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Crit Care Nurs Q
Vol. 41, No. 3, pp. 340–344
Copyright c
2018 Wolters Kluwer Health, Inc. All rights reserved.
Multifactorial Strategies for
Sustaining Safe Patient
Handling and Mobility
Deborah L. Totzkay, DNP, RN, ACNP-BC, CNOR
Reduction in nursing staff injuries has occurred with the use of an evidence-based approach to
safe patient handling and mobility. Parts of the evidence-based practice initiative include hav-
ing the appropriate equipment, such as mechanical patient-lifting devices, a no-lift policy, and
the use of peer coaches. The combination of the implementation of a culture of safety can sus-
tain evidence-based, safe patient-handling practices that reduce patient-handling injuries. Patient-
handling programs should include adaptations for an aging nursing workforce. The use of safety
checklists in health care can improve communication and compliance with safe patient-handling
and mobility policy and program components. Key words: peer coaches,safe patient handling,
safety checklists,shared governance
PROTECTING PATIENTS and employees
from patient-handling and movement
injuries has proved to be a challenging
endeavor. The use of an organized framework
that includes the following evidence-based
strategies—engineering controls (equip-
ment), administrative controls (policies,
algorithms, and education), and behavioral
controls (unit-based peer coaches)—has
been demonstrated to help sustain a safe
patient-handling initiative.1-5 Three key
elements to successfully sustain a safe
patient-handling and mobility (SPHM) pro-
gram include the following: creating a
culture of safety including administrative
controls, ensuring appropriate and avail-
able equipment (engineering controls), and
having unit-based peer coaches (behavioral
Author Affiliation: Michigan Medicine, Ann Arbor.
The author has disclosed that she has no significant re-
lationships with, or financial interest in, any commer-
cial companies pertaining to this article.
Correspondence: Deborah L. Totzkay, DNP, RN, ACNP-
BC, CNOR, Michigan Medicine, 1500 E. Medical Cen-
ter Dr, SPC 5862, Ann Arbor, MI 48109 (dtotzkay@
umich.edu).
DOI: 10.1097/CNQ.0000000000000213
controls) to address and remedy issues as
they occur.
A significant gap exists in current patient-
handling strategies and the use of evidence-
based practices to reduce musculoskeletal
injuries (MSIs) in health care workers. For
example,in 2016, the Bureau of Labor
Statistics determined that registered nurses
incurred 10 290 MSIs, one of the highest
incidences of MSIs among US health care
workers.6For nursing assistants, the rate
of MSIs (19 360) was nearly double that of
registered nurses.6The repetitive nature
of nursing work puts them at high risk for
MSIs.7The most common MSIs seen in health
care workers included injuries or disorders
of the tendons, joints, nerves, muscles, spinal
discs, or cartilage.8
Multiple factors influence the occurrence
of MSIs in nurses. These factors include the
need to lift patients,7and the tendency for
nurses to lift more than the recommended
35 lb of weight.2,9 Ngan and colleagues10
determined that 83% of all employee in-
juries were musculoskeletal. For employees
who provided direct patient care, 59% of the
injuries were attributed to patient-handling
responsibilities such repositioning, transfer-
ring, preventing a patient fall, and assisting
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
340
Multifactorial Strategies for Sustaining Safe Patient Handling and Mobility 341
apatientduringaprocedure.
10 The average
age of nurses in the United States (50 years) is
an additional factor that contributes to MSIs.
As the age of health care workers increased,
so did the rate of MSIs. For instance, for em-
ployees younger than 30 years, the MSI rate
per 100 person-years was 4.6; for employees
60 years or older, the rate increased to 7.4.10
The Centers for Disease Control and Pre-
vention, National Institute of Occupational
Safety and Health established a maximum
amount of compressive force that the hu-
man spine should be exposed to during lift-
ing activities, which should be incorporated
into the ergonomic principles of SPHM.2,11
As compressive force increases, the lumbar
and sacral spines at the L4/L5 and L5/S1
levels become increasingly more vulnerable
to spinal compressive injuries.12 Methodolo-
gies that mitigate patient-handling injuries to
health care workers include mechanical lifts,
lift teams, air-assisted lateral transfer devices,
and minimal-lift patient-handling policies.13
While mechanical lifting devices can re-
duce MSIs from patient-handling activities,
nurse motivation also influences the use of
lifting devices.14 Factors such as peer pres-
sure and physical pain have been shown to
influence nurses when choosing or deciding
to use patient lift equipement.15 Exacerbat-
ing this problem is the increasing number of
obese patients who require lifting, and the
increasing number of older individuals who
require assistance with self-care.16 To gain a
greater understanding of the SPHM initiative
rolled out at a large academic medical cen-
ter, please refer to the article in this issue by
Dickinson, Anton, and Taylor. Once an estab-
lished SPHM program is in place, elements to
address sustainability of the program should
be integrated.
CREATING A CULTURE OF SAFETY
The Agency for Healthcare Research and
Quality (AHRQ) has identified several key
features that support a commitment to
safety.1These practices include collaboration
between all levels and disciplines to effec-
tively address patient safety issues; recogni-
tion of high-risk activities within the envi-
ronment; development of processes that pro-
mote safe practices; providing necessary re-
sources to mitigate safety concerns; and sup-
porting a blame-free environment that em-
powers people to report errors or near-misses
without the fear of discipline.
When developing SPHM programs and poli-
cies, input from multidisciplinary stakehold-
ers such as nurses, physicians, physical ther-
apists, ergonomic specialists, and other roles
aid in identifying potential barriers and gaps
to a successful SPHM program. Sokas and
colleagues17 observed that some members of
the health care team, such as nursing aides,
orderlies, or janitors, are frequently over-
looked when considering system improve-
ments for patient and employee safety. The in-
clusion of all frontline health care workers in
the development, implementation, and evalu-
ation of SPHM programs may improve patient
and safety outcomes.
As characterized by the AHRQ, a culture
of safety includes a commitment to iden-
tifying errors and mitigating them before
harm can occur while also implementing
systems that address human factors and en-
able staff to learn from mistakes and prevent
reoccurrences.1The multidisciplinary team
is instrumental in ensuring the sustainability
of appropriate administrative controls, such
as patient-handling policies, algorithms, and
education. The concept of a minimum lift
policy requires administrative support to en-
sure that sufficient and proper patient-lifting
equipment is available to support caregiver
use.18
A culture of safety should encourage em-
ployee empowerment. The essence of em-
powerment can be summarized as individ-
uals’ belief that they can complete their
work in a meaningful manner.19 The influ-
ence of employee empowerment should be
considered when designing and implement-
ing safe patient-handling policies and pro-
grams. When nurses feel empowered in the
workplace, they are more likely to use strate-
gies that empower patients and, ultimately,
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
342 CRITICAL CARE NURSING QUART E R LY/JULY–SEPTEMBER 2018
improve patient outcomes.20 Kanter also the-
orized that, when employees have access
to adequate resources, information, and sup-
port,theyareempoweredtomaximizetheir
ability to fulfill their work responsibilities.19-20
ENGINEERING CONTROLS: HAVING THE
APPROPRIATE EQUIPMENT TO MOVE
PATIENTS SAFELY
Engineering controls are designed to miti-
gate work environment risks that contribute
to staff MSIs. Examples of engineering SPHM
controls include ceiling lifts that move pa-
tients vertically to another surface without
requiring manual assistance and air-assisted
lateral transfer devices. Any gaps in the type
or amount of patient-handling equipment
required for the unit should be identified by
the unit leadership. Ready access to appropri-
ate equipment, in good repair, supports the
use of that equipment. The Veterans Health
Administration’s Center for Engineering &
Occupational Safety and Health recommends
conducting ergonomic-site visits of each
unit of a facility.21 This assessment should
include the availability of storage space for
patient-handling equipment; consideration
of patient room sizes and configurations;
and identification of the location of power
outlets and batteries for the equipment.
Instructions for the correct and safe use of
each piece of patient-handling equipment
should be secured to the equipment for ready
reference. By providing adequate and conve-
niently located patient-handling equipment,
accompanied by instructions for use, staff are
more likely to use the equipment.
Adaptations for an aging nursing workforce
must also address patient-handling respon-
sibilities. In their review of the literature,
Phillips and Miltner22 identified fatigue and
repetitive motion injuries as major work haz-
ards for an aging nursing workforce. These
hazards are mitigated during patient-handling
activities by providing appropriate and read-
ily available patient-handling equipment, to
include standardized instructions for use.22
BEHAVIOR CONTROLS: SUPPORT FOR
NURSES TO IMPLEMENT SPHM
Behavioral-based controls include educa-
tion on proper use of patient-handling equip-
mentandSPHMpolicyandtheuseofSPHM
unit peer coaches.18 Peer coaching can be de-
scribed as a nonhierarchical interaction be-
tween 2 health care workers who work in the
same environment and share similar experi-
ences and work responsibilities.23 As applied
to the sustainment of safe patient-handling
programs, the use of peer coaches provides
support and expertise to staff regarding the
correct use of patient-handling equipment
in a supportive and nonjudgmental manner.
This interaction exemplifies the AHRQ rec-
ommendation that development of a blame-
free environment empowers people to re-
port near-misses without fear of discipline.1
Moreover, Cox24 suggested that peer coach-
ing uses cost-effective, in-house expertise that
provides highly relevant support that is read-
ily accessible.
While the implementation of an evidence-
based, safe patient-handling program pro-
vides the foundation for reducing patient-
handling injuries, processes must be
established to provide sufficient support
for maintaining program components. The
use of a shared governance model empowers
employees while also supporting the sus-
tainment of safe patient-handling practices.
Furthermore, Porter-O’Grady25 observed that
shared decision-making models in nursing
provide a framework that supports auton-
omy, organizational influence, and service
excellence.
In collaboration with unit leadership, the
peer coach also shares trends with the staff
regarding injuries attributed to patient han-
dling. For instance, are staff experiencing lost
workdays or modified workdays because of
patient-handling injuries, and if so, what were
the contributing factors? Sharing this infor-
mation with staff on a regular basis helps
emphasize the importance of safe patient-
handling methodologies while also providing
staff with the opportunity to share concerns
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Multifactorial Strategies for Sustaining Safe Patient Handling and Mobility 343
and suggestions for refining patient-handling
practices. Agenda time should be allocated
for the peer coach to present updates re-
garding patient-handling injuries during unit-
based council meetings.
SUMMARY
SPHM programs have been shown to de-
crease direct caregiver and patient injuries
while reducing health care cost (see article
by Adamczyk in this issue). To successfully
sustain an SPHM program, 3 key elements
must be included: a culture of safety includ-
ing administrative controls, engineering con-
trols including appropriate equipment, and
behavioral controls such as education and
unit peer coaches. A great example of the
use of these 3 elements in practice is the
work completed by the Department of Veter-
ans Affairs Tampa Patient Safety Center of In-
quiry. They developed a multifactorial SPHM
program in 2001 that included the evidence-
based use of SPHM unit peer coaches, a
risk assessment to define unit-specific patient-
handling equipment requirements, sufficient
patient-lifting devices appropriate for the pa-
tient population, proper training on patient-
handling equipment, and a minimal-lift SPHM
policy.26
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344 CRITICAL CARE NURSING QUART E R LY/JULY–SEPTEMBER 2018
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Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.