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Examining how well students use correct handling procedures

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VOL: 101, ISSUE: 04, PAGE NO: 38

Dev Jootun, MPhil, BA, RGN, RNT, ONC, is lecturer

Alasdair MacInnes BEd, RGN, RNT, ONC, is lecturer; both at School of Health Studies, Caird Park, Hamilton

Jootun, D., MacInnes, A. (2005) Examining how well students use correct handling procedures. Nursing Times; 101: 4, 38-40.

Jootun, D., MacInnes, A. (2005) Examining how well students use correct handling procedures. Nursing Times; 101: 4, 38-40.

Aim: To explore the extent to which undergraduates apply taught principles when performing handling and moving activities during practice placements and the factors that influence their application.

Method: A seven-item questionnaire comprising closed and open-ended questions was administered to 10 undergraduate third-year students, which was followed by a semi-structured interview after they had completed their practice placements.

Results: This study found that there were many situations where students were unable to apply the principles as taught in the classroom. The constraints imposed by the combined effects of the environment, resources and time limited the application of the safe principles. In areas where handling and moving was seen to be an integral part of patient management, students were encouraged to use the correct techniques.

Conclusion: The emphasis on educational input in relation to the safe application by students of the principles of handling and moving should be to provide a structured programme that is consistent with practice on the wards.

Handling and moving patients is an integral part of nursing, however, there is a high incidence of back injury in nursing staff while manually handling patients (Hollingdale, 1997). This level of injury and the passing of health and safety legislation in 1992 (Health and Safety Executive, 1992) has lead to changes in the way new nurses are prepared for moving and handling.

The RCN has developed a Code of Practice for the Handling of Patients (RCN, 2002), which advocates new nurses be given a sound theoretical base for safe handling and moving complemented with adequate practice.

In 1994 Bell College's School of Health Studies in Hamilton, Scotland, introduced a new approach to teaching handling and moving based on the neuromuscular approach (NMA) to efficient handling and moving. This approach is primarily concerned with teaching students to move efficiently, which means moving in a way that produces the least possible fatigue and strain, and consequently minimising injury (Crozier and Cozens, 2002).

Aims of the study
The aims of the study were to:

- Find out the extent to which undergraduates apply the NMA principles when performing handling and moving activities during practice placements;

- Explore undergraduates' perceptions of factors that influence the application of the NMA principles when performing handling and moving during placements.

Literature review
Much of the research into handling and moving has revolved around back pain and injury in nurses. Few studies have explored the factors that promote safe application of principles. In a review of over 80 studies, Hignett (1996) concludes the traditional approach to training in manual handling has had no lasting benefit in reducing prevalence of back injury despite the correlation between back injury and increased patient handling. She found no evidence supporting training as an effective intervention. Hignett states that there is a need for organisational change to prevent such injuries. While the evidence provided by the studies links manual handling with occupational injury, limited reference has been made to the impact handling and moving training has had on changing practice.

Smaller-scale studies have explored the correlation between teaching and practice. Kane and Parahoo (1994) argue that teaching safe handling and moving throughout training is important but does not guarantee use of appropriate methods. They found knowledge and skills important but insufficient to ensure effective practice.

Various factors in the clinical environment may influence students' behaviour. McGuire and Dewar (1995) found attitudes have a strong influence on handling and moving practice. Some nurses in their study did not want to risk unpopularity with the ward team and were prepared to carry out unsafe handling and moving practices.

Other studies report a more positive outcome. Lagerstrom and Hagberg's (1997) evaluation of a three-year nurse education programme found 93 per cent were still using new client transfer techniques one year after the programme. Dixon et al (1996) reported with continued on-site support and supervision, provision of individualised training and appropriate resources, many staff 'simply stopped lifting'. Priority within this strategy to adopt a 'no lifting' policy was given to learning new ways of moving people and encouraging clients to move themselves.

It is evident from these studies that in most cases a change in nurses' practice of handling and moving of clients can be achieved through effective training.

Methodology
A seven-item questionnaire comprising closed and open-ended questions was administered to 10 undergraduate third-year students after they completed semester five theory in the middle of their third year (Box 1). The questionnaire was designed using information gained from the literature review and consultation with colleagues involved in teaching handling and moving. Open questions, formulated to allow respondents to express themselves in more depth in some instances, were used with closed questions. The questionnaire was designed to be self-administered and completed in about 15 minutes. It was piloted with the preceding semester five group. The questionnaire was anonymous. It was especially important for the undergraduates to feel comfortable about disclosing accurate information. The data was analysed to identify the main themes.

This was followed by a semi-structured group interview after semester five practice placements, which lasted for approximately 40 minutes. The main themes emerging from the collected data were used as a basis to inform the interview in the hope that it would generate more information. This provided an opportunity to clarify ambiguous points emerging from the questionnaire.

Ethical considerations
The head of the School of Health Studies granted ethical approval and permission for the study to be carried out. The students were informed of the purpose of the study and all agreed to take part. Participants were assured no identifiers were attached to questionnaires and all data would be treated anonymously.

Results and discussion
This study found it is not as easy to practise moving and handling as taught in college. Patients' handling and moving needs were not assessed and documented on care plans, and students had to rely on ward staff to guide them on how to move and mobilise patients. Some were allocated to work with auxiliary staff who had received no formal instruction on safe handling and moving.

Two of the students felt confident enough to opt out of handling and moving situations because they felt they were unsafe. These students were concerned for:

- Their own health and safety;

- The safety of the patient;

- The safety of other staff working with them.

They felt if handling and moving needs were assessed properly, they would have been more aware of the appropriate interventions while caring for patients.

A study by Pugh (1989) showed while nurses say they assess handling needs, this is at an unconscious level and they do not record the results. They also viewed this more as a health and safety matter than part of care.

The other eight participants were prepared to be involved in unsafe practice to avoid negative reactions from ward staff. One student explained: 'The ward staff are set in their ways. As a nursing student just passing through their ward, it is difficult to tell them what they are doing is wrong. It is probably better to go with the flow rather than make yourself unpopular.'

All the students felt they had enough training and were confident to perform safe handling and moving. Inhibiting factors for application during placements were lack of clarity on ward protocols and students feeling they were not in a position to tell ward staff how to handle patients. The students' status in the pecking order did not grant them the authority and confidence to inform staff or initiate change in handling and moving.

The responses from the questionnaire showed all the students in this study demonstrated a good basic knowledge of the principles of safe moving and handling. However, only three could apply these principles in practice. These three students felt staff were more aware of guidelines and had more support from management to continue their professional development through study days. Mechanical lifting aids were more readily available to staff and they spent more time with patients.

The other seven participants felt the principles were only applied sometimes, depending on the wards. The reasons given were that nurses they were working with were unaware of the principles and only a few had received any form of guidance apart from during training.

Davies et al (1999) found less than one-quarter of the registered nurses they interviewed were engaged in any form of continuing professional education. Some auxiliary nurses they worked with had had no formal instruction on handling and moving safety. Students found it difficult to stand back and not get involved even if they felt the technique being used was unsafe. This was clarified by one: 'As a student, you can't say 'No. I am not helping you.' They will probably think that you are not interested and this may influence your practical assessment.'

Some of the students felt it was impractical to expect staff and students to apply the safe principles all the time. They mentioned various factors such as time and resources, which prevented the safe application of principles. They felt because of the nature of the work, there would always be some situations where they would have no alternative.

In some situations they felt patients were being moved more than was required. This could be due to most of the wards not performing handling and moving assessments at admission. Naish (1996) explains some of the reasons nurses cannot stop lifting patients. Nurses are so used to doing everything for the patient they find it very difficult to keep their hands off them. They will instinctively pick up patients and move them even though in some cases they are able to move themselves. Naish argues that we have to shift nurses' attitudes towards handling and moving patients from the habitual to the unusual.

The increasing amount of national and European legislation on handling and moving has forced hospital managers to place greater emphasis on the health and safety of nurses (Hack and Potter 1996). The students in this study stated that change in practice is very slow and patchy. They felt many of the ward staff were unaware of the legislation and little information was available on the wards to guide students. Hignett et al (2003) systematically reviewed the literature. They found the key factors leading to slow change and patchiness of application of theory to practice were:

- Ritualistic practice,

- Time and resources;

- The changing nature of the staff population.

The students felt even though some staff had taken the handling and moving course, they were unable to apply the principles. This was elaborated upon: 'They [staff] want things done very quickly. They don't take time to assess the patient in the morning and the staff nurse I was working with told me that it takes too long to go and get the hoist. It is much quicker to lift the patient.'

Hack and Potter (1996) supported this by arguing the two major problems with the manual handling policy were the nursing staff's low ability to retain the principles of procedures and the difficulty of applying these.

Eight students felt the constraint of time, resources and environment restricted the safe application of principles. The emphasis on 'getting the work done' as quickly as possible put a lot of pressure on them to perform manual handling quickly. Often, appropriate equipment was on the ward, but staff felt it would take too long to use.

Some students described how the environment interfered with manual handling practices. They had patients in single rooms often cluttered with furniture. Staff failed to clear a space around the patient's bed or chair. One student said: 'They [staff] don't want to waste time rearranging the furniture. They have so much to do. They just rush into things without any planning.' The students felt these problems could be prevented if staff took more time to assess manual handling manoeuvres.

Areas where the correct principles were applied included places where recent re-designing or ergonomic changes had been made. Nurses here were keener to facilitate movement in patients. They were more receptive to change and encouraged autonomy and independence in patients. This was more evident in wards with older patients. The nurses' understanding of the need for older people to maintain independence influenced the implementation of safer handling practice. Nursing care was based more on patients' needs, and nurses collaborated with patients in care planning. In these situations students saw more positive patient outcomes. Staff from these wards were given better ongoing support and guidance from managers, and this was reflected in the quality of supervision students received.

Conclusion and recommendations
Training in safe handling and moving is a statutory requirement educational establishments must provide for students (HSE, 1992). Regularly updating students during the courses is seen as a good way of helping them become safe practitioners. Unfortunately, many factors in practice placements interfere with the safe application of principles.

This study has shown there are many situations where students are unable to apply taught principles. They tend to be guided by practice on the wards. In areas where handling and moving is integral to patient management, students were encouraged to use correct techniques. In other areas, constraints imposed by the environment, resources and time limited applying principles.

Clearly, an ergonomic approach which evaluates the complex nature of nursing practice is vital for a move towards safer handling and moving in future. The NMA advocates the design of safe systems similar to an ergonomic approach. Educational input needs to have considered wider aspects of nurse training beyond the confines of the classroom. It is important for lecturers and clinicians to work in unison to promote greater collaboration, facilitating students' application of theory. Staff attitudes towards change need to be explored in parallel with other initiatives if effective change is to take place.

Although this study is limited in its applicability beyond the arena in which it took place, it has provided valuable information, which can be used to formulate a strategy to ease transference of taught principles into practice. The emphasis on educational input in relation to the safe application of the principles of handling and moving should be to provide a structured programme consistent with practice on the wards. Schools should provide ongoing support for clinicians who supervise students during practice placements, allowing them to reinforce what is taught in the classroom.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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