Ac c o rding to the American

Continuing Nursing Education Series Safe Patient Handling and Movement in a Pediatric S e t t i n g Kathleen Motacki Lisa Marie Motacki Although evidence-based practice exists to apply the principles of safe patient handling and movement (SPHM) to prevent nursing musculoskeletal injuries in the workplace, nurses and nursing staff continue to use body mechanics when moving, lifting, and transferring patients. In this day of a nursing shortage, one that will continue to worsen, valued professionals must remain on the job and free from preventable, workrelated injuries. As states enact laws requiring health care facilities to develop and institute SPHM programs, hospitals will be held to task to produce SPHM policies, procedures, plans, and protocols in their institutions. Ac c o rding to the American Nurses Association (ANA) (2006), up to 38% of all nurses experience back injuries. Musculoskeletal disord e r s (MSDs), more than any other workrelated injury or illness, are re s p o n s i- ble for lost work time, the need for p rotracted medical care, and perm a- nent 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, 2 0 0 9 a ). In September 2003, ANA (2008) developed the American Nurses Association Ergonomics Handle with C a re Campaign to mount a pro f e s- sion-wide eff o rt to prevent back and other musculoskeletal injuries in health care facilities. The campaign a d d ressed issues that included gre a t e r 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 curr i c u l u m. Kathleen Motacki, MSN, RN, BC, is a Clinical Assistant Pro f e s s o r, 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 re p o rted no actual or potential conflict of i n t e rest in relation to this continuing nursing education series. Objectives and the CNE posttest can be found on pages 232-233. 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, perf o rm e d 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 evidencebased 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 d i rection of Dr. Audrey Nelson, which can be found on the center s Web site (U.S. Department of Veterans A ff a i r s, 2009). The study found that when using the curriculum, nurse educator and student knowledge improved sign i f i c a n t l y, as did the intention to use mechanical lifting devices in the near f u t u re (Menzel, 2007; Nelson et al., 2007). The curriculum module won the 2008 National Occupational Res e a rch Agenda (NORA) P a rt n e r s h i p Aw a rd and can be accessed on the I n t e rnet for use by all nursing schools to reduce the risk of musculoskeletal d i s o rders among nurses (U.S. Dep a rtment 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 p e rf o rmed at the diff e rent states of a p a t i e n t s health status. For example, patients needs will differ pre - o p e r a- tively 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 re n d e red the act of strict manual patient handling an unnecess a ry function of nursing care. Furt h e r, the use of mechanical lifts can substantially reduce patient skin tears and the frequency of patients being d ropped. 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 c a re workers could use a ceilingmounted 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 PEDIATRIC NURSING/July-August 2009/Vol. 35/No. 4 221

special needs are often discharg e d home with their parents and have re s o u rces, 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 c a re 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 b a t h room. He is transferred to and f rom his bed to the tub and shower, and to and from his bed to his motorized wheelchair with one care g i v e r using the ceiling-mounted lift and patient sling. To d a y, 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. C h i l d ren may re q u i re 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 d a y. 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 diff e rent classro o m s, to the nurse s office, or to other are a s 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 m e d i c a l / s u rgical unit would apply. The Patient Assessment Tool and the Generic Algorithms should also be u s e d. T h e re 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. Legislation Several states have either initiated or enacted safe patient handling and movement laws (see Table 1) (ANA, 2 0 0 9 b ). As state laws pass, each health care facility is re q u i red to develop and implement institutionwide SPHM plans. Movement is also Ta ble 1. State Legislation Regarding Safe Patient Handling and Mov e m e n t States Where SPHM Has Been Initiated Florida Hawaii Minnesota Maryland New Jersey Ohio Rhode Island Texas Washington States Where SPHM Has Been Enacted Connecticut California Illinois Iowa Massachusetts Michigan Missouri Nevada New York Wisconsin S o u rc e : Adapted from ANA, 2009b. taking place at the federal level. In June 2009, The Nurse and Health C a re Worker Protection Act of 2009 was introduced in the U.S. Congre s s (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 s t a ff to safely lift and transfer patients. An overview of the patient assessment tool follows (Nelson, 2006, p. 61): P a t i e n t s level of assistance. Weight-bearing capacity. Upper extremity strength of the p a t i e n t. Level of cooperation and compreh e n s i o n. Patient height and weight. Patient conditions. Specific physician ord e r. Once the patient assessment is completed, the algorithms are used. T h e re 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 s t re t c h e r, tro l l e y. Transfer to and from chair to s t re t c h e r, 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 f l o o r. 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 p ro c e d u res in their facilities. A paradigm shift must occur within the institution at diff e rent levels for the SPHM plan to be successful. The institution needs to create a c u l t u re of safety in the workplace re g a rding SPHM. The five rights of the p rogram include 1) a patient assessment, 2) proper lifting equipment, 3) c o rrect approach, 4) appro p r i a t e number of caregivers based on the algorithms, and 5) correctly measure d sling size and type of sling. Three levels of support are re q u i red for an SPHM program to be effective: administrative, engineering, and behavioral (Nelson & Baptiste, 2004). Administrative Controls At this level, top administration must p rovide hospital personnel with the financial backing re q u i red for the program to be effective. The vice pre s i d e n t of nursing must clearly be the nursing administrative re p resentation needed, and the vice president of human re s o u rces must also play a key role in the re c ruitment and retention of the h o s p i t a l s nurses. Administrative cont rols include financial support for capital budget equipment and the purchase of slings. Time needed for education supp o rt staff to provide instruction at all levels and to all shifts is essential. The hospital can hire an erg o n o- mist to evaluate each unit and shift for needs for engineering controls in the workplace. Leaders include the nurse manager and nursing superv i s o r s, along with the Education Depart m e n t and the clinical nurse educators, to e n s u re the program is successful. Specific policies and pro c e d u res must be defined and incorporated into the daily nursing care plans of the patients. The Education Depart m e n t 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 222 PEDIATRIC NURSING/July-August 2009/Vol. 35/No. 4

Safe Patient Handling and Movement in a Pediatric Setting The safe patient handling and injury prevention standard shall require the use of engineering controls to perfo rm lifting, tra n s fe r ring, and repositioning of patients and the elimination of manual lifting of patients by direct-care registered nurses and all other health care wo rke r s, through the use of mechanical devices to the gr e a t- est degree fe a s i ble except where the use of safe patient handling practices can be d e m o n s t rated to compromise patient care. The standard shall apply to all health care employers and shall require at least the fo l l ow i n g : 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 nu r s e s, health care wo rke r s, and employee representatives of direct-care registered nurses and health care wo rkers in developing and implementing the safe patient handling and injury prevention plan, including the purchase of equipm e n t. 4. Each health care employer to establish and maintain a data system that tra ck s 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 ava i l a ble to employees and employee representative s. 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 conc e rns about patient care and to generate a written report in each such i n s t a n c e. The report shall list the fo l l ow i n g : a. The wo rk task being perfo rm e d. b. The reason why safe patient handling equipment was not used. c. d. Ta ble 2. S a fe Patient Handling and Injury Prevention Standard The nature of the risk posed to the wo rker from manual lifting. The steps taken by management to reduce the likelihood of manual lifting and tra n s fe r ring when perfo rming similar wo rk tasks in the future. Such reports shall be made ava i l a ble to OSHA compliance officers, wo rke r s, and their representatives upon request within one business day. 6. Each health care employer to train nurses and other health care wo rkers on s a fe patient handling and injury prevention policies, equipment, and devices at least on an annual basis. Such training shall include providing info rmation on hazard identification, assessment, and control of mu s c u l o s keletal 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 intera c t i ve classroombased and hands-on fo rm a t. 7. Each health care employer to post a unifo rm notice in a fo rm specified by the s e c r e t a ry that: a. Explains the safe patient handling and injury prevention standard. b. Includes info rmation regarding safe patient handling and injury preve n t i o n policies and tra i n i n g. c. Explains procedures to report patient handling-related injuri e s. 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 injuri e s, and new safe patient handling and injury preve n t i o n technology and devices that have been deve l o p e d. The evaluation shall be conducted with the invo l vement of nu r s e s, other health care wo rke r s, and their r e p r e s e n t a t i ve s, and shall be documented in wri t i n g. Health care employe r s shall take corrective action as recommended in the written eva l u a t i o n. S o u rc e : U. S. C o n gr e s s, 2009. key for this hospital-wide eff o rt to be successful. Some hospitals have developed a patient/family teaching pamphlet explaining that the institution uses engineering controls to safely transfer patients. This inform a t i o n can include facts, such as a decre a s e in patient falls as well as decre a s e d skin shearing injuries, when using the technologic solutions to transfer p a t i e n t s. Engineering Controls F ront-line patient care employees should be allowed the opportunity to evaluate the diff e rent 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 pro p e r chain of command must be followed with the maintenance of all equipment that will be used. Just as a depart m e n t will be responsible for equipment maintenance, a department and specific personnel will be responsible for maintaining both disposable and nondisposable slings. Behavioral Controls Each specific clinical area will be c h a rged with development and implementation of the specific policies for the units. For example, the medicals u rgical 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 re s p o n s i b i l i t i e s 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. Conclusion 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 ( N C L E X T M ) 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 pro c e d u res. Health PEDIATRIC NURSING/July-August 2009/Vol. 35/No. 4 223

Appendix A A teenager with spinal cord injury who is ventilator dependent is able to be at home with friends due to s a fe lifting equipment for transfers. A teenager transfers into the shower using a ceiling-mounted lift and stretcher by a home care nurse. A teenager is transferred to a wheelchair by a nu rse using a floor-based lift and sling in a pediatric rehabilitation center. 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. A teenager transfers to a wheelchair using a floor-based lift and sling by the nu rse and nu rsing assistant in a pediatric rehabilitation hospital. 224 PEDIATRIC NURSING/July-August 2009/Vol. 35/No. 4

Safe Patient Handling and Movement in a Pediatric Setting c a re facilities should be proactive in the development of these plans. T h e re is a nursing shortage, one that will become increasingly worse as nurses re t i re and people live longer. Hospitals that already have SPHM plans in place can use their plans in re c ruitment and retention strategies. During initial interviews, the interv i e w- er 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 t o w a rd their nursing personnel. Retention strategies will be in place, and as a result, nurses will be re q u i re d to use safe lifting equipment, safe lifting policies and pro c e d u res, the patient assessment, and the corre c t algorithm in daily patient care. The retention of nurses will follow suit as nurses continuously believe the facility holds their best interest at the foref ro n t. ANA supports the eff o rts of the VISN Patient Safety Center and NIOSH in the eff o rt 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 there f o re imperative that these policies, pro c e d u res, and programs be implemented for the benefit of the health care worker as well as for the patient. from http://www. nu r s i n g wo rl d. o r g / m a i n- m e nu c a t e g o ri e s / A N A Po l i t i c a l Powe r / S t a t e / S t a t e L e g i s l a t i ve A g e n d a / S P H M. a s p x M e n zel, N. ( 2 0 0 7 ). 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