect clinical practice of both physical therapists and nurses. First, implementing a program such as the one described in this study could potentially increase the overall quality of care received by the patient and frequency and consistency of patient mobility during the hospital stay. This has the potential to increase both the patients' safety and the safety of the nursing assistant. Hospitals may see a decrease in costs from patient complaints and litigation, length of stay due to iatrogenic falls and injuries, and worker's compensation costs. Second, job satisfaction may be improved leading to a possible decrease in nursing assistant turnover rates. Having a high level of job satisfaction could translate into a less stressful and more productive experience for the patient and the nursing assistant. Third, increasing nursing assistants' confidence in their skills, knowledge and performance may positively affect the frequency, compliance and proficiency in providing daily activity and mobility to the hospitalized patient, thereby assisting in avoiding medical sequelae of bedrest and immobilization and subsequent increased demands on acute care physical therapists.

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The findings of this study have implications that relate to the physical therapy profession. It is a profession centered on teamwork and part of a physical therapists' job is to educate patients and coworkers on body mechanics and safe movement. (18) Physical therapists are highly qualified to implement and lead such educational programs at hospital systems where they are employed and leadership in these programs can have intangible benefits beyond patient care productivity. By providing education on body mechanics and proper patient handling, physical therapists are setting a positive example and maintaining a higher standard of care. One of the philosophies used in physical therapy is that the patient plays an active role in rehabilitation. When using safe patient-handling techniques, patients take a more active role during transfers and mobility tasks. This encourages patients to be accountable for their own care and well-being as well as preparing them to be more independent in their home environments.

The risk-benefit ratio of patient handling and assistance with mobility is being re-evaluated with the recent emergence of the no-lift environment, which attempts to eliminate or dramatically reduce the physical assistance provided to patients by healthcare workers. (13,19) This has prompted hospital administrators to consider reducing or replacing current patient-handling training with technology-related dependent lifting concepts. The negative effects to the human body with regard to hospitalization and immobilization are well known in the literature, especially in the elderly. (20-23) Because of the value of patient-assisted mobility to prevent the sequelae of patient immobilization, the impact of replacing a patient's assisted mobility by devices that dependently lift the patient from one location to another is a concern. Although no-lift equipment and policies may prevent caregiver injuries, (13,24) further study is indicated to assess for unanticipated consequences such as patient deconditioning, slower progression in physical therapy, patient and family satisfaction, and longer durations of institutionalization before being able to return home independently. Further study in this area would be valuable to assist institutions in determining which areas of a no-lift approach would be most beneficial to their facilities. In addition, implementation of an integrated no-lift environment has been cited as being cost-prohibitive to many institutions. (13)

Study limitations

Due to the retrospective nature of the study, randomization and a control group could not be used. Also, because the outcome measures used were developed internally and are unique, validity could not be determined beforehand. Although a slide presentation provided a consistent standard for the delivery of the information, four different clinicians with individual teaching styles instructed the program The individuality of teaching style may potentially have led to variation in outcomes between different classes of nursing assistants. A standard protocol for completing the test was not given to the nursing assistants, potentially contributing to missing answers and the inability to use some data. During data analyses, aberrance appeared which could indicate possible group collaboration during exams. Lastly, hospital politics played a role in limiting this study because the nursing assistants were required to participate in the educational program as part of their job performance expectations with little other positive incentives to perform well.

Suggestions for future research

Further research is needed regarding the effect of an educational session and its translation to direct patient care procedures and whether long-term retention of knowledge or confidence occurred after this intervention. Suggestions for improving an educational program such as the one described would be to add an initial manual competency examination to assist in determining whether motor skills were carried over to clinical care and determine whether the nursing assistant was proficient from a psychomotor perspective. Also, standardized testing instructions would be valuable to maintain the consistency of the assessments. Annual competency checks would be beneficial for retention of skills and knowledge gained from the program. These concepts were suggested to hospital administration but these were not deemed to be feasible as the resources and time available to this learning endeavor were limited due to economic and patient care demands on participants and instructors. Importantly, we must consider that in the era of healthcare reform, hospital systems may continue to have limited resources while still striving to enhance patient care and safety programs. In addition, prospectively analyzing injury rates, worker's compensation claims, and patient fall rates would help us determine the effect of a similar educational program on these items.

Future outcomes to be studied include perceived quality of care by patients, fiscal analysis of worker injury compensation, and injury and fall rates after a training program similar to the one described. Comparing statistics of DVT occurrence, pressure ulcer incidence, nursing assistant injury rates, workers compensations costs, and patient fall incidence between hospitals that implement a safe patient handling program and hospitals that use a no-lift policy would help determine whether no-lift policies produce negative patient outcomes. Finally, if a prospective study is conducted, valid and reliable data collection measures should be used.

CONCLUSION

The purpose of this retrospective analysis was to determine whether staff confidence and comfort regarding mobility procedures increased and to determine whether knowledge of patient handling techniques improved after an educational program administered jointly by physical therapy and nursing. The results of this study demonstrated that scores increased significantly with regard to nursing assistants' confidence and knowledge after a standardized hospital-based patient handling program. This study suggests that further exploration of an educational program on general mobility basics and the implementation of the training in this population is warranted.

Appendix 1-Confidence Survey

Patient Safety Program

Survey Posttest Number:

All responses are anonymous. Please circle the one answer that fits best.

1. I feel that I have the skills to assist an average patient with their daily mobility needs.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

2. I feel that I have the skills to assist an obese patient with their daily mobility needs.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

3. Beaumont provides me the tools to assist my patients with their mobility needs.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

4. I feel confident to plan and coordinate a patient transfer that requires 2-3 people.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

5. I have a good understanding of what the difference is between Physical and Occupational Therapy.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

6. I am confident in my ability to make sure a walker or crutches fit my patient.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

7. I have a good understanding of how to minimize injury during lifting and transfers.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

8. I am confident in instructing and correcting my patient's technique in using a walker.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

9. I understand the benefits of preventative positioning and range of motion.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

10. I am confident in my understanding of the reasons that a patient should not be ambulated or get out of bed.

A. Strongly Agree

B. Agree

C. Neutral

D. Disagree

E. Strongly Disagree

Appendix 2-Knowledge Test

Patient Safety Program

Content Pretest

Number:__

Date:__

Unit:__

1. Your patient Ms. Peterson requires a walker. The purpose of a walker is to:

A. Relieve WB through the UE; provide lateral stability

B. Relieve WB through the UE; provide lateral and anterior stability

C. Relieve WB through the UE; provide lateral, anterior and posterior stability

D. Relieve WB through the UE; provide anterior and posterior stability

2. You are documenting the physical assistance needed to t/f your patient w/c -> mat. Your patient performed 75% of the work. This patient needed__assistance.

A. Maximal

B. Moderate

C. Minimal

D. Standby

3. PROM is indicated for a patient when:

A. Passive stretching is required

B. You want to improve strength

C. When the patient cannot actively move a body segment

D. All of the above

4. Which of the following is NOT a common location for pressure sores:

A. The heels of the feet

B. Behind the knees

C. The tailbone

D. The back

5. The physician has indicated that your patient Ms. Klein can put as much weight on her legs as she can tolerate. She is__on the bilateral lower extremities.

A. NWB

B. 20 % PWB

C. TTWB

D. WBAT

6. Mr. Box is a patient who has been bedridden for several days. The first time you stand him up to walk he complains of nausea and light headedness. This most likely indicates:

A. Increased blood pressure

B. Orthostatic hypotension

C. DVT in his legs

D. He does not feel like getting up

7. You are helping Mr. Peters walk to the bathroom with bilateral axillary crutches. Mr. Peters is PWB 50% on the right LE. Which sequence is most appropriate when walking with crutches?

A. Crutches, right leg, left leg

B. Crutches, left leg, right leg

C. Left leg, crutches, right leg

D. Right leg, crutches, left leg

8. The type of ROM in which assistance is provided by a caregiver because muscles need assistance to complete the motion is:

A. ROM

B. AROM

C. APROM

D. AAROM

9. Movement within the unrestricted range of motion for a segment that is produced by the patient's own muscles is:

A. PROM

B. AROM

C. APROM

D. AAROM

10. Which of the following is a common precaution for preventing dislocation for a THA?

A. No sitting longer than 30 minutes

B. No weight bearing through surgical leg for 2 months

C. No hip flexion past 90[degrees]

D. Wear immobilizer when in bed

Acknowledgments: The authors would like to thank Sherry Wiggins-Baker PT, Thomas Voytas PTA, for data collection and participating in the educational program, Judith Boura MS for data analysis and statistical support, Victoria Lucia, PhD for outcomes guidance, and Reyna Colombo PT, MA, Debra Guido-Allen, RN, MBA, BSN, Janet Wiechec Seidell PT, MPT and Michael Khoury, MD for program support and logistics.

The Start from the Heart educational seminar received a financial grant by the Beaumont Foundation, Royal Oak, MI for material costs, to offset instructor salary costs, and to supply each participant with an embroidered transfer belt.

Golvo Mechanical Lift System: Liko North America, 122 Grove Street, Franklin, MA 02038 USA.

The SAS System for Windows, version 9.2: SAS Institute Inc., 100 SAS Campus Drive, Cary, NC 275132414 USA.

REFERENCES

(1.) Bureau of Labor Statistics (BLS), U.S. Department of Labor. (2006). Nonfatal occupational injuries and illnesses requiring days away from work. Retrieved February 23, 2008, from http:// stats.bls.gov/iif/oshwc/osh/case/ osnr0029.pdf

(2.) Waters T, Collins J, Galinsky, T, Caruso C. NIOSH research efforts to prevent musculoskeletal disorders in the healthcare industry. Orthop Nurs. 2006; 25(8): 380-389.

(3.) Kneafsey R, Haigh C. Learning safe patient handling skills: Student nurse experiences of university and practice based education. Nurs Educ Today. 2007;27:832-839.

(4.) Nelson ML, Olson DK. Health care worker incidents reported in a rural health care facility. Am Assoc of Occup Health Nurs J. 1996;44:115-122.

(5.) Powell-Cope G, Hughes NL, Sedlak C, Nelson A. Faculty perceptions of implementing an evidence-based safe patient handling nursing curriculum module. Online J Issues Nurs. 2008; 13, www.nursingworld. org/ojin. Retrieved February 15, 2011.

(6.) Bureau of Labor Statistics, U.S. Department of Labor. Nursing and Psychiatric Aides. Occupational Outlook Handbook. 2010-11 Edition. www.bls.gov/ oco/ocos327.htm. Accessed February 14, 2011.

(7.) Cornish J, Jones A. Factors affecting compliance with moving and handling policy: Student nurses' views and experiences. Nurs Educ Practice. 2010; 10: 96-100.

(8.) Schoenfisch AL, Lipscomb HJ. Job characteristics and work organization factors associated with patient-handling injury among nursing personnel. Work 2009; 33: 117-128.

(9.) American Nurses Association. Enacted Safe Patient Handling Legislation. American Nurses Association website. http:// www.nursingworld.org/ MainMenuCategories/ ANAPoliticalPower/State/ StateLegislativeAgenda/SPHM/ Enacted-Legistation.aspx. Accessed February 15, 2011.

(10.) Akpala CO, Curran AP, Simpson J. Physiotherapy in general practice: patterns of utilisation. Public Health. 1988;102:263-268.

(11.) Battie MC, Cherkin DC, Dunn R, et al. Managing low back pain: attitudes and treatment preferences of physical therapists. Phys Ther.1994;74:219-226.

(12.) Foster NE, Thompson KA, Baxter GD, Allen JM. Management of nonspecific low back pain by physiotherapists in Britain and Ireland: a descriptive questionnaire of current clinical practice. Spine. 1999;24: 1332-1342.

(13.) Nelson A. Safe Patient Handling and Movement. New York, NY. Springer Publishing Company, Inc; 2005.

(14.) Nelson A, Lloyd JD, Menzel N, Gross C. Preventing nursing back injuries: Redesigning patient handling tasks. Am Assoc of Occup Health Nurs J. 2003;51:126-134.

(15.) Guthrie PF, Westphal L, Dahlman B, Berg M, Behnam K, Ferrell D. A patient lifting intervention for preventing the work-related injuries of nurses. Work. 2004;22:79-88.

(16.) Lett, Kelly K, McGill, Stuart M. Pushing and pulling: personal mechanics influence spine loads. Ergonomics. 2006; 49: 895-908.

(17.) Nelson A, Baptiste AS. Evidence-based practices for safe patient handling and movement. Online J Issues Nurs. 2004; 9: www. nursingworld.org/ojin. Retrieved February 15, 2011.

(18.) American Physical Therapy Association. Guide to physical therapist practice. 2nd ed. Phys Ther. 2001;81:s31-s42.

(19.) Engkvist IL. Nurses' expectations, experiences and attitudes towards the intervention of a "no lifting" policy. J Occup Health. 2007. 49, 294-304.

(20.) Creditor MC. Hazards of Hospitalization of the Elderly. Annals of Internal Medicine. 1993; 118: 219-223.

(21.) Hoenig HM, Rubenstein LZ. Hospital-associated deconditioning and dysfunction (Editorial). J Am Geriatr Soc. 1991; 39:220-2.

(22.) Harper CM, Lyles YM. Physiology and complications of bed rest. J Am Geriatr Soc. 1988; 36:1047-54.

(23.) Mobily PR, Skemp Kelley LS. Iatrogenesis in the elderly. Factors of immobility. J Gerontol Nurs. 1991; 17:5-11.

(24.) Flanders SA, Harrington L, Fowler R. Falls and Patient Mobility in Critical Care: Keeping Patients and Staff Safe. AACN Adv Crit Care. 2009; 20: 267-276.

Christopher M. Wilson PT, DPT, GCS is Coordinator of Clinical Education in the Physical and Occupational Therapy Department at Beaumont Hospitals, Troy, Michigan and is Clinical Assistant Professor in the Department of Physical Therapy, School of Health Sciences, Oakland University in Rochester, MI.

Margaret M Beaumont, RN, MSN, was a Clinical Nurse Specialist in the Nursing Department at Beaumont Hospitals, Troy, Michigan at the time the study was completed.

Katie M Alberstadt PT, DPT was a doctoral candidate in the entry-level DPT program at Oakland University, Rochester, Michigan at the time the study was completed.

Jennifer M Drake PT, DPT was a doctoral candidate in the entry-level DPT program at Oakland University, Rochester, Michigan at the time the study was completed.

Karen G Ednalino PT, DPT was a doctoral candidate in the entry-level DPT program at Oakland University, Rochester, Michigan at the time the study was completed.

Meagon M Thornsberry PT, DPT was a doctoral candidate in the entry-level DPT program at Oakland University, Rochester, Michigan at the time the study was completed.

Sarah G Zahringer PT, DPT was a doctoral candidate in the entry-level DPT program at Oakland University, Rochester, Michigan at the time the study was completed.

Correspondence should be addressed to Christopher Wilson, 44201 Dequindre, Suite 203, Rehabilitation Services, William Beaumont Hospital, Troy MI 48085; Fax at 248-964-8099; or by email at christopher. wilson@beaumonthospitals.com.
Table 1. Sample Agenda for Educational Session

Time Sample Agenda

7:00-7:30 AM Sign in, administration of
 survey, and pre-test

7:30-7:45 AM Introduction

7:45-9:00 AM Affects of bed rest, red flags,
 contraindications

9:00-9:15 AM Break

9:15-10:15 AM Lecture and demo on bed mobility
 and transfers

10:30-11:00 AM Practice session-2 groups; bed
 mobility and transfer

11:10-11:40 AM Switch groups

11:45-12:00 AM Mechanical lift demonstration

12:00--1:00 PM Lunch and practice with
 mechanical lift

1:00-2:00 PM Lecture and demo of assistive
 Devices

(20 minutes per group) Group 1: canes
 Group 2: crutches
 Group 3 walkers

2:00-3:15 PM Emergency situations, range of
 motion, braces and prostheses,
 common conditions

3:15--3:30 PM Questions, discussion, post-test
 and post-survey, receive letter
 of attendance and further
 instructions

3:30 PM End class

Table 2. Participants' Demographic Information

Participants' Frequency Percent
 Age (in years) (n = 254)

18-25 101 39.76 %
26-30 21 8.26 %
31-35 30 11.81 %
36-40 26 10.23 %
41-45 23 9.05 %
46-50 18 7.08 %
51-55 15 5.90 %
56-60 4 1.57 %
61 + 4 1.57 %
Not indicated 12 4.72%

Experience Frequency Percent
 (in years) (n=254)

< 1 69 27.16 %
1-5 106 41.73 %
5-10 30 11.81 %
10-15 13 5.12 %
15 + 22 8.66 %
Not indicated 14 5.51 %

Participants' Frequency Percent
 Primary (n=254)
 Nursing Unit
 Location

Orthopedics 33 12.99 %
Emergency 1 0.39 %
Surgery/Pre Op 4 1.57%
General Medical 57 22.44 %
 Surgical
Oncology 17 6.69 %
Critical/Intensive 32 12.59 %
 Care
Progressive Care 40 15.74 %
Obstetrics/Labor 30 11.81 %
 and Delivery
Other 10 3.93 %
Not Indicated 20 7.87 %

Table 3. Confidence Survey Results

Confidence Survey Results Strongly Agree Neutral
 Agree

Question 1 Pre 107 123 14
"Comfort moving an average Post 149 89 4
 pt"
Question 2 Pre 40 105 72
"Comfort moving an obese pt" Post 101 124 15
Question 3 Pre 54 121 52
"I have tools to help my Post 127 104 11
 pts move"
Question 4 Pre 74 124 39
"Confident to do a 2-3 person Post 128 108 7
 TF"
Question 5 Pre 82 111 38
"Know difference between Post 146 89 4
 PT/OT"
Question 6 Pre 49 74 69
"Confidence fitting assistive
 devices" Post 149 59 2
Question 7 Pre 60 134 30
"Able to minimize injury
 during transfers" Post 131 80 3
Question 8 Pre 45 95 68
"Able to correct pts walker
 technique" Post 134 76 2
Question 9 Pre 83 108 35
Understand preventative
 positioning and ROM Post 140 70 4
Question 10 Pre 85 115 30
"Confident in medical reasons
 not to get out of bed" Post 139 73 1

Category Totals Pre 679 1110 447
 Post 1344 872 53

Confidence Survey Results Disagree Strongly Value
 Disagree Missing

Question 1 Pre 3 0 7
"Comfort moving an average Post 1 0 11
 pt"
Question 2 Pre 22 8 7
"Comfort moving an obese pt" Post 2 1 11
Question 3 Pre 17 2 8
"I have tools to help my Post 1 0 11
 pts move"
Question 4 Pre 10 0 7
"Confident to do a 2-3 person Post 0 0 11
 TF"
Question 5 Pre 16 0 7
"Know difference between Post 3 0 12
 PT/OT"
Question 6 Pre 41 4 17
"Confidence fitting assistive
 devices" Post 2 0 42
Question 7 Pre 13 0 17
"Able to minimize injury
 during transfers" Post 0 0 40
Question 8 Pre 26 3 17
"Able to correct pts walker
 technique" Post 1 0 41
Question 9 Pre 11 0 17
Understand preventative
 positioning and ROM Post 0 0 40
Question 10 Pre 6 0 18
"Confident in medical reasons
 not to get out of bed" Post 0 0 41

Category Totals Pre 165 15 105
 Post 10 1 260

Table 4. Knowledge Test Results

Variable Number 25th Median
 (N) Percentile

Pre-Test 254 2.0 4.0
 Score
Post-Test
 Score 254 6.0 7.5

Variable 75th Mean Standard
 Percentile Score Deviation

Pre-Test 6.0 4.0 2.2
 Score
Post-Test
 Score 9.0 7.0 2.2

Table 5. Group Analysis of Tests and Surveys

Mean [+ or -] Male Female P value
 SD Median N=21 N=220
 (25th, 75th)
 Min to max

Content scores 3.9 [+ or -] 2.0 4.1 [+ or -] 2.1
 before class 4 (2, 5) 4 (2, 6) 0.73
 1 to 7 0 to 10

Content scores 6.0 [+ or -] 3.0 7.2 [+ or -] 2.0
 after class 7 (5, 8) 8 (6, 9) 0.13
 0 to 9 0 to 10
 2.1 [+ or -] 3.2 3.1 [+ or -] 2.6

Difference in 2 (1, 4) 3 (1, 5) 0.13
content scores -5 to 8 -8 to 8
 P=0.0054 P<0.0001
 N=20 N=209

Survey values 41 [+ or -] 6 39 [+ or -] 6 0.20
before class 41 (38, 46) 39 (35, 43)
 26 to 49 25 to 50
 N=18 N=185

Survey values 46 [+ or -] 4 46 [+ or -] 4 0.98
after class 48 (41, 49) 47 (41, 50)
 38 to 50 36 to 50

Difference in N=17 N=176
 survey values 4.5 [+ or -] 4.4 6.5 [+ or -] 5.2
 4 (2, 8) 6 (2, 10) 0.15
 -3 to 13 -5 to 21
 P=0.0006 P<0.0001

Mean [+ or -] No previous Previous P value
 SD Median injury N=164 injury N=77
 (25th, 75th)
 Min to max

Content scores 4.0 [+ or -] 2.1 4.3 [+ or -] 1.9
 before class 4 (2, 6) 4 (3, 6) 0.26
 0 to 10 1 to 10

Content scores 7.l [+ or -] 2.2 7.2 [+ or -] 2.2
 after class 8 (6, 9) 7 (6, 9) 0.74
 0 to 10 0 to 10
 3.l [+ or -] 2.7 2.8 [+ or -] 2.6

Difference in 3 (1, 5) 3 (2, 4) 0.73
content scores -8 to 8 -5 to 8
 P<0.0001 P<0.0001
 N=159 N=70

Survey values 39 [+ or -] 6 40 [+ or -] 6 0.10
before class 39 (35, 43) 40 (36, 44)
 25 to 50 26 to 50
 N=138 N=65

Survey values 46 [+ or -] 4 46 [+ or -] 4 0.69
after class 47 (41, 50) 48 (41, 50)
 36 to 50 37 to 50

Difference in N=134 N=59
 survey values 6.6 [+ or -] 5.1 5.8 [+ or -] 5.3
 6 (3, 10) 6 (1, 9) 0.28
 -3 to 21 -5 to 20
 P<0.0001 P<0.0001

Mean [+ or -] 0-10 yrs 10+ yrs P value
 SD Median experience experience
 (25th, 75th) N=205 N=35
 Min to max

Content scores 4.1 [+ or -] 2.1 4.4 [+ or -] 1.7
 before class 4 (2, 6) 4 (3, 6) 0.25
 0 to 10 l to 8

Content scores 7.0 [+ or -] 2.2 7.5 [+ or -] 2.1
 after class 8 (6, 9) 8 (6, 9) 0.30
 0 to 10 0 to 10
 3.0 [+ or -] 2.7 3.0 [+ or -] 2.5

Difference in 3 (1, 5) 3 (1, 5) 0.82
content scores -8 to 8 -3 to 8
 P<0.0001 P<0.0001
 N=195 N=33

Survey values 39 [+ or -] 6 40 [+ or -] 6 0.92
before class 40 (35, 43) 39 (37, 44)
 25 to 50 28 to 50
 N=176 N=26

Survey values 46 [+ or -] 4 45 [+ or -] 5 0.30
after class 48 (42, 50) 47 (40, 49)
 37 to 50 36 to 50

Difference in N=168 N=24
 survey values 6.4 [+ or -] 5.3 5.5 [+ or -] 4.7
 6 (2, 10) 4.5 (1, 11) 0.42
 -5 to 21 0 to 14
 P<0.0001 P<0.0001

** Nursing units worked in: There were too many
nursing units with too few observations to test
for significant differences between them. The
within unit changes were examined using paired
ttests and wherever the numbers were sufficient,
the differences significantly increased.
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Title Annotation:RESEARCH
Author:Wilson, Christopher M.; Beaumont, Margaret M.; Alberstadt, Katie M.; Drake, Jennifer M.; Ednalino, K
Publication:Journal of Acute Care Physical Therapy
Date:Mar 22, 2011
Words:6967
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