SAFETY DEVELOPMENT FUND PROJECT

SAFETY DEVELOPMENT FUND PROJECT MUSCULAR-SKELTAL INJURY PREVENTION PROGRAM FOR DISTRICT NURSES -Making community nursing safer FINAL REPORT The aim of the project was to implement a best practice solution a No Lift Policy into the community nursing environment. JANUARY 2003

CONTENTS Introduction 1 1. Project Partners 2 2. Project Summary 3 4 Anticipated outcomes Pre implementation 3 5 Outcomes and Findings Post implementation 5 6 Final Evaluation 6 7 Communication to the broader community care sector 9 8 Recommendations 10 9 Financial Statement 12 Appendices: 1. Implementation Model 2. Methodology and work plan 3. Article in Newsletter of the ACCNS 4. BDNH No Lift Policy 5. No Lift Flow Chart 6. Risk Assessment 7. Equipment Recommendations Matrix 8. BDNH Care Contract 9. Interim Care Plan 10. Care Plan 11. Client Information 12. Letter to other health service providers 13. Compliance Monitoring Form 14. BDNH Incident Injury Report

INTRODUCTION In October 2001, the new executive at Ballarat District Nursing and Healthcare Inc. (BDNH) together with staff and the Committee of Management completed an organisational review and developed a Strategic Plan. It was during this time that it was identified that there were significant risks in relation to Occupational Health and Safety and compliance with the Act. Significant resources were allocated over a threemonth period to develop and implement policies and procedures to ensure that BDNH was complying with legislation. Risk assessments were performed on all identified risks and a system document was developed that ensured that every client had a risk assessment completed. During the course of these actions, it was identified that a No Lift Policy needed to be implemented. Fortunately there had not been a lot of injuries however, the potential for nursing staff to obtain muscular-skeletal injuries was considered to be a high risk for the following reasons: There are over 1600 single workplaces per annum. The workplace (the clients home) was considered to be an uncontrollable environment. People who need supportive services are staying at home longer than they had in the past due to the changes in community expectations and aged care policies. Therefore client care is becoming more complex and the manual handling needs are greater. The average age of nursing staff is increasing. The average age of our workforce is 41 years with an average of 23 years employment as a nurse. Other issues were: That there was an increasing awareness that No Lift Policies were being implemented into both acute and aged care services. At this time BDNH was also reviewing Human Resource issues and recognised that if nurses were going to be retained or recruited, that an attractive work environment was needed. Unfortunately around this time two nursing staff did obtain muscularskeletal injuries and the cost to both the staff and the organisation has been high. Equipment is often provided as determined by allied health personnel who are not involved in day-to-day care. Complex clients often are case managed and there may not be a lot of consultation between the brokerage agency and the service provider with regard to what the equipment requirements were. Often nursing staff felt that inappropriate equipment was put in place for a client. Management recognised that implementing a true No Lift Policy was necessary but the community setting has its own particular issues. If the change was not managed as a total project it may fail. In the short term it was also going to be costly for a small organisation however it was anticipated that the long-term gain would make it very cost effective and beneficial to both staff and the organisation.

A submission was made to the Victorian WorkCover Authority s Safety Development Fund with a view to implementing a Best Practice Model to eliminate/minimise the risks associated with manual handling of clients. The O Shea No Lift Policy has been implemented into acute and aged care services and has been demonstrated to be a complete system to bring about an effective change to processes, attitudes and behaviours. It is also VETEC registered and involves competency based training. However the model needed to be tailored due to the needs of staff working in the home care environment. BDNH received $18,055 from the VWA to assist with the implementation of this project, which included purchasing appropriate equipment. The total cost of the project was $34,741. Linkages: Central Highlands Co-ordinated Community Care was sought out as a partner because they broker our services and case manage many of our complex clients. They are also responsible for the purchase of equipment. It was recognised that implementation of the project may impact on Linkages clients and we needed their support for the policy to be effective. The project commenced with the first meeting on 29 th May 2002. There were four meetings and the final meeting was held on the 11 th December 2002. A committee was established which oversaw the project. A No Lift Coordinator was elected who worked in partnership with Louise O Shea. Pre implementation included an audit of current processes and attitudes as well as consultation and awareness raising. Training commenced in September over one week. Eight trainers were trained in the first instance and then each trainer assisted Louise for a half day training session. Over all thirty-nine (39) staff were trained. A number of issues arose during the project which are described in the body of the report. Overall the project has been very successful and monitoring of the outcomes will be ongoing.

1. Project partners: Ballarat District Nursing & Healthcare Inc. (Lead agency) Linkages: Central Highlands Co-ordinated Community Care 2. Description of the organisations: Ballarat District Nursing & Healthcare Inc.(BDNH) is one of only two stand alone district nursing organisations in Victoria, the other being Royal District Nursing Service. All other district nursing services in Victoria are part of the public hospital system. Our core business is to provide district nursing services, however we also provide some allied health services podiatry and occupational therapy, as well as a software development unit. Linkages: Central Highlands Co-ordinated Community Care manages Linkages, Community Care Packages and Extended Aged Care at Home (EACH) programs. This organisation provides Case management to clients with complex needs and brokers service delivery, such as district nursing services. 3. Project Summary: The aim of the project was to implement a No Lift Policy into the community nursing environment. This would be a best practice solution to eliminate/minimise the risks associated with manual handling of clients. It was a collaborative project between (BDNH) and the Central Highlands Linkages program (Linkages CHCCC). BDNH provides the nursing services and in many cases, complex clients are case managed by Linkages who broker BDNH s service and provide the equipment. BDNH also provides an after hours call out service. Client who use this service may have fallen and needed to be picked up. BDNH needed to implement a safe strategy to care for clients in this situation. 4. Anticipated outcomes- Pre implementation: 4.1 Immediate and short-term BNDH, a district nursing service would have an effective No lift Policy in place. Prior to the project, staff were still lifting and manually moving clients. Equipment was often purchased by the client or provided by brokerage agencies without adequate assessment and consultation. Develop a model which can be implemented throughout the home health care sector. Reduction in pain and fatigue by nursing staff from manual handling activities. Reduction in muscular-skeletal injuries. There would be an increased awareness by staff of OH&S processes, legislation and procedures. It was anticipated that staff would consider their own safety before the clients. Risk assessments would become part of normal practice and

that there would be increased knowledge of how to control hazards within the workplace. Increased liaison between the services purchasing and services providing nursing services to clients. 4.2 Long term A reduction in the direct and indirect costs of muscular-skeletal and back injuries. Improved retention of staff. Compliance with relevant statutory requirements.

5. Outcomes and Findings Post implementation Immediate and short-term outcomes BNDH, a district nursing service would have an effective No Lift Policy in place. Prior to the project, staff were still lifting and manually moving clients. Equipment was often purchased by the client or provided by brokerage agencies without adequate assessment and consultation. A No Lift Policy has been fully implemented. It is effective and easier than expected. Develop a model that can be implemented throughout the home health care sector. Reduction in pain and fatigue by nursing staff from manual handling activities. Reduction in muscular-skeletal injuries. There would be an increased awareness by staff of OH&S processes, legislation and procedures. It was anticipated that staff would consider their own safety before the clients. Risk assessments would become part of normal practice and that there would be increased knowledge of how to control hazards within the workplace. There would be increased liaison between the services purchasing and services providing nursing services to clients The O Shea No Lift model was modified to be effective in the community health care sector. This outcome will be evaluated by a questionnaire to be completed at three months and six months post implementation This outcome will be assessed medium to long term with a report to be completed three months, six months and ongoing post implementation. This outcome was evidenced during competency testing. There will also be ongoing evaluation. There has been increased liaison between agencies with regard to equipment supply and care planning. Long term outcomes A reduction in the costs of direct and indirect costs of muscular-skeletal and back injuries. To be measured long term

Improved retention of staff Compliance with relevant statutory requirements. To be measured long term As evidenced by Workcare inspection

6. Evaluation of the Project Initial Concerns The project has been very successful. BDNH has been able to successfully implement a No Lift Policy however, there were a number of concerns from all stakeholders prior to and during the project. Some stakeholders including staff were sceptical that a true No Lift could be implemented, given the various environments and the types of clients that we have. Management was concerned about the logistics, reputation, loss of clients and cost implications. Brokerage agencies were concerned about equipment costs and the possibilities that some clients may be refused care or would be referred to other agencies. There were also concerns about transferring risk from one agency to another. Overview of the Implementation Process A No Lift Committee was established which included representatives from management and OH&S reps from BDNH, Linkages, RDNS and Jeanette Sdrinis from ANF Vic Branch. The committee elected a No Lift Coordinator Dianne Brayshaw, a nurse who is also the part time Safety Officer. Louise O Shea from O Shea and Associates was contracted to assist with the implementation of a No Lift model. Dianne and Louise met to gain an overview of the type of work and issues involved. They also reviewed the current documentation and work practices. The advantage of using O Shea s No Lift system is that it is a complete system which has been designed to effectively bring about a change in both attitudes and behaviour an effective change management system. It is also a registered program through the Vocational Educational Training and Employment Commission (VETEC). The Minister for WorkCover, Bob Cameron and the Victorian WorkCover Authority launched the project publicly. There was also an in-house launch for staff and brokerage agencies to gain support and understanding. This was followed by a week of training with Louise O Shea. Eight trainers were trained in the first instance and then thirty-nine (39) staff. The risks and problems in relation to particular clients were identified and problem-solved during the training sessions. In all but three cases problems were solved during that time. Practical training was part of the session and Louise s practical common sense approach made it all so logical. The morale and buzz within the organisation was palpable as the week progressed. As each group of staff went through the half-day session, they were buoyed and could understand how sensible the system was and in some cases wondered why they hadn t identified such a simple solution themselves. As the training progressed Louise O Shea developed an equipment assessment and care matrix.

There were three clients who were identified as high risk. Controls were put in place. At this stage it was identified that a client agreement or Care Contract was needed. This tool was used to document the areas of risk as well an action plan including timeframes for implementation of necessary changes to be made. An interim care plan would be put in place and an agreement that recommendations would be implemented within a timeframe. In circumstances where the client/carer or case manager refused or was unable to provide a safe work environment, care would be withdrawn. Case Study: Hazard identification: During the No Lift training session one client was identified as having several hazards which were of concern. These hazards included: Repetitive or sustained application of force Repetitive or sustained awkward postures Application of high force Handling of live people Risk Assessment: The No Lift Co-ordinator and Louise O Shea went to visit this client to perform a risk assessment. Recommendations from the assessment were that we cease showering this client until some changes to the environment could be made. The staff had been pushing this client up a steep ramp into the shower recess, the bathroom was very small and this whole process was very unsafe for the client as well as the nursing staff. There was a lifting hoist in the home that was being used to lift the client out of bed, however the client was in a low double bed. This client is a Veteran Affairs client and an OT had recently recommended the purchase of a standing chair for this client who cannot weight bear. The lifting hoist could not accommodate the width of the chair and so the nursing staff were lifting the client back into the chair manually. The carpet on the floor was also identified as a risk as it was thick and was offering too much resistance on the wheels of the lifting machine. The client s wife was very upset and initially refused to consider making any changes, she no longer wanted us to care for the client and contacted DVA to ask what other service provider could care for her husband. DVA contacted us and stated that they were supportive of the No Lift program and they also stated that they would not recommend another service to care for this client. We had several phone conversations with the client s wife and the client s daughter to look at ways that we could provide the care that the client required safely. Following negotiations, it was agreed that DVA would pay for a High/low bed so that we could sponge the client in bed, the family stated that they would not make changes to the bathroom as they believed that home care was only going to be a medium term option. The family chose not to remove the carpet, so the nurses ceased pushing the client in the lifting machine and instead transferred the client into a wheel chair, which is easier to push over the carpet. A meeting with the OT from the brokerage agency, the Primary Care Nurse, the No Lift Coordinator and the family was also arranged to look at the appropriateness of the chair that the

Achievement of outcomes It is too early to assess some of the expected outcomes, however, at this stage we know that staff are much more aware of their obligations in relation to Occupational Health & Safety, Hazard Identification, Risk Assessment and Manual Handling. Staff are less likely to put themselves at risk in any given situation. This has been demonstrated through the increase in primary care nurses requesting one of the No Lift Trainers to assist and support them with risk assessments in complex cases. Staff confirm that since the introduction of the no lift policy, they are now able to say no to carers and clients who request them to manually lift. Instead they can work through issues together to find a solution. In a couple of cases nurses are now sponging their clients, as the bathroom is unsafe to use. Some of our client s homes are miner s cottages and it is impractical to renovate the bathroom. Staff also spend time in educating carers ie relatives/friends, on safer ways to move the client. Many homes are using slide sheets in particular. Staff s increased awareness of safety is being evidenced by their problem solving of other OH&S issues, such as security and fire safety. This demonstrates that nurses now think about and have some control over their workplace. It is anticipated that the ongoing impact of the No Lift Policy will be that staff will have less injuries, are less fatigued, will remain with the organisation for longer and that new people are keen to work in this environment. Our staff are proud and happy that the organisation is valuing and caring for nursing staff. Some staff commented that the no lift training was commonsense and practical. One nurse who has been a district nurse for 30 years said that what she learnt most of all out of the training, was to step back and allow the client to do more for themselves. Our staff were committed to making sure that implementing a No Lift Policy should not mean a transfer of risk to another agency eg Council Home Care staff. The cost of equipment to implement the project was less than expected. Two portable lifters have been purchased by BNDH to be used for emergency callouts when clients have fallen. Previously, BDNH would call the ambulance to pick up fallen clients who did not require medical attention. Our ambulance service now has a manual handling policy in place, and our organization became responsible for picking up our own clients when uninjured. Hence the need for portable lifters. The lifters chosen are light and easy to transport. They could also be used for a short period where clients are waiting for equipment to be purchased. BDNH provides a twenty-four hour call out service to clients. Only one staff member is on call between 9pm and 7am. When a staff member attends to a client who has fallen during this time, they are to assess their physical wellbeing and call an ambulance if medical attention is required. Otherwise, if it is not safe for the nurse to assist the client back to bed, they are to make the client comfortable, safe and warm on a yoga mat. Two of the day staff will then attend to the client after 7am. Our nurses are also now able to have input into to the type of equipment that is being provided for their clients. This equipment is their tools of trade. Nurses have been meeting with Occupational Therapists on assessment day in client s homes to discuss needs and making direct recommendations to brokers on what equipment they

actually need to provide safe care to their clients. This is a great achievement for our nurses, as quite often inappropriate equipment would arrive at client s homes for nurses to use. Vehicles Whilst lifters were trialled there was some debate about the types of cars that would be needed. The lifters that were purchased will fit into the boot of the sedans that BDNH uses. The lifters come apart so that they are in three packages to enable transport and two staff are to attend if the lifter is required. The other solution that was considered was that the lifter would be couriered to the required address however it was decided that it is better if the client is not lifted and is made comfortable until daylight hours. Ongoing Sustainability. The key to the success of the program will be to ensure ongoing sustainability. Ownership/responsibility needs to be given to one particular position, in our case, the Safety Officer to ensure that all new staff are trained and that competency testing occurs on an annual basis. Management must budget appropriate resources to enable the ongoing training and evaluation of the program. Compliance with the No Lift Policy will need to be assessed. The Safety Officer and No Lift Trainers are responsible for ensuring compliance but all staff must be responsible for ensuring the need for compliance. Compliance will be formally tested, however, it is more difficult to supervise in the community setting. 7. Communication to the broader community care sector. Letters were sent to clients and other relevant service providers to inform them about the project. Information about the No Lift Policy will be included in the information given to all new clients. Communication about the project to the broader community has been disseminated through a number of avenues. The BDNH website has been used, an initial article about the project has been published in the Australian Council of Community Nursing Services Newsletter. There have also been several articles in the local media. Dianne Brayshaw and Louise O Shea gave a presentation about the project at the Australasian Aged Housing Summit. It has also been discussed at the Victorian ANF No Lift Expo. Final reports will be sent to WorkCover, ANF, Department of Human Services and Department of Child and Family Services. The final report will be disseminated through the BDNH Website, and will also be sent to ACCNS and RCNA for publication. An information session is being planned for early in the New Year to disseminate information to District Nursing & other home health care agencies.

8. Recommendations 1. That the Ballarat District Nursing Service No Lifting Project be used as a model for district community nursing agencies. Further to this, that the Victorian WorkCover Authority consider an addendum to the "Transferring People Safely" Guidelines using the community-nursing matrix developed under this project. 2. VWA approach DHS Disability Unit to have Victorian Aids and Equipment Program Guidelines include that nurses who have undertaken VETEC NS 0222 The No Lift System can make recommendation for hoists and hi/low beds. Clients often wait several weeks for Occupational Therapy assessments. District Nurses are trained and competency tested to assess for equipment needs and it would speed up the process to have the appropriate equipment in place and improve client care if appropriate equipment was in place sooner. 3. VWA needs to develop a community education strategy. For the No Lift Policy to be effective it is important that clients, their families and the community in general understand the need for a safe environment and workplace. 4. The acute sector needs to be educated about discharging clients into community care such as to enable consistency with no lifting principles and safe handling methods in the home care environment. Processes need to be established which ensure that any issues in the home environment are identified prior to discharge and that adequate preparation for discharge is made. 5. While it is beyond the scope of this project to address, it is strongly recommended that the Department of Human Services ensure that Health Agreements with agencies or services providing brokerage services, community or home care, include requirements for compliance with Occupational Health and Safety Standards and the no lifting policy, including where services are contracted out to community agencies. 6. That the Victorian WorkCover Authority take appropriate action to ensure compliance with relevant OHS standards and guidelines, including the relevant Manual Handling Regulations & Code of Practice 1999 and relevant guidelines, across the home care sector. 7. That WorkSafe Victoria undertake research into identifying optimal features for vehicle design such as to ensure elimination/minimisation of manual

handling risks associated with loading and unloading client handling and other equipment in the community nursing setting. That this be done in consultation with the community nursing sector. 8. That the Report and recommendations arising out of this project be disseminated to the following agencies and organisations: District/community nursing services, local councils, and other providers of nursing or personal care services to the community. other brokerage services Australian Council of Community Nursing Services Royal College of Nursing WorkSafe Victoria Department of Human Services Victorian Health Industry Association Commonwealth Department of Health and Aged Care Australian Nursing Federation Australian Resource Centre for Hospital Innovations References: Transferring People Safely VWA 542/01/06.02 Occupational Health and Safety Act 1985 Manual Handling Regulations and Code of Practice 1988 Australian Nursing Federation (Victorian Branch) No Lifting Policy 1998 Policy and Best Practice Guidelines for the Prevention of Manual Handling Incidents in NSW Health August 2001 The No Lift System O Shea and Associates