A Controlled Evaluation of a Lifts and Transfer Educational Program for Nurses A multifaceted educational program can increase nurses' knowl- edge of the mechanics and procedures underlying safe lifting and transferring.

B Y J A N 1 C E G R A Y ] J A N E C A S S / D A N W . H A R P E R / P A T R I C I A A . O ' H A R A

N 'urses have been shown to be at especially high risk for back injury. 1-3 Such injuries, as well as other musculoskeletal problems nurses face, are

thought to be due, in large parL to lifting and transferring patients. 4-7 For nurses working in a geriatric setting there seems to be an even greater risk of encountering this type of problem. 8 The result may be lost work time and even the premature ending of a career. 9,1~

Despite the importance of the problem, relatively few systematic evaluations of programs designed to address musculoskeletal injury in nurses exist in the literature. Table 1 summarizes 12 studies of musculoskeletal in- jury-prevention programs for nursing staff identified from a comprehensive search of the literature of the last decade.11-21

The populations of previous studies include nursing students and practicing nursing personnel, either with or at risk for musculoskeletal injury. The reported programs ranged from a single didactic session to ambitious teach- ing and practical courses lasting dozens of hours over many weeks. Content of the courses has tended to em- phasize the ergonomics of safe lifting behavior. All of the researchers attempted to assess the program being studied by reference to some comparison data, although only five studies included a comparison/control group in the as- sessment design.

JANICE GRAY, RPT, is an occupational physiotherapist, JANE CASS, RN, BScN, is a nurse educator, DAN W. HARPER, PhD, is director of re- search, and PATRICIA A. O'HARA, MA, is a research associate at Saint- Vincent Hospital, in Ottawa, Canada. G~RIAXR NURS 1996;17:81-5 Copyright �9 1996 by Mosby-Year Book, Inc. 0197-4572/96/$5.00 + 0 34/1/62966

In these studies, program outcome was assessed vari- ously by indications of knowledge, performance, and actual incidence of musculoskeletal injury. Several studies showed improvement in knowledge and behavior, 15,16,19-zl but a reduction in injuries was reported less often. 13,14-16,19,2~

Attempts to demonstrate the effectiveness of lifts and transfer educational programs in geriatric settings have been inconclusive because: (1) changes other than educa- tional sessions were simultaneously instituted (confounding variables)12,1s; (2) data were gathered retrospectively, 13 or (3) the intended result was not demonstrated, u There continues to be need for carefully controlled trials of musculoskeletal injury-prevention programs in geriatric nursing settings.

In recognition of the high risk for this type of injury to our nursing staff, our facility (Saint-Vincent Hospital, Ottawa, Canada, a 516-bed long-term care and rehabilita- tion hospital) in 1984 developed a lifts and transfer edu- cational program for nursing personnel. In 1993 an updated program was designed to provide "continuing" education regarding lifts and transfers to augment and provide a "booster" to the ongoing program. This report describes this program and its effectiveness as estab- lished in a controlled trial.

Method

The program. The original program was developed in 1984 by an interdisciplinary team consisting of members from nursing, physiotherapy, and occupational therapy. The program was based on several sources, including: "The Back Pack" program (1983) developed by the Queen Elizabeth Hospital, Toronto, Ontario, Canada; a

GERIATRIC NURSING Volume 17, Number 2 Gray et al. 81

TABLE 1. S U M M A R Y OF RECENT EVALUATIONS OF MUSCULOSKELETAL INJURY- PREVENTION PROGRAMS IN NURSING STAFF

S t u d y (year) Populat ion Sett ing I n t e r v e n t i o n O u t c o m e

St-Vincent et al. Orderlies Geriatric hospital Unknown Large deviations from (1987) 11 "taught" procedures

Wood (1987) 12 Staff Geriatric hospital Significantly fewer claims (nursing assistants) than comparison group -

mostly due to administration

Aird et al. (1988) 13 Nursing staff Hospital Study I

Study II Nursing staff Nursing home

Linton (1989) TM Nurses with Swedish hospital back pain (medical center

hospital)

Videman (1989) 18 Nursing students Training in school, outcome in hospital

Venning Klein Nursing staff Teaching hospital- (1990) 1~ at risk 7 inpatient

nursing units

Galka (1991) 17 Treatment staff V.A. Medical Center Spinal Cord Unit

Treatment staff (nursing assistants)

Garg et al. (1992) TM

Feldstein Nursing staff (1993) 19

Hellsing et al. Nursing studies (1993) 2o

Scopa (1993) 21 Treatment staff

Nursing home

Kaiser Home Medical Center, Portland

Nursing school (Swedish)

Rural general medical- surgical hospital

Administration program focusing on checking claims, etc. + "back program" program (confounding variable)

Focus on assessment of workers, training, and on- site problem-solving

Focus on job demands rather than worker capabilities (e.g., resident characteristics)

Physical and behavioral therapy package: 8 hrs a day, 5 weeks (work days). "Control" group = waiting list

+40 hrs practical and theoretical training over 2.5 years treatment setting (emphasis on biomechanics and ergonomics) versus controls (much less instruction)

Two 30-minute sessions: lectures, slides, demonstrations, ergonomics & techniques

Preventative program: • 1 hr teaching • 5 -10 min stretch • wear lumbar sacral support while on duty

• Training in use of devices • Changed problematic structure/designs (confounding variables) • Taught lifting techniques

• 2 hrs didactic instructional session • 8 hrs (over 2 weeks of practical assistance and feedback on transfer techniques on wards

Control-5 hrs ergonomy over 2 years Experimental-2 hrs per week ergonomy

Random assignment to one of two groups learning same information (minimizing high risk factors): • Didactic or demonstration (2 hrs), or

• Independent study (written module)

Decrease in number & frequency of back injuries (greatest in orthopedic wards where intense program conducted)

"Encouraging" retrospective findings but sample too small to judge reduction in injuries

"Treat group" better (self-report): pain intensity, anxiety, sleep quality, fatigue, pain behavior, activity, mood, helplessness; generally maintained at 6- month follow-up; medication use and absenteeism not significantly different (NS)

Controls less competent but NS in injuries or back pain

Staff liked sessions: improved techniques but no change in injury rate

Low injury-rate comparable with other less demanding areas of hospital

• Pre-intervention: 83 back injuries per 200,000 work hours • Post-intervention: 47 back injuries per 200,000 work hours

• Composite back pain scale, NS • Composite fatigue scale, NS • 19% improvement in judged techniques (blind)

Experimental group increased satisfaction and performance, no difference in injuries

• Used "Work-Related Body Mechanics Evaluation" (standardized performance measure) • NS difference after training: 9.7 vs 10.22 (out of 12)

video entitled, "Transfer Techniques: Part I and II" (1982)

from the G. F. Strong Rehabilitation Centre in Vancouver,

British Columbia, Canada; and the "Bobath Concept of

Normal Movement" developed by B. Bobath, director of

The Western Cerebral Palsy Centre, London, England. 22

"The Back Pack" program consists of a leader's man-

82 Gray et al. March/April 1996 GERIATRIC NURSING

TABLE 2. ADJUNCT MATERIAL/AIDS USED IN LIFTS AND TRANSFER PROJECT

Pre-Shift Warm-up Video SOURCE: Developed on-site, Saint-Vincent Hospital, Ottawa

Instructional videos SOURCE: Developed on-site, Saint-Vincent Hospital, Ottawa

Lifts and Transfer Program Manual SOURCE: Developed on-site, Saint-Vincent Hospital, Ottawa

Pictograms SOURCE: Adapted from "Transfers and Lifts for Care-Givers'23

Sliding carpet SOURCE: Commercially available as child's sliding toy

Transfer belt SOURCE: Made on-site, Saint-Vincent Hospital, Ottawa

Transfer disk SOURCE: Commercially available

Illustrates stretching movements to be completed by staff before beginning their shift (approximately 5 minutes in length)

Portraying various types of transfers used in the facility: • Methods of patient assessment for transfer • When transfer should and should not be utilized • Equipment required for safe performance of transfer • Correct body mechanics/methods of performing transfer

Manual depicting the policies and procedures used to transfer the patients in this facility

Visual tools that illustrate various transfers/procedures; placed at patients' bedside and on care plan as a reminder to all staff what transfer/procedure is to be used for each patient.

Small plastic carpet used to facilitate the repositioning of patients in bed

Belt with quick-release buckle used to assist both patients and staff in transferring safely

Rotating disk placed on floor and used to assist patients turn without having to move their feet.

ual, slides, and a videotape. The leader's manual contains three modules: (1) fundamentals of back-care, (2) tech- niques for transferring patients, for staff involved di- rectly in patient care, and (3) care group training for staff selected to assist coworkers in practicing good back care techniques. The slides provide basic principles of back care, and the videotape provides demonstrations of the various techniques associated with back care. These au- diovisual components were designed for all categories of workers in a health care facility, including those not di- rectly involved in patient care.

The "Bobath Concept of Normal Movement" utilizes the principles underlying normal body movement. The staff are encouraged to move this way themselves and to assist their patients to move in as normal a way as possi- ble. This results in greater independence for the patient and a decrease in work strain for the staff. Much of the material taught in the program was based on clinical ex- perience and the adaptation of transfer techniques to fit the type of patient at our facility.

The original program was taught to 14 nursing units for 12 weeks: 8 weeks of theory and practice, and 4 weeks of clinical application. This program was in effect until 1989. A new program was started in 1989 for all new nursing employees. This program consisted of 4.5 hours of lifts and transfers education as applied to direct patient care. A review was conducted in 1993, and an up- dated version of the program based on the review is the subject of the present investigation.

An interdisciplinary committee, comprising occupa- tional therapists, physiotherapists, and nurses, used its knowledge of good body mechanics, as well as recom- mended procedures for lifts and transfers, to design a

program that would be aimed specifically at nursing personnel.

The updated educational program was conducted pri- marily by the resource team, consisting of the occupa- tional health physiotherapist and a nursing education coordinator. Two staff members and the nurse manager of the training unit were given additional training and ex- pected to act as on-unit resource people for their cowork- ers. The major components of the program, which required approximately 4 hours on-site per week for 5 weeks, were as follows:

• Each shift began with the staff stretching to a warm-up video (made in-house, 5 minutes in length). The occupational health physiotherapist initially conducted the sessions, demonstrating the correct method of performing the stretches.

• A "transfer of the week" was selected each week and a video (made in-house) depicting the desig- nated transfer was to be viewed by all staff at their convenience (but during that week).

• Formal teaching sessions on the transfer were held early in the week, with follow-up practice sessions later that same week.

• "Silent hour" (evening and night shifts) education was provided, focusing mainly on bed repositioning techniques.

• Problem solving for individual patients and staff members was done at any time, and staff members were encouraged to make use of the resource team.

• New techniques and equipment--specifically the use of the sliding carpet and the transfer d i sk- -were demonstrated by the resource team and participa-

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GO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~fi-:.5 ........................................................ 50.~ -------4

40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . .

20 ..........................................................................................................................................................................................

I I

P.qE POST

CONTROL UNIT 4C ~TRAINING UNIT 5A

Figure 1.

tion was encouraged by staff members during the practice sessions.

�9 A loose-leaf binder was left on the unit to facilitate communication. Staff were encouraged to write any questions, feedback, or comments they had in the book, and these concerns were addressed either ver- bally or in writing by the resource team.

�9 "The Lifts and Transfer Program Manual," summa- rizing the policies and procedures regarding patient transfers in our facility, was also available on the unit and staff were encouraged to read any appro- priate material.

Table 2 presents the materials and aids used in the project (including sources), which are available from the authors) 3

Study design and outcome measures . For the pur- pose of the present study, two comparable nursing units in our long-term care facility were selected. One unit (5A) was chosen, at random, to receive the program (de- scribed below) for 5 weeks. The comparison unit (4C) was assessed before and after but did not receive the ed- ucational program. The patients in each unit were of com- parable diagnostic and demographic types, and a survey of the types and frequencies of lifts used before the edu- cational program yielded similar patterns.

Two major outcome measures were employed: knowl- edge of lifts and transfer procedures as outlined in the ed- ucation program, and satisfaction with the training.

A "Lifts and Transfer" quiz to assess nursing personnel knowledge of appropriate procedures in a variety of situ- ations was developed in three versions. Each nurse subject in each group received, at random, one of the three ver- sions of the quiz for pre-education assessment. For post- education assessment each respondent received a different version of the questionnaire--again, on a random basis.

The second outcome variable, staff satisfaction with the program, was assessed by means of a Likert scale

ranging from "5" ("very useful") to "1" ("no use"), ad- ministered to nursing staff who participated in the pro- gram.

Results

Figure 1 shows the average percentage of correct an- swers on the "Lifts and Transfer" quiz for nursing staff on the two units studied, before and after the staff of one o f the units (5A) received the "Lifts and Transfer Educational Program." Initially there was no difference between the units. After the educational program staff from unit 5A had a significantly higher percentage of correct answers than did staff from the comparison unit (p < 0.001).

Staff satisfaction with the program was indicated by 88 of a possible 120 (73%) responses on the questionnaire being in the "very useful" or "useful" categories.

Discussion

This study has shown that a multifaceted educational program can increase knowledge of nursing staff con- cerning the mechanics and procedures underlying safe lifting and transferring behavior. Of course, it is hoped that increased knowledge concerning appropriate lift and transfer techniques will lead to alterations in behavior and the prevention of musculoskeletal injuries-- the eventual goal of all such programs.

To determine whether the increased knowledge demonstrated by our trained group was translated into ap- propriate lifting behavior, 6-week and 6-month follow-up observations were made on a random basis. These in- volved 1-day and one evening shift of staff who had re- ceived instruction during our program. The results were encouraging; during the time of observation all observed lifts were performed within acceptable parameters.

Each nursing unit now has a

representative who attends a

monthly 1-hour lift and transfer

session.

As a direct result of this project the following changes have been implemented throughout the hospital: (1) the use of pictograms as a visual reminder of the appropriate trans- fer techniques, (2) increased use of a sliding carpet in repo- sitioning patients in bed, and (3) increased use of transfer belts. Each nursing unit now has a representative who at- tends a monthly 1-hour lift and transfer session. The agenda is prepared in consultation with all the unit representatives. This is a method of providing education that can be relayed to all units and still tailored to their special needs.

It is anticipated that the core of the education process, wh ich was found so valuable in our program, will be car-

84 Gray et al. March/April 1996 GERIATRIC NURSING

ried on at the unit leve l on a continuing basis. This places the responsibi l i ty for education on the nursing staff but also provides them with a resource team for help and encouragement. •

Financia l support f rom the Saint-Vincent Hospi tal Foundat ion and f rom the Chawkers Founda t ion is grateful ly acknowledged .

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11. St-Vincent M, Lortie M, Tellier C. A new approach for the evaluation of train- ing programs in safe lifting. In: Asfour SS, ed. Trends in ergonomics/human fac- tors IV. Amsterdam: Elsevier (North Holland Division), 1987:847-54.

12. Wood DJ. Design and evaluation of back injury prevention program within a geriatric hospital. Spine 1987;i2:77-82.

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23. Health Care Occupational Health and Safety Association. Transfers and lifts for care-givers. 2nd ed. Toronto: Health Care Occupational Health and Safety Association, 1991.

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