Clinical skill: Moving and Handling

Introduction

The ‘Moving and Handling’ clinical skill has been chosen for this essay. The aim of this essay is to consider other research and highlight the key factors that healthcare professionals must take into account while developing appropriate moving and handling plans for patients, as professional carers. The discussion will also include the role of moving and handling strategies in the delivery of palliative rehabilitation services in the community, and will describe key pieces of equipment to support moving and handling strategies.

LO 2- Critically review evidence which enables effective and efficient care delivery

Across the world, whether in hospital or community environment, workers in health care, a have a big issue with back pain and other related injuries all the time. Betts (2011) states that since 1981, Safe Patient Handling has become a major issue because of the rise in in cases of low back pain and injury to nurses. Consequently, National Back Exchange(NBE) was established in 1988 by the people experts in this field. While NBE operates across the globe and has members everywhere, they are the experts in UK in all matters pertaining to moving and handling. Around the world, there is a differing and evolving picture on Handling and Movement of patients. In USA, safe patient handling and movement is a comparatively new concept, as compared to Europe and Australia ( Monaghan, 2012) and Mcmahon(2013) states Moving and handling in New Zealand is covered in the Health and Safety in Employment (HSE) Act (1992), with amendments (2002) and requires employers to undertake hazard management by assessing, identifying and removing any possible hazards at work for employees, and to educate them on how they should manage identified risk and injury. What is impact?????—Although moving and handling has been improved but still due to that health workers and patients have injuries as states.

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Furthermore Monaghan (2011) states the use of lifting technology and approved handling and movement techniques have proven to be very beneficial to patients. Enormous amounts of money are spent in providing new and suitable equipment, as well as training for patients and health care staff. Yet, despite spending extraordinary amounts of money on state-of-the-art equipment, staff continue to demonstrate resistance to using suitable new equipment in many healthcare facilities. It is often seen that newly purchased equipment is stored in bathrooms and other such places while healthcare staff continue to use the more traditional forms of repositioning a patient with a draw sheet, or transferring them with a gait belt, while placing over reliance on the use of good body mechanics to keep patients and themselves safe from injury.

Moreover, Monaghan (2011) describe that in spite of this, safe patient handling is a big challenge for organisations and care workers providing all types of health care Regulatory/mandatory requirement entail changes in the way of working and lead to additional precautions, facilities, work and training to be undertaken. Care workers resist this change, although they know it reduces the risk to their backs and bodies, risk of other musculoskeletal injuries. Alarmingly, due to musculoskeletal injuries, 12% nurses and 1 out of 6 physiotherapists leave their healthcare jobs every year. The loss of a career can have a significant impact on care workers, and the subsequent impact to their families, both financially and emotionally, can be considerable. Also the problems can be enhanced by the enforced move into an area of work that they may not have chosen, and that may not be adequately rewarding. Clearly, safe manual handling approaches are more complex than simply offering a training day for staff.

With the passage of time, there has been changes in the pattern of work, techniques for safety, delivery of appropriate care along with the evolution of new ways of working(M&H RIDDOR, 1995).

LO-3 Critically review available policy that supports contemporary nursing practice

Manual handling practices have been seen as a mandatory requirement for some years in the UK. Following the Manual Handling Operations Regulation 1992 Legislation, all European Union Member States were required to demonstrate compliance. In the USA, only a few States have recently introduced manual-handling legislation, and Texas was the first state to require hospitals and nursing homes to implement safe patient handling programs was in 2006. (Treadwell, 2013). Due to hazardous working practices, health care professionals have suffered injuries and problems for a long time in the USA. According to the U.S. Bureau of Labor Statistics (2006), over a period of 10 years from 1995 to 2004 nearly 800,000 health-care workers were injured or became sick while at work, mostly due to musculoskeletal disorders. This has resulted in the re-examination of the factors that impact or prohibit appropriate care giving and protection processes.

Different segments of the care giving community has responded to the regulations with a number of initiatives, but they have all identified training as a key mandatory requirement. Since the legislation was introduced in the UK, the initial findings indicated that the number of healthcare workers suffering injuries was not significantly lowered after implementing generic training programmes. In fact, it was seen that nursing was a high-risk occupation that was impacted by lower back problems, and that training only was of no benefit (Hignett, 1996). Also, sickness absence due to back injury resulting from manual handling incidents was still too high (Department of Health, 2002).

Yet, employers were continuing to operate a ‘tick box’ exercise in providing training for their employees, believing that providing training alone was enough to satisfy their legal obligations for manual handling. In spite of numerous recommendations, legislations and plans, care providers were still not taking enough care. Very often there were no sliding sheets on the ward. Staff had to lift because it took too long to use the hoist. They pulled on the bed sheets to move the patient up the bed instead of using a sliding sheet as it would take time to get the equipment and the nurses were too busy on the ward. No one else was using the handling belt, everyone used the drag lift to assist patients out of the chair. It is therefore not surprising that patients are subjected to friction injuries and shoulder damage from poor handling practices.

A number of different initiatives and approaches have been tried over the years to promote and embed safe handling and movement techniques, however none have been truly successful. Effective Manual Training is the only approach that has been effective. Organisations, such as the National Back Exchange, and professional bodies, such as the Royal College of Nursing and the Chartered Society of Physiotherapists, have produced detailed guidance on safe manual handling, and the impact. However, the positive results of this guidance support working to reduce both the pain and suffering of individuals and the cost to the National Health Service (NHS) through sickness, ill health and inflated insurance costs following litigation cases. Clearly, more research should be carried out, to identify the most effective approach to manual handling education.

For safe manual handling and movement to become part of the culture, recent evidence supports a combined approach (White and Gray, 2004; Hignett and Crumpton, 2005) of the following as the most likely approach to succeed:

• Trust policy-commitment by the organisation, and the development of a culture that facilitates this approach
• Training-specially prepared for the particular field of practice; it would include problem solving
• Experts to lead-back care advisors and others
• Resources to support the proposed changes in practice.

Safe manual handling approaches are much more complex than simply providing a training day for staff. A holistic and complete approach requires: organisational support; staff participation and involvement; resources, including equipment provision; and review and monitoring. The recent Francis report (2013) covering healthcare within the UK, states how everyone must all be mindful of how they handle their patients and interact with their families and carers. Communicating and working with patients, families and carers, and to reduce the risk of harm is an integral part of the work of a care provider, both in hospitals and community settings. The USA has a completely different health care set up than in the UK, and many of the approaches, methods and systems would not necessarily be transferable.

Critical Review of the available policies pertaining to Moving and Handling, and its effectiveness

Regulations have a very important role in presenting appropriate and acceptable ways of working. They also have a great impact and influence in getting organizations, businesses and individuals to conform to approved standards.

At the Global level, there are the policies issued by the World Health Organization and others. At the national level, in the UK there are the guidelines contained in Acts by the governing bodies including Nursing & Midwifery Council, Royal College of Nursing, Care Quality Commission, Health & Safety Executive, Royal College of Physicans, Department of Health, National Patient Safety Agency 2007, etc. The legal requirements of various laws and Acts such as the Mental Health Act, Human Rights Act, Consent, Health & Safety at Work Act, etc. are quite comprehensive and pervasive. They have helped revamp the way healthcare for the health worker was perceived, and have changed the landscape. Compliance with NMC Code is mandatory, even though the NMC code is written in a paternalistic manner.

The policies also consider continuing education, and enhancement, along with safe nursing practices for care providers. Regular training is mandatory, and these need to be reported for all staff. Update training is also required, and the Auditors/Inspectors check training records and practices during their audits. They pay great attention to those instances where staff have not been given training or given opportunities to obtain training. The auditors adopt a very strict stance where staff have had to compromise on training due to excessive workloads. This is similar to the concern where in order to make do with limited resources, managers balance the books by cutting corners. Sometimes, managers forget to look after patients in favour of running their hospitals (Francis report).

Training must be comprehensive. In addition to training for proper handling and movement, training must also be provided for related aspects like handwashing, communication skills, professionalism, ethics and decision making. There are legal reasons why hand washing competency is necessary before and after moving and handling, and health worker need to be trained in this so that they do not compromise the patient’s or their own safety.

LO 4 -Synthesise critical understanding and insight of the concept of competency and the influence that ethics, law and professionalism have on decision making

(For some time, the blanket term of ‘no lifting policies’ was used in the UK, which led to misinterpretations of this guidance, where staff were not willing to assist patients to move who needed only light assistance. Organisations have generally replaced this term with ‘minimal lifting policy’ to avoid such confusion. Health practitioners must not lose sight of the fact that safe manual handling practices are in place to help not only reduce the risk of injury to care givers but also to allow the safe transfer and handling of patients.One of the major responsibilities is that dignity and respect must be accorded to patients in all circumstances. A patient, who has fallen on the toilet floor and is unable to get up independently is in a very vulnerable position. The Policy of the Trust and training to care givers says that patients must be hoisted off the floor. However, the human factor here is of paramount importance and requires that empathy must be demonstrated and the patient’s dignity must be protected(Treadwell, 2013)

In one case Holbrook (2003) reports that a woman with multiple sclerosis slept in her wheelchair for over 15 months because the policy of the local Health Trust did not allow staff to manually lift patients in to and out of their beds that create a dilemma in decision making—

Ethics involves having the understanding and competency to know what is the right thing and how to do it. The following 4 principles were introduced by Beauchamp and Childress:

1. Non-maleficence – do no harm; practicing moving and handling procedures to ensure that both patients and care givers are not harmed.
2. Beneficence – for the benefit of patients; implementing procedures to ensure that the patients are getting the best possible care, and colleagues are able to work for longer without workplace injuries.
3. Autonomy – patients have the right to decide what treatment they must get, and the right to refuse to endure painful lifting manoeuvres.
4. Justice – fairness and equal treatment of all patients and staff.

While addressing ethical principles, sometimes moral dilemmas may be faced. Given below are some examples:

Sauceda, Falco (2014) state It is ethically unacceptable for healthcare facilities to accept bariatric patients into a healthcare environment if the physical environment is ill equipped to provide safe, equal, and optimum health care. Such environments fail in their moral and ethical obligations by challenging the safety of the bariatric patient and that of their direct care providers. Such ill-equipped environments further fail in their responsibility of maintaining patient dignity and treating patients with respect.

The question then lies in what we do as medical professionals and how we should proceed. Some believe if ethics fail, legislation is needed to breach the gap. Will the development of concrete legislation, however, meet the varying needs of bariatric patients and the ever-changing healthcare arena? In reflection, the case study depicts the organization ignoring their ethical responsibilities to care for all those in need. With the limited resources available in health care, bariatric patients have not been given fair and equitable treatment. Often the deciding factors of who receives what resources and treatments come with hidden weight restrictions. If legislation is the answer, then it is the responsibility of all healthcare providers in all disciplines to lobby for change, take action, and always act in the best interest of the patient-the true meaning of beneficence.-

From the point of entry into the hospital, the bariatric patient is at risk for increased harm. While there are instances and conditions that forgive the existence of unsupportive environments, such as emergencies or disasters, it is not acceptable for bariatric patients to receive substandard care in healthcare facilities simply because of their size and weight. The continuing rise in obesity rates demand healthcare organizations, providers, and those professions that work with the healthcare industry to commit to supporting a culture of patient and staff safety and equality. In addressing the health challenge of providing optimum care to the bariatric individual, healthcare providers and their institutions must remember their duty to “do no harm.” I think it would cover ethics if we paraphrase, make it short and put add some more comments.

• The Policy states that a person who has fallen should be left on the floor, but ethically is that the right thing? What if the fall happened outside when the weather was poor? Would it mean that the person will suffer more harm by being left until further help arrives?
• Another potential moral issue arises where the patient doesn’t like being hoisted as they find it undignified, but the staff don’t want to use drag lifts, etc. because it was causing them injury. In this situation, who has the right to decide the best way forward?
• If time is an issue, by taking more time with one person does it mean that the next person has less time or their appointment gets missed? Is this ethically fair on the next person or the person after that?

When people choose to cut corners, it is an ethical consideration. A further ethical problem is related to hierarchy – new staff are often afraid to question their older more experienced colleagues/managers, and therefore go along with bad practice.

Care worker must balance the law, professionalism and ethical competencies to make the best decision. They need to consider what the law says to avoid prosecution, what local policy and the NMC (2015) code says to maintain their career and profession, and they must decide on the ‘right thing to do’ to make a morally good decision.

Ethics again, is a very important area to be considered for training. Competence of a care worker means that the person is adequately trained and capable to perform moving and handling in the required time, by following the policies and procedures which keep patients safe from harm. Autonomy implies that the staff is able to perform any procedure with patient consent, for example according to the choice of the patient, and they want, their dignity and privacy. In this regard, legal obligations always come first. They may create moral dilemmas, but these can be dealt with by using Professionalism. These are the essential and are actually the basics of a career – a health worker must get this right if patients are going to trust them. Ethical principles include Justice, i.e. being fair to all and treating everyone the same without discrimination, Beneficence i.e. to do good, Non-maleficence, i.e. to do no harm, and respect for autonomy and truthfulness. An important example is that a care giver may do chest compressions in attempts to preserve life (Beneficence) but during this process if he/she break the person’s ribs, this goes against the principle of Non-maleficence.

Ethically speaking the care of patients and keeping them safe from harm should be the first concern. The principle of “do no harm” is paramount, and must be respected. Discrimination can happen by blindly applying a policy which discriminates against minorities.

Accordingly, competency along with ethics, law and professionalism have a lot of influence on decision making. The legal and professional implications for moving and handling competence need to be considered, in accordance with the NMC Code (2015), and have crossovers with legal and moral competence, for example, negligently moving and handling a patient could be punished legally in a court of law and professionally by the NMC.

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To comply with the Code, care workers need to always practise in line with the best available evidence. They must maintain the knowledge and skills that are needed for safe and effective practice, and must recognise and work within the limits of their competence. Where any action or procedure is beyond the limits of their competence, they should ask for help from a suitably qualified and experienced healthcare professional to carry out their duties, but they must always take care of their own personal safety as well as the safety of people in their care. It is important that they complete all required training before carrying out a new role. They must be aware of, and as far as possible, reduce any potential for harm associated with their practice. This would include taking measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place. Their training must take account of current evidence, knowledge and developments in reducing mistakes, and limiting the effect of these mistakes, as well as the impact of human factors and system failures. They must take all reasonable precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public.

Gallagher(2012) states From a historical perspective, the US is considered largely individualistic, its roots grounded in the ethical principle of respect for personal autonomy. To that extent, it is no surprise that US policies generally focus on the needs of individuals rather than the needs of whole population segments. The challenge to caregivers, policy makers, and other stakeholders is to balance the care of individuals with efforts to protect whole segments of the population. The Georgetown mantra, individualism, collectivism, and entitlement are described. This theoretical frame is then used to raise specific ethical questions and debate within the context of ethically sound Safe Patient Handling policy formation, designed to protect whole segments of the caregiver population-Please see attached a short article, if we can use the material for this Learning outcome.

Moving and handling is an integral and important part of community nursing practice, and should be considered as part of a holistic assessment of patient needs. Staff need to be aware of the legislation which covers this aspect of practice, and ensure that they are kept informed of updates according to trust policy. Accurate assessment of moving and handling needs are paramount to ensure the safety of both practitioners and patients. Employers are required to assess all risks, and action must be taken to minimize these risks as far as reasonably practicable. Using equipment that is appropriate will also help to maintain safety and minimize risk.

Staff have their part to play by ensuring that employers are aware of the specific risks they face and that assessments are carried out. They must also attend all mandatory training provided by their employer. These steps are vital to protect our vulnerable workforce from injury and the significant impact that injuries arising from moving and handling can have on health, finances and quality of life.

References

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