There are many barriers to getting safe patient handling equipment at the bedside when needed, but you may not have considered that the altruistic nature of nurses could occasionally be one of them. Nurses may be reluctant to leave patients in certain situations, perceiving that their immediate need to get to a bedside toilet, for example, leaves little time to get lifting equipment in the room.
“Nurses are quite self sacrificing and they always put the patient first,” says Heather M. Monaghan, MHSc, RN, president and CEO of Sarasota, FL-based Visioning HealthCare Inc., a consulting firm that deals with safe patient handling as part of an overall culture of safety.
“If the patient needs to get to the bedside commode quickly, then they will manually transfer them there because they don’t want the patient too have an embarrassing episode.”
Unfortunately, that very scenario has resulted in injury as nurses and their health care colleagues continue to be in harm’s way when manually lifting or moving a patient population that has both high acuity and obesity. According to a scathing report on National Public Radio (NPR) — which cited many accounts of nurses being injured trying to manually move patients — a nurse called for a four-person lift team to help get a 300-pound patient onto a bed pan. Only one staff member showed up and the patient was getting desperate.
“[The nurse] worried that they couldn’t safely handle the patient. But they also knew if they didn’t act quickly the patient would soil himself, ‘which would humiliate him,’” NPR reported, quoting the nurse as follows.1 “So, as the helper pulled the patient’s shoulder and hip, ‘I’m pushing on the other side, one hand on his back and one hand to slide a bedpan underneath him. And it’s really hard. He’s having pain from his chest tubes, he’s short of breath, he’s panicking, he’s saying, ‘Hurry, hurry.’” The helper was almost as frenetic, “saying, ‘Are you ready yet? Have you got the pan in place?’ Because we’re both straining trying to hold him in place and do the maneuvering that’s necessary for this procedure.”
The two were able to get the bedpan under the patient in time. But a couple of days later, the nurse could hardly walk, NPR reported. The nurse missed months of work, eventually retiring at 57 because she didn’t want to work in pain. Such cases are all too familiar, unfortunately, but some hospitals still take some convincing that patient safe handling equipment is a cost-effective investment.
“The evidence is so strong — it’s like do cigarettes cause lung cancer? But there are still people who smoke,” Monaghan says. “We shouldn’t need to keep making the business case; the facts are there. But we do, because each hospital has to look at the financial [impact].”
To cite but one recent example, the federal Occupational Health Safety Network recently reported that of all patient handling injury reports collected, 62% included data on the use of lifting equipment. Of those, 82% of the injuries occurred when lifting equipment was not used.2 (See HEH June 2015, page 69.) While preventing nurse injuries and reducing compensation claims and lost workers is one clearly defined aspect of the equation, the patient safety issues may ultimately be the tipping point for more widespread adoption and routine use of lifting equipment.
As evidence accumulates that handling and lifting equipment is actually safer for patients, health care workers, and more importantly, hospital administrators may be more receptive to viewing the equipment as a necessary component of clinical care. If so, the altruistic nature of nurses could motivate them to use the lifts and safe handling equipment as much for patients as themselves.
“We’re starting to see a connection between the use of equipment and improved patient outcomes,” Monaghan says. “I think that’s where we are going to get a much stronger buy-in from the hospitals, from executive leadership, from the nurses and aides. Nurses are like doctors — they don’t want to do their patients any harm. Now we are finding that we can reduce pressure ulcers using the equipment, it’s more comfortable for patients, less painful and reduces falls. So I think the culture of safety needs to be focused on the patient, and the nurse hopefully will follow.”
As it currently stands, too often safe handling programs lose momentum after the initial excitement of bringing the equipment in and receiving some basic training from the vendor.
“We revisit the same things all the time,” she says. “What I am finding with safe patient handling is that hospitals are purchasing the equipment and they’re having the vendors come in to do the training — which is fine. But the culture — a culture of ‘ownership’ is not there. So the programs are failing.”
Monaghan cites four key ingredients for the kind of a safety culture needed to sustain the gain and ensure equipment is used appropriately and as often as needed: effective leadership; ongoing education and competency assessment; personal safety; and accountability.
“It dawned on me that it is not just about engaging staff — though that is a vital part of changing the culture,” she tells HEH. “It is looking at it on a much more global perspective within the organization.”
Monaghan recently presented her safety culture concept at a conference in Glendale, AZ, called “Safe Patient Handling and Mobility—Transforming Clinical Practice.”
Accountability must be shared across the board, not just on the frontlines by the patient bedside, but in the boardrooms of hospital administration, she emphasizes. With committed and effective leadership at the helm, a culture of safety can be realized that is non-punitive, encouraging staff to ask questions and giving them the power to intervene to stop unsafe practices. In addition, “near misses” should be reported and analyzed to assess the need for change.
“You also have to make sure that there is enough equipment and the way to do that is a very thorough risk assessment of the patient group and what the staff perceive as their needs,” she says.
Of course, purchasing the right type of equipment for the patient population is critical, but even then surprisingly common barriers to use remain.
“It has to be accessible,” Monaghan notes. “I went to a hospital where you had to unlock two doors to get to the one and only lift. Nobody is going to use that lift — it takes too much time and you have to find the key.”
Indeed, failure to use purchased lifting equipment is an abiding frustration in many safe patient handling programs. Your program should include elements to overcome the common barriers to proper compliance, says Terry Snyder, MBA, senior ergonomics consultant with P.S. Associates in Sudbury, MA.
“There are many reasons why people don’t use [the equipment] and a lot of them are good reasons,” says Snyder. “It’s not the right equipment. It’s been a while since they’ve had training. They aren’t comfortable with it.”
As with any quality improvement process, safe patient handling needs sustained attention, she says. “You need constant reinforcement so this doesn’t die out,” she says.
Snyder cites the following barriers to having a successful safe patient handling program and strategies to overcome them:
Frontline workers weren’t included in identifying the equipment needs. The first rule of change management is to get the users involved in the solution, says Snyder. Confidential surveys are helpful to obtain feedback on patient handling practices and obstacles. “The frontline people know the job the best, and their support is needed to make the program work.” she says.
Staff didn’t have the right kind of training. Users need more than a one-time demonstration by a vendor. They need someone who can reinforce the proper use and benefit of the equipment, says Snyder. “Super-users” or safe patient handling champions are co-workers who provide peer-to-peer coaching at the bedside, identify and resolve any problems, and encourage their co-workers to use the equipment.
The right kind of equipment and supplies weren’t available. Do you have lifts but no available slings? Portable equipment that haven’t been recharged? To sustain your program, you need to maintain your equipment and supplies. You also need equipment that addresses the range of your patients’ needs, including repositioning a patient in bed, moving a patient between a bed and chair, and safely assisting semi-dependent patients to stand or walk.
There wasn’t enough time. Surveys often reveal the perception that using a lift takes too much time in the high-pressure environment of health care. Yet gathering co-workers to help lift takes time, too. As people become more comfortable with the equipment, the time it takes to use it greatly decreases. Management needs to reinforce the importance of safe patient handling for both the patient and care providers, says Snyder. “It is important to have commitment as high up in the organization as possible, to let staff know that this is what’s expected,” she says.
Employees were worried that the patient or the patient families would not like the equipment. Patients often feel more secure when they are in a lift rather than being manually lifted, says Snyder. Safe patient handling is part of a patient safety plan to avoid pressure ulcers and reduce patient falls. And increasingly, patients come into the hospital already familiar with mechanical lifts, she says. “A lot of the patients who are not weight-bearing are using these products at home,” she says. “They will expect hospitals to have them as well.”
- Zerwdling D. Hospitals Fail To Protect Nursing Staff From Becoming Patients. NPR Feb. 4, 2015: http://n.pr/1I3xF4o
- Centers for Disease Control and Prevention. Occupational Traumatic Injuries Among Workers in Health Care Facilities — United States, 2012–2014. MMWR 2015:64(15);405- 410.